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Some Unusual Paraneoplastic Syndromes

CASE 4. PARANEOPLASTIC NEPHROTIC SYNDROME IN A PATIENT WITH LUNG CANCER

Dana-Farber Cancer Institute, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA

A 69-year-old man with a 100 pack/year history of cigarette smoking was noted to have a lung mass on screening chest x-ray. A chest computed tomography (CT) revealed a 4 x 3–cm right lower-lobe (RLL) lung mass and a 1-cm precarinal node. Non–small-cell lung cancer was diagnosed by CT-guided biopsy of the pulmonary mass. A head CT and bone scan were negative for metastases. He was asymptomatic, and he chose to defer treatment of his lung cancer for 3 months until after his daughter’s marriage. Four months after diagnosis and before any therapy, he developed hemoptysis, worsening dyspnea, and bilateral lower-extremity edema. He noted that his urine had become extremely frothy. On physical examination, he had decreased breath sounds in the right lung base, abdominal distension, and 3+ lower-extremity edema. A chest CT showed progression of his malignancy with RLL collapse, mediastinal adenopathy up to 3 cm in size, and a left upper-lobe nodule. Laboratory studies were significant for a serum albumin of 2.3 mg/dL and a creatinine unchanged at 1.4 mg/dL. Urinalysis showed 3+ protein, and a 24-hour urine collection contained 10.2 grams of protein. His serum cholesterol level was elevated at 308 mg/dL. A serum protein electrophoresis, antinuclear antibody (ANA), and renal ultrasound were unremarkable. He was treated with concomitant chemotherapy and radiation therapy consisting of 3,750 Gy of radiation to the RLL in 15 fractions, as well as weekly carboplatin at an area under the curve of 2 and taxol 50 mg/m² for 5 weeks. Hemoptysis and dyspnea resolved in the first month of treatment. Lower-extremity edema and abdominal distension improved gradually over 3 months. According to CT scans, his RLL mass decreased in size, and his RLL collapse resolved and remained stable over the subsequent 9 months (Fig 1). His blood pressure was controlled with lisinopril (Zestril; AstraZeneca, London, United Kingdom) and hydrochlorothiazide. His albumin increased to 3.7 gm/dL, his proteinuria decreased to 540 mg/24 hours, and his creatinine remained stable (Fig 2).

View larger version (100K): [in this window] [in a new window]   Fig 1. Computed tomography scan showing decreased right lower lobe mass.

View larger version (13K): [in this window] [in a new window]   Fig 2. Graphs showing (A) 24-hour urine total protein, (B) serum albumin, and (C) serum creatinine.

Hypoalbuminemia is common in patients with lung cancer. A small subset of these patients will have nephrotic syndrome because of a paraneoplastic process.

REFERENCES

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3. Shikata Y, Hayashi Y, Yamazaki H, et al: Effectiveness of radiation therapy in nephrotic syndrome associated with advanced lung cancer. Nephron 83:160–164, 1999[Medline]

4. Davison AM: Renal diseases associated with malignancies. Nephrol Dial Transplant 16:13–14, 2001 (suppl 6)[Free Full Text]

5. Boon ES, Vrij AA, Nieuwhof C, et al: Small cell lung cancer with paraneoplastic nephrotic syndrome. Eur Respir J 7:1192–1193, 1994[Abstract]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ebert, B. Articles by Rennke, H. Search for Related Content PubMed PubMed Citation Articles by Ebert, B. Articles by Rennke, H. Social Bookmarking                            What's this?