Nephrotic syndrome associated with metastatic thymoma treated with chemotherapy

Nephrotic syndrome as a possible indicator of colonic cancer: A case report

The concept of paraneoplastic syndromes encompasses a spectrum of indirect clinical manifestations caused by secretion of bioactive products by malignant cells. Paraneoplastic glomerulopathy represent a distinct clinical entity where nephrotic syndrome can arise as a manifestation of underlying malignancies, particularly solid tumors. Membranous nephropathy is notably associated with such malignancies, highlighting the intricate relationship between nephrotic syndrome and cancer. The present study reports the case of a 44-year-old Caucasian male, smoker (22 pack-years) and chronic ethanol consumer who presented in the Emergency County Hospital of Craiova in March 2018 with abdominal distension, genital and leg edema and no prior medical history. Laboratory tests revealed inflammatory syndrome (erythrocyte sedimentation rate=110 mm/h, fibrinogen, 150 mg/dl, high levels of C reactive protein=6.87 mg/dl), as well as hypoproteinemia (total protein levels=3.90 g/l), hypertriglyceridemia=213 mg/dl, hypercholesterolemia=475 mg/dl, total urinary protein excretion of 12,500 mg/24 h and normal levels of urea (38 mg/dl) and creatinine (0.90 mg/dl). After meeting the diagnostic criteria for nephrotic syndrome (edema, proteinuria, hypoalbuminemia, and hyperlipidemia, it was investigated whether the syndrome was primary or secondary in origin. Notably, an unexplained inflammatory syndrome in conjunction with elevated tumor marker levels (carbohydrate antigen 19-9, 82.47 U/ml; Carcinoembryonic antigen-CEA=9.46 ng/ml) prompted a thorough imagistic investigation, using computer tomography. A polyp was discovered during colonoscopy, prompting a biopsy. The presence of adenocarcinoma was confirmed by histopathological analysis. The only clinical manifestation of the colonic malignancy was the symptomatic presentation of nephrotic syndrome, which led to early detection of the underlying cancer. Paraneoplastic nephropathy connects kidney disease with systemic cancer, showing that renal symptoms may aid in diagnosing hidden malignancies. Nephrotic syndrome, especially membranous nephropathy, is associated with various solid tumors. The present case demonstrated that paraneoplastic syndrome, though rare, may lead to early cancer detection. Ongoing research is essential for improving understanding, targeted therapy and patient management.

Autoimmune disorders and paraneoplastic syndromes in thymoma

Thymomas are counted among the rare tumour entities which are associated with autoimmune disorders (AIDs) and paraneoplastic syndromes (PNS) far more often than other malignancies. Through its complex immunological function in the context of the selection and maturation of T cells, the thymus is at the same time highly susceptible to disruptive factors caused by the development and growth of thymic tumours. These T cells, which are thought to develop to competent immune cells in the thymus, can instead adopt autoreactive behaviour due to the uncontrolled interplay of thymomas and become the trigger for AID or PNS affecting numerous organs and tissues within the human body. While myasthenia gravis is the most prevalent PNS in thymoma, numerous others have been described, be they related to neurological, cardiovascular, gastrointestinal, haematological, dermatological, endocrine or systemic disorders. This review article sheds light on the pathophysiology, epidemiology, specific clinical features and therapeutic options of the various forms as well as courses and outcomes of AID/PNS in association with thymomas. Whenever suitable and backed by the limited available evidence, the perspectives from both the thymoma and the affected organ/tissue will be highlighted. Specific issues addressed are the prognostic significance of thymectomy on myasthenia gravis and other thymoma-associated AID/PND and further the impact and safety of immunotherapies on AID and PND relating to thymomas.

A systematic review of paraneoplastic syndromes associated with thymoma: Treatment modalities, recurrence, and outcomes in resected cases

OBJECTIVE

Paraneoplastic syndromes associated with thymomas remain incompletely understood. The objective was to examine the association between surgically resected thymomas and paraneoplastic syndromes over the past half century.

METHODS

A primary PubMed/MEDLINE search was used to identify published articles describing paraneoplastic syndromes associated with thymomas from 1960 to 2019. A secondary search identified additional articles referenced in the articles found in the primary search. Kaplan-Meier and log-rank test were used for time-to-event data analyses.

RESULTS

From 407 articles describing 507 patients, 123 different paraneoplastic syndromes were associated with thymoma. The 5 most common paraneoplastic syndromes were myasthenia gravis, pure red cell aplasia, lichen planus, Good syndrome, and limbic encephalitis. Complete or partial resolution of paraneoplastic syndrome symptoms after surgery was noted in 76% of patients, of whom 21% had a relapse or new paraneoplastic syndrome onset after surgery. The most common adjunctive therapy associated with resolution of paraneoplastic syndrome was corticosteroids (30%). For all patients after surgery, thymoma recurrence was observed in 17% of cases, whereas recurrence of paraneoplastic syndrome was observed in 34% of cases, and both were observed in approximately 11% of cases. The 5- and 10-year overall survivals were 78% and 66%, respectively. Improved overall survival was associated with patients who had total resolution from paraneoplastic syndrome.

CONCLUSIONS

A comprehensive assessment of publications over the past half century suggests that a multimodal treatment approach that includes surgical resection of thymomas is able to achieve paraneoplastic syndrome resolution in a majority of patients. Onset of new paraneoplastic syndromes after surgery is associated with the recurrence of the first paraneoplastic syndrome, and resolution of paraneoplastic syndrome is associated with improved overall survival.

Secondary membranous nephropathy in a patient with myasthenia gravis without thymic disease, and partial remission induced by adrenocorticotropic hormone therapy

Membranous glomerulonephritis is the most common glomerular disease in adults. Its primary form has been characterized with formation of phospholipase A2 receptor antibodies. Malignancy, infections, and autoimmune disorders are the most common causes of secondary membranous glomerulonephritis. We present a case of a 55-year-old African American female who presented with nephrotic range proteinuria and diagnosed with secondary membranous glomerulonephritis based on distinct pathological features on kidney biopsy and absence of serum phospholipase A2 receptor antibodies. She initially underwent extensive workup for malignancies, infections, and common autoimmune disorders which were all negative. Her proteinuria remained resistant to steroid treatment and she was treated with subcutaneous adrenocorticotropic hormone injections. Meanwhile, she was also diagnosed with the anti-muscle specific kinase antibody variant of myasthenia gravis. In literature, there are few case reports of myasthenia gravis as a cause of secondary membranous glomerulonephritis. In our case, the lack of other inciting factors also suggested this association.