Abstract: SA-PO223
Myeloma-Like Cast Nephropathy in a Patient with Pancreatic Mixed Acinar-Neuroendocrine Cancer
Session Information
- Trainee Case Reports - V
October 27, 2018 | Location: Exhibit Hall, San Diego Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Trainee Case Reports
- 1502 Pathology and Lab Medicine: Clinical
Authors
- Zhang, Haiyan, The University of Texas Health Science Center, Houston, Texas, United States
- Mamlouk, Omar, University of Texas Health Science Center at Houston, Houston, Texas, United States
- Bhattarai, Manoj, The University of Texas Health at San Antonio, San Antonio, Texas, United States
- Lahoti, Amit, M D Anderson Cancer Center, Houston, Texas, United States
- Workeneh, Biruh, MD Anderson Cancer Center, Houston, Texas, United States
- Glass, William F., University of Texas – Houston Medical School, Houston, Texas, United States
Introduction
Myeloma cast nephropathy is a very serious diagnosis, which triggers immediate work-up for multiple myeloma and aggressive chemotherapy. However, there are rare renal conditions with morphological features similar to myeloma cast nephropathy but without evidence of plasma cell dyscrasia or monoclonal gammopathy. “Myeloma”-like casts result from precipitation of abnormal proteins along with Tamm Horsfall glycoprotein in distal tubules and collecting ducts leading to an inflammatory response with giant cells and acute kidney injury. Myeloma-like casts have been reported occasionally in patients with pancreatic adenocarcinoma, thyroid cancer, HIV, antibiotic and cisplatin use. We present here a case of myeloma-like cast nephropathy in a patient with pancreatic mixed acinar-neuroendocrine cancer (MANEC).
Case Description
The patient was a 60-year old male undergoing chemotherapy for biopsy-confirmed pancreatic MANEC with metastasis to liver. He presented with acute kidney injury (AKI) and mild proteinuria without hematuria or pyuria. Ultrasound showed normal renal size and echogenicity with no signs of obstruction. The kidney biopsy was obtained due to AKI with no clear etiology. The biopsy showed diffuse acute tubular epithelial injury with focal tubular obstruction by casts that varied in size. Some casts appear crumbled or moth-eaten. Focal casts were also associated with an inflammatory reaction that included neutrophils and/or syncytial multinucleated giant cells. No monoconal paraprotein detected in the biopsy, serum or urine. HIV screening test was negative and patient had no history of cisplatin use.
Discussion
Pancreatic MANEC is very rare. Myeloma-like cast nephropathy associated with pancreatic neoplasia is even rarer and has been seen only with adenocarcinomas. Thus, in this case, the myeloma-like cast are more likely associated with the exocrine component (acinar carcinoma), which produces excessive proteins obstructing the distal tubules, and cause tubular epithelial injury and inflammation with multinucleated giant cells. To our knowledge, this is the first report of myeloma-like cast nephropathy associated with neuroendocrine neoplasms. Because of the significant clinical associations and treatment differences, it is critical not to misdiagnosis this entity as myeloma cast nephropathy.