Esophageal Cancer Case Study

FSHN 450 MNT

11/19/15

Jonathan Jeffrey

“I have not given, used, or received any unauthorized assistance on this assignment.”

Esophageal Cancer Treated with Surgery and Radiation

FSHN 450

Fall 2015

Nick S. is a 58 year old male seeking medical attention for recurrent heartburn of 1 year duration. He presented with difficulty swallowing for past 4 – 5 months and unexplained weight loss

Education: College degree

Occupation: Contractor

Social Hx: Married, wife age 52, son age 17 in high school, daughter 19 away at college. Smokes 20 cigarettes/day for past 40 years. Drinks 2 beers per day.

Medical Hx: States that “food gets stuck in throat”. Takes TUMS and Pepcid consistently for the past year. Wt loss of 30 pounds past 3 – 4 months. Patient states he has been unable to eat because of heartburn and difficulty swallowing, especially anything with course or crunchy texture.

Physical Exam: thin, pale white male. Temp 98.3, BP 132/90, HR 88 bpm, RR 13 bpm, Ht: 6’3” UBW: 220 # CBW: 190 #

HEENT: eyes sunken, sclera clear, dry mucous membranes

Skin: warm, dry

Chest/lungs: cleat to auscultation and percussion

Abdomen: epigastric tenderness

Nutrition Hx:

Appetite general poor PTA. Regurgitation of some foods, reports pain upon swallowing

Usual Dietary Intake:

AM: eggs, toast, coffee with 2 tsp sugar (but no longer drinks coffee with heartburn)

Lunch: cold sandwich packed for worksite (3 oz meat, two slices white bread). Lately c/o bread sticks in the throat – 24 hour recall notes only tomato soup and 4 crackers

Dinner: Generally eats all meats, vegetables, potato or rice but 24 hour recall notes only baked macaroni and cheese and 1 scoop vanilla ice cream

Evening: Two beers (but has contributed to heartburn so has mostly cut out beer lately)

Food purchased and prepared by wife.

Food allergies: NKA

Dx: Diagnosis following X-ray, endoscopy and biopsy – Stage II (T1,N1,M0) adenocarcinoma of the esophagus

See admission laboratory report (attached)

Tx Plan: Transhiatal esophageal esophagectomy. Jejunal tube placed for later feeding. Radiation planned post-operatively.

Rx: NPO with TPN post-operatively progressing to tube feeding as tolerated.

Case report:

Answer the following questions.

1. What does the term adenocarcinoma mean?

Adenocarcinoma refers to cancer of glandular tissue, specifically affecting the epithelium, and may occur in many different organs or areas of the body.

2. What are the two most common risk factors for esophageal cancer? Does the patient have these risk factors?

Two major risk factors for esophageal cancer are alcohol consumption and cigarette smoking. Both of which, our patient engages in. When done in combination, the risk becomes much greater.

3. The patient’s stage was TII. What is the meaning of the terms T1, N1, M0?

T, N, and M are cancer staging terminology abbreviations. T stands for tumor, N stands for Nodes, and M stands for metastases. T1 means an initial tumor is present 1 represents the size and extent of the tumor, N measures the degree of lymph node involvement based on number of nodes and location. N1 means the cancer has reached some distant lymph nodes. M0 means it has not metastasized to any distant tissues

4. Why is cancer therapy multi-modality?

Cancer treatment is multimodal because involving a combination of regimens reduces the amount of side effects, decreases tumor resistance, each modality attacks the cancer at a different stage of cell differentiation, and is all around more effective. Some methods involved include chemotherapy, radiation, surgery, and bio/immunotherapy.

5. Evaluate the patient’s usual body weight and current body weight and risk factors for malnutrition.

This patient has lost 13.6% of his usual body weight, unintentionally in 3-4 months. (220-190=30), (30/220= 13.6%). This is very concerning considering the standard for risky unintentional wt. loss is 10% of bodyweight in 6 months or less. Also considering he is suffering from esophageal pain, and is eating considerably less calories per day than

usual definitely puts him at risk for malnutrition. Additionally, the calories he is eating to compensate for the pain are coming from foods with less calories and nutrients that are easy-to-eat foods ie. Tomato soup and crackers for lunch instead of a sandwich with bread, and meat, and mac and cheese and ice cream for dinner instead of meat, potatoes and veggies.

6. Assess the patients Kcal and protein needs for TPN. You do not need to calculate a TPN but suggest a protein sources and % Kcal from protein, fat and glucose.

The suggestion for most cancer patients with malnourishment is 30-35 kcal/kg bodyweight. I would start this patient off with 30 kcal/kg which would equate to 86kg x 30kcal = 2,591 kcal/day. I would start with 30kcal/ day to not risk overfeeding the patient and possibly causing metabolic stress, then evaluate whether or not it’s enough and adjust accordingly. For cancer patients, the recommendation for protein is 1.0-1.5 g/kg for most or 1.5-2.0 g/kg for depleted patients. Considering our patient recently lost 30lbs, I would start with 1.5g/kg protein, so 129 g/day, 516kcal or 19.9% of calories. I would get the protein from freamine, I would use 30% of calories from fat, so 777.3kcal/day or 86g for fat and the remaining 50% I would get from glucose; 323.8 g/day or 1295kcal.

7. Describe how you will transition the patient from TPN to tube feeding. Suggest a product that you will use for tube feeding that will meet the need of this patient a) in the post-operative period and 2) long term.

I would transition the patient off of the TPN and onto the enteral nutrition support by weaning them off the TPN and adding in the enteral nutrition to avoid any sort of shock to their body or aggressive changes in nutrient absorption. One product I found for EN that seemed like it would be good for this patient was Jevity 1.2 Cal by Abbot, as it is high protein (18.5% of total calories from protein), which is close to what I prescribed for TPN, and it is ideal for malnourished patients which this patient is at risk for. In the long term, the patient could probably switch to a standard adult EN product like Ensure or Boost, once he begins to maintain his weight and recover.

8. Describe the volume and method of administration of the TF you selected for a) post-operative recovery in the hospital and b) TF you selected for home (long term).

Since the product I chose for this patient is 1.2 kcal/ml, I would use 2160ml/day which is 2,592 kcal/day, or 30kcal/kg for this patient. For standard boost, the caloric content is 1.0 kcal/ml so I would recommend 2591 ml/day.

9. Compare fluid requirements to the amount of fluid provided in each tube feeding. How will you make up the difference?

Adults require 30 ml of fluids per kg bodyweight, so this patient would require at least 2591 ml of fluids per day. Boost is 85% water, so the patient would be receiving 2,202 ml of fluid per day from the boost. This would require and additional 389ml of fluid you could add to the tube feeding, divided by the number of feedings per day. I would just use water for this.

10. Write a PES statement for the patients discharge plan including goals and follow –up (list at least four factors you should monitor)

Inadequate energy intake r/t excessive unintentional weight loss aeb dietary recall and daily activity.

Goals:

- Patient should begin to regain weight or maintain current weight without losing any more.

-Patient should maintain adequate caloric intake/ hydration through tube feeding as instructed.

Factors to monitor

1. Is patient getting enough calories/fluids through tube feeding?2. Is the patient maintaining weight or making healthy gains in weight?3. Have patient return for follow up visit and look at lab values to make sure they don’t

have any deficiencies 4. Is the patient feeling better do they have energy for daily activities?

11. The patient will receive outpatient radiation therapy following D/C. List additional nutritional complications that may occur.

When receiving radiation treatment, patients may experience acute nausea and vomiting, abdominal bloating, diarrhea, malabsorption, ulcers, obstruction, esophagitis, stomatitis, xerostomia, dysgeusia, dysomia, odynophagia, and dysphagia.