Thyroid Cancer: A Case Study Report

Elizabeth Mellott

Sodexo Dietetic Intern 2012

Introduction:

The patient I chose to study was diagnosed with an unusual squamos cell carcinoma of

the thyroid, and was receiving nutrition support through a percutaneous endoscopic gastrostomy

(PEG) tube while she underwent chemotherapy and radiation therapy. I chose this patient

because she was unique in that she had a very rare type of thyroid carcinoma that was being

aggressively treated, and she also had a feeding tube. I met the patient during one of my clinical

choice days in outpatient oncology when she was receiving her radiation therapy treatments, and

at my main hospital site during my staff relief rotation. It was beneficial for me to see her and

learn more about her case in both the inpatient and outpatient settings.

She was admitted to the hospital due to dehydration and nausea after a recent

chemotherapy treatment. I admired this patient because she was her own best advocate in terms

of making sure that she was receiving adequate nutrition, and she was very positive in spite of

her diagnosis. I definitely enjoyed working with this patient because she was different than a

nursing home or vent patient on a tube feeding. I was actually able to converse with the patient

instead of a doctor or a nurse about her tube feeding, and she was very receptive to the education.

I am interested in head and neck cancer patients because of the impact of that particular type of

cancer on nutrition status. Thyroid cancer is similar to neck cancers because of the location of

the gland, but there are also differences in the way it is treated and diagnosed that I wanted to

learn about.

By choosing this patient, I hoped to learn more about various thyroid diseases and

conditions and their treatments. Many patients I had assessed in other rotations had a history of

hypothyroidism or hyperthyroidism, and I wanted to learn more about these conditions because

they seemed to be so common. I am also interested in nutrition support, and wanted to know

what the perceived benefits and risks were for using it with head and neck cancer patients. There

is also so much to be learned about cancer and its treatment, because it encompasses such a large

class of diseases.

Abstract:

The thyroid is an endocrine gland that synthesizes hormones using iodine from the blood.

Secretion of these hormones helps to regulate metabolism, body temperature, heart rate, blood

calcium concentration, and normal growth and development. Thyroid cancer (including most

thyroid diseases) occurs 3 times more often in women than in men, and can occur at any age. The

National Cancer Institute at the National Institutes of Health estimates that there will be 56,460

new cases of thyroid cancer and 1,780 deaths from thyroid cancer in the United States in 2012.

Thyroid cancer may be treated with surgery, radioactive iodine treatments, radiation,

chemotherapy or a combination of 2 or more treatments depending on the stage, grade, and type

of cancer. The registered dietitian (RD) can play a great role in the life of the cancer patient by

lending emotional support, as well as helping the patient to maintain their nutritional status

despite the limitations to achieving adequate intake due to treatment side effects.

Discussion:

The thyroid is an endocrine gland that lies over the trachea just below the larynx. The

butterfly shaped organ consists of 2 lobes connected by a thin strip called an isthmus.1 It is the

first of the body’s endocrine glands to develop on approximately the twenty-fourth day of

gestation, and is deep red in color due to its extensive blood supply.2,3

Functions of the thyroid

gland include regulation of cell metabolism, body temperature, heart rate, blood calcium

concentration, and normal growth and development.4 The 2 thyroid hormones secreted by the

follicular cells of the thyroid gland are iodine-containing hormones derived from the amino acid

tyrosine. They are named thyroxine (T4 or tetraiodothyronine) and triiodothyrone (T3). The

subscripts 4 and 3 denote the number of iodine atoms incorporated into each of these

hormones.3(p553)

The thyroid takes iodine out of the blood to synthesize these hormones. T4

accounts for roughly 90% of all thyroid secretions, but T3 is more potent.2(p342)

T4 can be

converted to T3 in the anterior pituitary gland, the liver, and the kidneys. 3(p553)

The thyroid gland

contains numerous thyroid follicle cavities where these hormones are stored until the thyroid is

stimulated to secrete them. 2(p342)

Both of these hormones increase cell metabolism when they bind to receptor sites on the

mitochondrion and nuclei of cells. The rate of adenosine triphosphate (ATP) production is

increased when thyroid hormones bind to receptor sites on the mitochondrion. When thyroid

hormones bind to receptor sites in the nuclei of cells, gene coding for the synthesis of enzymes

involved in glycolysis and energy production are activated. This results in an increase in cellular

rates of metabolism and oxygen consumption. 2(p342)

The anterior pituitary gland secretes thyroid

stimulating hormone (TSH) or thyrotropin to stimulate the thyroid to release T3 and T4. TSH is

released in response to thyrotropin-releasing hormone from the hypothalamus.2(p338)

When TSH

is released, the epithelial cells remove hormones from the follicle cavities of the thyroid and

secrete them into the bloodstream. Many thyroid hormones become attached to plasma proteins

in the bloodstream, and are not able to diffuse into the target cells of body tissues. The small

percentage of hormones that are unbound in the blood are able to diffuse into target tissues, and

as the concentration of these unbound hormones decreases, the plasma proteins release additional

bound hormones to allow them to be able to be absorbed.2(p342)

The blood stream normally contains a week’s supply of thyroid hormones. 2(p342)

The

cellular response to increased thyroid hormone secretion may not become apparent immediately.

Thyroid hormones are not rapidly degraded, and the body’s response to their increased secretion

continues to be expressed over a period of days or even weeks after plasma thyroid hormone

concentrations return to normal.3(p533)

When they thyroid secretes too much thyroid hormone, the

condition is called hyperthyroidism and is characterized by symptoms such as rapid or irregular

heartbeat, weight loss, hunger, insomnia, and elevated body temperature. Hyperthyroidism is

most commonly caused by an autoimmune disorder called Graves’ disease (60% to 80% of

cases). An antibody targets TSH receptors on follicular cells and stimulates secretion of thyroid

hormones despite elevated T3 and T4 blood levels. Hyperthyroidism may be treated with

radioactive iodine and antithyroid drugs such as methimazole and propylthiouracil. If these

treatments are unsuccessful, a subtotal thyroidectomy may be performed. If most of the thyroid is

removed it is called a subtotal thyroidectomy. 3(p568)

Decreased production and secretion of thyroid hormones results in a condition called

hypothyroidism. Symptoms include weight gain, fatigue, and bradycardia. Hypothyroidism is

found in 4.6% of the population in the United States, and is most prevalent in the elderly

population. Hypothyroidism in infants is known as cretinism. Hashimoto’s disease, an

autoimmune disorder, results in inflammation of the thyroid when the immune system attacks the

thyroid gland. Also known as chronic lymphocytic thyroiditis, Hashimoto’s disease can lead to

hypothyroidism. Hypothyroidism can cause increased blood levels of total cholesterol and low-

density lipoprotein (LDL) cholesterol, as well as increased insulin resistance. Patients with

hypothyroidism or hyperthyroidism do not need to follow a special diet, but they should be

monitored for drug-nutrient interactions related to any medications they receive. However, if

iodine deficiency is the cause of hypothyroidism, it should be corrected with adequate intake of

dietary iodine.3(p564)

The parafollicular cells or the C cells of the thyroid secrete calcitonin. Calcitonin

regulates the amount of calcium in the bloodstream. When the calcium ion concentration in the

blood is above normal, the C cells release calcitonin. Calcitonin inhibits osteoclasts (cells that

break down bone and promote bone resorption) and stimulates calcium excretion at the

kidneys.2(p343)

The parathyroid glands are four small glands located on the posterior surface of

the thyroid gland in the neck. The chief cells secrete parathyroid hormone (PTH) or

parathormone when blood calcium levels are low. PTH stimulates osteoclasts, inhibits

osteoblasts (bone building cells), and reduces the urinary excretion of calcium ions. PTH also

stimulates the kidneys to form and secrete the main active form of vitamin D called calcitriol

(1,25-[OH]2 D3). Calcitriol enhances the absorption of calcium and phosphorus by the digestive

tract.2(p344)

The National Cancer Institute at the National Institutes of Health estimates that there will

be 56,460 new cases of thyroid cancer and 1,780 deaths from thyroid cancer in the United States

in 2012.5 Cancer is defined as a class of diseases characterized by uncontrolled cell division and

the ability of these cells to invade other tissues either by direct growth into adjacent tissue

(invasion) or by migration of cells to distant sites through the bloodstream or lymph vessels

(metastasis). These uncontrolled dividing cells contain deoxyribonucleic acid (DNA) that has

been damaged. Damaged DNA may be inherited, or it can be damaged during normal cell

division due to exposure to a carcinogen such as radiation or tobacco. Cancer cell development

occurs in several stages. Initiation is the first stage in cancer development. During initiation, the

healthy cells are exposed to a carcinogen which predisposes the cells to genetic mutation. Next,

promotion occurs when the process of the development of abnormal cells is enhanced. These

abnormal cells are allowed to continue to develop due to a failure of natural cellular repair

mechanisms. Progression, or the third phase in cancer cell development, happens when the

preneoplastic lesion is transformed into a tumor that has the ability to spread to other parts of the

body.6

Many types of tumors or nodules can develop in the thyroid gland. Sometimes the nodule

or tumor is large enough that it can be felt or seen by a patient or physician during a physical

examination. Fewer than 1 in 10 adults have thyroid nodules that can be felt by a physician. Most

thyroid nodules are benign (lack the ability to metastasize), however benign tumors may need to

be removed if they grow too large and press on other organs and tissues. About 1 in 20 thyroid

nodules is cancerous (malignant), and some nodules may even secrete too much thyroid hormone

and result in hyperthyroidism. Thyroid nodules occur most commonly in older adults. A thyroid

ultrasound (US) study can be used to find thyroid nodules that cannot be seen or felt. The US

uses high-frequency sound waves to create an image of the thyroid. Nodules may be solid or

fluid-filled, and solid nodules are more likely to be malignant. Signs and symptoms of thyroid

cancer can include lump or swelling in the neck, pain in the front of the neck, sometimes going

up to the ears, hoarseness or voice changes that do not go away, dysphagia, difficulty breathing,

and a frequent cough not related to a cold.7

Thyroid cancers (including most thyroid diseases) occur 3 times more often in women

than men, and can occur at any age. However, risk of thyroid cancer peaks earlier for women

(who are most often in their forties and fifties when diagnosed) than for men (who are usually in

their sixties and seventies). Eighty percent of newly diagnosed thyroid cancer patients are under

the age of 65. Exposure to radiation is a risk factor for thyroid cancer. Having head and neck

radiation exposure during childhood especially increases the risk. Being exposed to radiation as

an adult carries much less risk of developing thyroid cancer. A family history of thyroid cancer is

also a risk factor for thyroid cancer. Follicular thyroid cancers are more common in parts of the

world where people’s diets are low in iodine.7 This is seldom a problem in the United States

because the typical American diet provides roughly more than 3 times the minimum daily

requirement (the recommended dietary allowance of iodine is 150µg per day for adults) of

iodine, thanks to the addition of iodine to table salt since the 1920s.2(p343),5

One teaspoon of

iodized salt contains approximately 400 μg iodine. A diet low in iodine can also lead to the

formation of what is called a goiter (abnormally large thyroid gland).7

Cancers are always named for the area of the body in which they originated. Sarcomas

are malignant tumors that are derived from the middle layer of the embryo which becomes

connective tissue (bones, muscle, cartilage, blood vessels, and fat). Carcinomas are derived from

the outer and inner layers of the embryo that develop into epithelial tissue that either covers or

lines the surface of the body. Eighty to ninety percent of malignant tumors are carcinomas. If the

cancer started in an organ or gland, it is considered an adenocarcinoma. If the carcinoma was

derived from squamos epithelium, it is considered squamos cell carcinoma.4(p601)

Squamos cell

carcinoma of the thyroid is an uncommon malignancy because squamos epithelium is not

normally present in the thyroid gland. It accounts for no more than one percent of all thyroid

malignancies, and has a very poor prognosis. The etiology of squamos cell carcinoma in the

thyroid gland is unclear, but there are several hypotheses that have been made to try to explain

why intrathyroid squamos cells are present.9

The embryonic nest theory suggests that present remnants of the thyroglossal duct,

thymic epithelium, or ultimobranchial body contain squamos cells. The C cells of the thyroid

gland originate from the ultimobranchial body during development in embryo. The thyroglossal

duct connects the tongue and thyroid during the development of the thyroid in embryo, and later

solidifies and subsequently obliterates entirely sometime during the seventh through tenth week of

gestation. However, remnants of the thyroglossal duct may be present in some individuals, and if

the duct fails to obliterate itself, a thyroglossal duct cyst can develop. The metaplasia theory

suggests that inflammation, such as that which occurs in Hashimoto’s disease, results in squamos

metaplasia. Metaplasia is defined as the transformation of one type of one mature differentiated

cell type into another mature differentiated cell type. Lastly, the de-differentiation theory

suggests that suggests that existing papillary, follicular, medullary and anaplastic thyroid

carcinomas can de-differentiate into a squamos cell carcinoma.9

Papillary carcinoma is the most common type of thyroid cancer and is responsible for 8

out of 10 cases of thyroid cancer. This type of cancer begins in the follicular cells, and grows

slowly, but may spread to lymph nodes in the neck. If diagnosed early, most people with

papillary carcinoma can be successfully treated and cured. Follicular carcinoma is the second

most common type of thyroid cancer accounting for approximately 1 in 10 cases of thyroid

cancer. It grows slowly, and does not usually spread to the lymph nodes, but may spread to the

lungs or bones. Follicular carcinoma is usually successfully treated if caught early.7

Medullary thyroid cancer (MTC) is not common. It usually occurs in 2 of every 100

cases, and develops in the C cells of the thyroid. These cancers usually release calcitonin and

carcinoembryonic antigen (CEA) into the blood, causing high levels of these when checked by

blood tests. Two out of 10 cases of MTC are genetically inherited, and can occur in each

generation of a family.7 A change in a gene called RET can be passed from parent to child.

Nearly everyone with a changed RET gene develops medullary thyroid cancer. A doctor may

recommend surgery to remove the thyroid before cancer develops if a blood test shows that a

patient has a changed RET gene.5 The least common type of thyroid cancer is anaplastic. About 1

of every 100 people with thyroid cancer has this type. It tends to grow and spread very quickly

and is very hard to control.7 Squamos cell carcinoma of the thyroid behaves clinically like

anaplastic carcinoma.9 Cancers of the parathyroid glands are very rare (less than 100 cases each

year in the United States), and cause blood calcium to be elevated. Parathyroid cancer is much

harder to cure than thyroid cancer.7

Thyroid cancer may be diagnosed using a physical exam, US, nuclear medicine

(radionuclide) thyroid scan, or fine needle aspiration (FNA) biopsy. During the thyroid scan, the

patient is administered radioactive iodine. Several hours later, a camera is placed in front of the

neck to measure the amount of radiation in the gland.7 Nodules that take up more of the

radioactive substance than the thyroid tissue around them are called “hot” nodules, and nodules

that take up less radioactive substance than the thyroid tissue around them are called “cold”

nodules. “Hot” nodules are usually not cancerous, but “cold” nodules may be benign or

cancerous.5 No blood tests can tell if a thyroid nodule is cancerous, but blood tests measuring the

levels of TSH, T3 and T4 may be done to see of the nodule is affecting the secretion of thyroid

hormones.7

Cancerous nodules are actually diagnosed by viewing a biopsy or a small sample of cells

from the nodule under a microscope. Before the procedure, the patient will be given a local

anesthetic to numb the area. The doctor taking the FNA biopsy may then use an US to guide the

placement of a small needle used to gather several tissue samples for examination. The

procedure may need to be repeated if the sample does not contain enough cells. If a diagnosis

cannot be made from an FNA biopsy, a surgeon may need to remove a lobe or the entire thyroid

especially if the nodule is thought to be cancerous. Cancer is clearly diagnosed in only about one

of every twenty FNA biopsies. About seven of ten FNA biopsies will show the nodule is benign.

Other tests including computed tomography (CT) scan, chest x-ray, whole-body radioiodine

scan, and positron emission tomography (PET) scan can be done to detect a possible spread of

cancer throughout the body. Tumors that invade or extend beyond the thyroid capsule have a

much worse prognosis because of a high local recurrence rate.7

Determining the size and spread of the tumor or pathologic staging is helpful for

physicians to determine the most effective treatment. The Tumor Node Metastases (TNM)

Staging System was developed by the American Joint Committee on Cancer. The T category

describes the original or primary tumor, and the numbers T1-T4 describe the size and/or level of

the tumor’s invasion into nearby structures. The higher the T number, the larger the size of the

tumor and/or the further it may have grown into nearby tissues. The N category describes

whether or not the cancer has spread to nearby lymph nodes. N0 means the nearby lymph nodes

do not contain cancer. NX means the lymph nodes could not be measured or found. The numbers

N1-N3 describe the size, location, and /or the number of lymph nodes involved. The higher the T

number, the more involved the lymph nodes are. The M category tells whether or not the cancer

has metastasized to other parts of the body. M1 means distant metastases are present, M0 means

there are no distant metastases, and MX means metastasis cannot be measure or found. As a

measure of their severity, cancers may also be graded depending on how much the cancer cells

appear different from their original form. Normal healthy cells are well differentiated, and cancer

cells are poorly differentiated. The higher the grade of the cancer (may be Grade I through IV),

the more cancerous or dedifferentiated is the tissue sample.4(p602)

Treatment options for people with thyroid cancer include thyroidectomy, lobectomy,

radioactive iodine therapy, external beam radiation therapy, and chemotherapy. Most thyroid

cancer patients are treated with a combination of these treatment options.7 The better survival

rates for squamos cell carcinoma of the thyroid have been achieved with aggressive combination

therapy (surgery followed by adjuvant radiation therapy with or without chemotherapy or

induction chemotherapy followed by surgery).10 If the cancer cannot be cured, then the treatment

goal would be to remove and destroy as much of the tumor as possible to prevent it from

spreading. Sometimes treatments are aimed at palliation to help relieve pain and trouble with

breathing and swallowing. Thyroidectomy is the most common surgery for thyroid cancer. If the

entire thyroid is removed, it is called a total thyroidectomy. If the cancer has spread to nearby

lymph nodes, they will be removed as well. Lymph nodes may also be removed to test for

cancer. After a thyroidectomy, the patient will have to take synthetic thyroid hormone

(levothyroxine) for the rest of their life. The synthetic form contains only T4. If a patient has only

a lobectomy, they may not need to take thyroid hormone because part of the thyroid is left

behind to synthesize hormones.7

Radioactive iodine (RAI) may be administered in a capsule or liquid form in combination

with surgery to ensure that all of the cancer cells are destroyed. Before receiving RAI, the patient

will need to follow a low iodine diet (<50 µg of iodine per day) for 1 to 2 weeks. Following a

low iodine diet helps to deplete the body of its stores of iodine, and increase the effectiveness of

RAI treatment. The iodine uptake of the thyroid cells will be increased because the body has

been depleted of iodine for 1 to 2 weeks. When the thyroid cancer cells absorb enough of the

RAI (I-131), they are destroyed along with any remaining cancer cells throughout the body.

Patients are instructed to avoid foods with more than 20 µg of iodine per serving. Foods high in

iodine that should be avoided prior to RAI treatment include saltwater fish, seaweed, dairy

products including milk, cheese, and yogurt, egg-yolks, soy products, chocolate, ice cream,

iodized table salt, and iodine-containing multivitamins. Patients will give off radiation for some

time after their RAI treatment, and may have to remain in isolation and take extra precautions for

a few days depending on the dose of RAI they received. Any RAI that is not absorbed by the

thyroid is excreted in urine, feces, sweat, and saliva. RAI may cause a patient to experience

nausea, taste changes, dry mouth, neck tenderness, and swelling and tenderness of salivary

glands.5

External beam radiation therapy is mostly used for cancers that cannot be treated with

RAI (most differentiated thyroid cancers). A large machine directs high-energy x-rays, gamma

rays, or charged particles at the neck to kill cancer cells by destroying their DNA. The amount of

radiation used in radiation therapy is measured using a unit known as a gray. Intensity Modulated

Radiation Therapy (IMRT) allows for the radiation dose to conform more precisely to the three-

dimensional (3-D) shape of the tumor. A CT scan or magnetic resonance image (MRI) of the

patient along with computerized radiation dose calculations are used to plan the dose intensity

pattern that will best conform to the tumor’s shape. Radiation therapy treatments typically only

last a few minutes, and are usually given 5 days a week for approximately 6 weeks. The

treatment itself is painless, but it can cause sore throat, dysphagia, and fatigue. The cells that are

dividing quickly such as those cells along the digestive tract are the most sensitive to the effects

of radiation. Symptoms will manifest by day ten of radiation therapy and can continue for two to

three weeks after the treatment has ended.7

Chemotherapy uses anti-cancer drugs to kill cancer cells. It is primarily used as a

treatment for medullary and anaplastic cancers. Drugs can be given by mouth, through a vein, or

injected into a muscle. Chemotherapy to treat thyroid cancer is most often given though a vein

every 3 to 4 weeks. A course of 6 treatments is typically given. The most common side effects of

chemotherapy include fatigue, mouth sores, nausea, vomiting, loss of appetite, and hair loss.

Chemotherapy also increases an individual’s chance of getting an infection due to low white

blood cell counts. Other drugs can be given to the patient to help prevent nausea and vomiting.7

Delayed chemotherapy induced nausea and vomiting (CNIV) may begin 24 hours after the

administration of chemotherapy and last up to a week after the drug is administered. Acute

nausea and vomiting can occur within 24 hours of the administration of chemotherapy. The

chemotherapy drugs most often used to treat thyroid cancer are doxorubicin and cisplatin. These

two drugs are some of the most emetogenic chemotherapeutic agents, and delayed nausea and

vomiting is most commonly seen after the administration of these drugs.6(p771)

Depending on the type, stage, and grade of thyroid cancer and chosen treatment path,

thyroid cancer patients may or may not be at risk for malnutrition. Patients with the more

common types of thyroid cancers who are having a thyroidectomy and/or RAI treatments would

not necessarily become malnourished or require nutrition support. Patients can typically return to

eating a normal diet within a few days of having a thyroidectomy. Patients receiving RAI would

need education about the types of foods they can eat while on a low iodine diet. Low iodine

foods that they would be permitted to have include fresh fruit and fruit juices (except rhubarb

and maraschino cherries), unsalted nuts and nut butters, five ounces of fresh meats (chicken,

beef, pork, lamb, veal) per day, egg whites, vegetable oil, herbs, sodas, tea, non-instant coffee,

lemonade, sugar, jelly, honey, unsalted crackers, grain and cereal products in moderate amounts,

and raw or frozen unsalted vegetables (except potato skins, soybeans, cowpeas, and lima, pinto,

navy, red kidney beans). Patients who are undergoing chemotherapy and/or radiation will more

likely need help from an RD in order to maximize caloric and nutrient intake while dealing with

side effects of these treatments.

Nausea and vomiting are two of the most common side effects that occur as a result of

oncologic therapies. Nausea and vomiting may occur as a side effect of medications,

chemotherapy, radiation, and/or delayed gastric emptying.6(p771)

Nutrition therapy

recommendations for nausea include eating small, frequent meals with bland, starchy, and ginger

containing foods, avoiding noxious odors, and drinking liquids throughout the day instead of

with meals. To aid in preventing CINV, the patient should have a small, low fat meal the

morning of the treatment, and avoid fried, greasy, and favorite foods for several days following

the treatment. If the patient vomits after eating their favorite foods or drinking supplemental

nutritional drinks, the likelihood that they will want to consume those foods or drinks again is

low. A clear liquid diet may be indicated for several days after chemotherapy if the patient is

experiencing severe vomiting, and cannot tolerate other foods or liquids. The RD should also

encourage patients to take their anti-emetic medications as prescribed by the physician.

Oral mucositis, xerostomia, and dysphagia are also common with head and neck

chemotherapy and radiation. To help moisten the mouth and increase saliva production, the RD

may recommend that patients sip water throughout the day, chew sugar-free gum or suck on hard

candies, and have very sweet or tart foods and drinks. If a patient has a sore mouth, they should

avoid spicy, salty, sour, and sharp, crunchy foods. Commercial mouthwashes often contain

alcohol which can be irritating to the mouth and should be avoided. Patients can use a mixture of

water, baking soda and salt to gently rinse their mouth several times a day. Foods can be made

easier to swallow when they are well cooked, cut up into small pieces, or moistened with gravy,

sauces, broth or yogurt. It is important that patients choose foods that are high in calories and

protein because many patients experience loss of appetite, early satiety, weight loss and fatigue

with treatment. The calories and protein in foods can be increased with the addition of nonfat

instant dry milk, cheese, nuts, seeds, dried fruit, eggs, and ice cream or frozen yogurt. If a patient

is struggling to eat, it may be beneficial to suggest a liquid or powdered meal replacement.5 Oral

nutritional supplements are effective at increasing nutritional intake and improving quality of

life, but do not necessarily reduce mortality risk in cancer patients.11

Energy, protein, and fluid requirements vary widely depending on the type of cancer

patient. Micronutrient requirements have not been established for cancer patients, but

deficiencies of vitamins and minerals can occur in cancer patients due to the effects of the tumor,

infectious processes, chemotherapy, radiation, or inadequate food intake. The use of a daily

multivitamin and mineral supplement that contains <150% of the dietary reference intakes

(DRIs) may be beneficial for patients who are undergoing chemotherapy and/or radiation

therapy, and are not able to meet the DRIs with their oral intake alone. Cancer patients should

consume adequate calories to maintain weight, and prevent treatment or disease related weight

loss. Many cancer patients experience cachexia or wasting syndrome. Cachexia is characterized

by involuntary weight loss, loss of lean body mass, fatigue, weakness, and metabolic alterations.

Hypermetabolic and stressed patients will have increased energy needs. The Harris-Benedict and

Mifflin St. Jeor equations, or kilocalories (kcals) per kilogram (Table 1) may be used to estimate

cancer patients’ energy needs. Patients may become dehydrated very easily due to diarrhea and

pain and inflammation of the mouth, throat, and esophagus. Fluid needs can usually be estimated

using 30 to 35 milliliters (mL) per kilogram.6(p770)

Head and neck cancer patients are more likely than patients with any other type of cancer

to experience nutrition deficiencies during all phases of their illness. Nutrition compromise has

been documented in between 40% and 57% of patients with head and neck cancer at the time of

diagnosis. Before beginning radiation and chemotherapy treatments, some patients may have a

prophylactic percutaneous endoscopic gastrostomy (PEG) placed in anticipation of a patient

developing dysphagia as they progress through the course of their treatments. Numerous studies

have reported varying prevalence rates for different points in time for feeding tube use in patients

undergoing combined chemoradiation therapy, with rates ranging from 4% to 18.7% before

treatment, 29.6% to 40.8% during treatment, 18% at 1 month, 40% to 45% at 3 months, 9% to

36% at 6 months, and 8% to 60% at 12 months post treatment. Lengths of time during which

patients are dependent on PEG tubes has ranged from a median of 21 weeks to 7.1 months.12

Reported benefits of feeding tube placement, including prophylactic placement, include

decreased weight loss, fewer hospitalizations for nutrition or dehydration issues, and fewer

treatment interruptions. Despite the benefits of placing feeding tubes in head and neck cancer

patients, there are also many know complications and risks including leakage at the tube site,

Table 1: Recommended Calorie and Protein Needs for Cancer Patients

Obese Patients 21-25 kcals/kg

Non-ambulatory or Sedentary Adults 25-30 kcals/kg

Patients who are Slightly Hypermetabolic,

Anabolic, or need to Gain Weight

30-35 kcals/kg

Patients who are Hypermetabolic, Severely

Stressed, or have Malabsorption

35 kcals/kg or greater as needed

Normal or Maintenance Protein Needs 0.8-1.0 g/kg

Non-Stressed Cancer Patient 1.0-1.5 g/kg

Bone Marrow or Hematopoietic Stem Cell

Transplant Patient

1.5 g/kg

Patient with Increased Protein Needs

(hypermetabolism, extreme wasting, protein-

losing enteropathy)

1.5-2.5 g/kg

Patients with Hepatic or Renal Compromise

(including elevated ammonia or blood urea

nitrogen approaching 100 mg/dL)

0.5-0.8 g/kg

infections near the tube site that require antibiotics, replacement of the tube, constipation,

diarrhea, hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, aspiration, GI bleeding,

peritonitis, tube extrusion, clogged lumen, perforation, and pain.12(p369)

A reactive nasogastric

tube (NGT) may be placed if and when required by the patient. Some research has suggested that

placement of an NGT over a PEG results in a better functional outcome with respect to

swallowing after treatment.13

In numerous studies, the average duration of enteral feeding has

been significantly longer in patients with a PEG than those with an NGT.14

Extended enteral

feeding dependence can decondition the muscles involved in swallowing, and make the process

of recovering swallowing function even longer and more difficult. The RD should actively

encourage swallowing rehabilitation and discontinuation of enteral feeding as early as possible to

avoid permanent dependence on enteral nutrition. Patients should also be encouraged to continue

to swallow small amounts of food and liquid to help preserve their swallowing function while

they are using enteral nutrition support. 13(p982)

The American Institute for Cancer Research recommends that cancer survivors follow the

recommendations for cancer prevention to reduce their risk of heart disease, diabetes, and cancer

recurrence. These recommendations include limiting consumption of salty foods, red meats

(beef, pork, and lamb), and energy dense foods. Patients should be physically active for at least

30 minutes a day and consume a variety fruits, vegetables, whole grains, and plant proteins such

as legumes. Alcoholic drinks should be limited to 1 drink per day for women and 2 drinks a day

for men. Sugary drinks including soda and juice drinks and processed meats like salami, hot

dogs, ham, and bacon should be avoided. Patients should work towards maintaining a healthy

weight.15

Presentation and Discussion of Patient:

Mrs. Mary Smith* was admitted to Holy Spirit Hospital with multiple diagnoses

including dehydration, acute renal failure, and hypokalemia. The patient was a 68 year old

Caucasian postmenopausal female with a past medical history of chronic obstructive pulmonary

disease (COPD), hypertension, nephrolithiasis, autoimmune hepatitis, hypothyroidism,

hyperthyroidism, and dyslipidemia. Her family medical history was negative for diabetes,

hypertension, coronary disease, and head and neck cancers. Her father had prostate cancer, and

her sister had breast cancer. Her past surgical history included a cholecystectomy, breast

reduction surgery, and surgery for the removal of nasal polyps. Mary’s allergies included

adhesive tape, sulfa drugs, and Depo-Medrol. She denied any use of tobacco, alcohol, or illicit

drugs. Mary was living with her husband, and had 3 grown children. She had been working as a

bookkeeper.

Before being admitted to the hospital, Mary had recently been diagnosed with invasive

moderately differentiated squamos cell carcinoma of the thyroid gland in the setting of

lymphocytic thyroiditis. She had undergone a total thyroidectomy, which revealed that her

cancer was pathologic stage T3 N0 and was invading through the thyroid capsule. Her tumor

measured 3.2 centimeters, and the surgeon removed 1 lymph node to test for the presence of

cancer. The lymph node was negative. After her thyroidectomy, Mary had a prophylactic PEG

placed for nutritional support, and was started on adjuvant concurrent chemoradiation therapy

with cisplatin. When her PEG was initially placed, she had some trouble with infection and

inflammation around the PEG site, but the infection and inflammation had cleared up by the time

she was admitted to the hospital. The amount of food that Mary could take by mouth had been

slowly decreasing as she progressed through her radiation treatment. Mary reported an

unintentional weight loss of approximately 10 to 15 pounds in the past 2 months since she started

her radiation therapy and chemotherapy. She was taking an average of 2 to 3 eight ounce (237

mL) cans of Jevity 1.2 per day through her PEG tube to supplement her oral diet. Her husband

was very involved in her care, and he usually administered her bolus tube feedings, but the

patient was able to self administer her own feedings as well. The patient was being followed by

an RD once a week at her outpatient radiation therapy treatment center.

When Mary was admitted, she reported that she was unable to take any food or drink by

mouth. Her voice was raspy and her chest area was reddened from receiving her radiation

treatments. She had received her most recent dose of cisplatin 5 days before she was admitted,

and she reported that she typically experienced nausea for 3 to 4 days after chemotherapy

treatments, but that her nausea had become progressively worse with each chemotherapy

treatment. The night before she was admitted, her husband had tried to give her a bolus feed of 2

cans of Jevity 1.2 one after another. After her husband finished administering her bolus feeding,

she had an episode of nausea and vomited her tube feeding. She had experienced nausea prior to

that night, but that was the first time she had actually vomited. She only saw a streak of blood

one time after her severe nausea and vomiting. She was not experiencing any diarrhea, chest

pain, dizziness, or dysuria, but she was weak and fatigued. Mary was admitted to the regular

hospital floor on room air for a total of 4 nights, and her radiation therapy was put on hold during

that time. She typically went for radiation therapy 5 days a week. The patient was scheduled to

have her next chemotherapy in two weeks.

Upon her admission to the hospital, Mary had an electrocardiogram (EKG) because she

was experiencing nausea and vomiting. Her EKG results showed normal cardiac function, and

her cardiac enzymes were within defined limits. The patient was negative for nasal methicillin-

resistant Staphylococcus aureus (MRSA). The admitting physician ordered a retroperitoneal US

because the patient was admitted with acute renal failure. Her blood urea nitrogen (BUN) and her

creatinine were elevated (Table 2). The patient was started on intravenous normal saline, and

nephrology was consulted. The admitting physician also started Mary on hydralazine for her

hypertension instead of lisinopril. Lisinopril is an angiotensin converting enzyme (ACE)

inhibitor. ACE inhibitors will not usually cause renal failure, but if a person develops

dehydration or hypotension, then ACE inhibitors can cause a form of reversible acute renal

failure. This reversible acute renal failure is called vasomotor nephropathy, and is caused by

inadequate blood flow to the kidneys. Mary’s potassium was low upon admission, so she was

started on K-Dur as an electrolyte replacement.

The retroperitoneal US showed mild bilateral hydronephrosis without perinephric fluid

collection. Urology was consulted, and the patient subsequently underwent an abdominal and

pelvic CT scan without contrast which revealed no hydronephrosis. The patient did have bilateral

small renal calculi which could be visualized on the CT scan. The patient reported that she has

had nephrolithiases for over 20 years, and periodically passes stones. The patient had a small

hiatal hernia and moderate sigmoid diverticulosis. The CT scan also showed scattered age-

appropriate degenerative changes in the patient’s lower thoracic and lower lumbar spine as well

as scattered age-appropriate atherosclerotic calcification in the lower descending thoracic aorta,

the splenic artery, throughout the abdominal aorta, and in the left iliac artery.

The CT scan showed no abnormalities in the pancreas, and the patient’s mildly elevated

amylase and lipase returned to normal overnight. The patient had two urinalyses during her

hospital admission (Table 3). The first showed microscopic hematuria, and the second urinalysis

was negative for urine occult blood (Table 3). Total urine protein was abnormally present in both

urinalyses due to her acute renal failure, but total urine protein had decreased by the time she was

discharged as her BUN and creatinine normalized. Urology would follow up with the patient to

recheck urinalysis post discharge. Nephrology determined that the patient’s acute kidney injure

was prerenal in nature, meaning that the patient would be able to recover with hydration therapy.

The patient was started on NeutraPhos due to a low phosphorus level. Her parathormone levels

were low due to damage to the parathyroid glands during radiation therapy treatments (Table 4).

The oncologist was consulted due to the patient’s history of thyroid cancer, and

determined that the patient could continue to use her PEG tube. Her abdomen was soft, and she

had normoactive bowel sounds. The patient had also had a bowel movement since admission.

The oncologist consulted the RD for further instructions for the patient and family for the goal

number of cans of Jevity per day via the PEG tube as well as recommendations for adequate

hydration via the PEG tube. The oncologist noted that the patient had been using less than 200

mL of water per day to flush her tube. The oncologist prescribed the Magic Swizzle mouthwash

for the patient to help with her oral mucositis. The patient was prescribed a 2 gram sodium diet

by the doctor, was eligible to order her own meals, and could eat independently. Nutrition also

needed to assess the patient because she had failed the initial nutrition screen due to her recent

reported weight loss.

Nutrition saw the patient on her second day of admission to complete an initial full

nutrition assessment. The patient was 61 inches tall, and weighed 160 pounds per the patient’s

profile on admission. She had a body mass index (BMI) of 30.3, and an ideal body weight of 105

pounds. She was 152% of her ideal body weight, so an adjusted body weight of 120 pounds (54.4

kilograms) was used to estimate her fluid, protein, and energy needs. Her daily energy needs

were estimated to range from 1360-1635 kcals using the 25-30 kcals per kilogram (kg) method.

Her daily fluid needs were estimated to be approximately 1635 mL based on the 30 mL per kg of

body weight method. Her daily protein needs were estimated to be 54 grams calculated based on

1 gram of protein for kg of body weight. Her skin was intact.

The chosen nutrition diagnosis statement for this patient was inadequate oral intake

related to thyroid cancer with chemotherapy and radiation therapy as evidenced by patient’s

reported symptoms of nausea and vomiting and existing PEG for nutrition support. The RD

recommended a continuous tube feeding via the PEG for nutrition. Jevity 1.2 was recommended

as the formula, since the patient had used and tolerated Jevity at home. The prescribed goal rate

was 50 mL per hour for 24 hours to provide 1440 kcals and 67 grams of protein. The patient

would receive a total volume of 1200 mL of tube feeding formula, and be meeting 100% of the

recommended daily intakes (RDIs) for vitamins and minerals. The recommended tube feed

prescription would meet 100% of the patient’s estimated nutrition needs because she was not

taking any food by mouth. However, it was recommended that the patient continue the 2 gram

sodium diet and any oral food or beverage intake as she was able. She was encouraged to try and

order foods from the light diet section of the menu. The patient had been on oral synthroid at

home, but it was not ordered while she was admitted, so the tube feed rate was calculated for 24

hours. If the patient had been prescribed oral synthroid while she was admitted, her continuous

tube feeding rate would have been calculated for a 22 hour day. Tube feeds must be held for 1

hour before and 1 hour after oral synthroid administration.

The RD monitored the patient’s enteral nutrition intake for formula, rate and patient’s

tolerance to the formula. Electrolyte and renal profile were also monitored for improvement in

BUN and creatinine, and the patient’s intake and output were monitored for hydration status. The

RD also monitored mealtime behavior for the patient’s ability to tolerate an oral diet. It was also

noted that the patient wore upper and lower dentures. The patient was followed at high nutrition

risk, and needed to be re-assessed within 3 days. At the time of follow-up, the RD would assess

the patient’s progress towards meeting their nutrition goals. The RD wanted the patient to

tolerate her tube feed at the recommended goal rate, and eat and drink as much as she could by

mouth to help preserve her swallowing function.

The day before the patient was discharged, I educated the patient and her husband about

the daily amount of tube feeding formula as well as the appropriate amount of free water that she

should be taking in through her PEG at home. The patient was alert and oriented to self, place,

and time. The patient thought she may have vomited before being admitted because her husband

tried to feed her too much at once through the PEG. She stated that she had never been a big

eater. I suggested that she might like to try nocturnal feedings through a continuous pump

instead, and referred them to the case manager to try to help them get a feeding pump. The

patient said that she would like to try a 10 hour nocturnal feeding, so I recommended that if she

was using Jevity 1.2 at home, she would need to run the tube feed at 120 mL per hour for 10

hours and add 220 mL of free water three times per day. If she continued with the bolus feeds,

she would need 5 cans of Jevity 1.2 per day with the 220 mL of free water three times per day.

The patient reported that she was no longer experiencing a thirst sensation, so it was very

important for her to know how much water she needed to be flushing down her tube.

On the day of discharge, the RD completed a follow-up nutrition assessment on the

patient. The doctor had ordered the continuous tube feed of Jevity 1.2 to run at 50 mL per hour

as the RD had recommended, but upon the RD’s visit to the patient’s room, the tube feed was

only running at 35 mL per hour. The patient was tolerating the tube feed at that rate. The RD also

included recommendations for Jevity 1.5 in the nutrition note in case the patient had difficulty

tolerating large volumes. If using the formula Jevity 1.5, the feeding would need to run at 96 mL

per hour for 10 hours, and the patient would need to flush her tube with 300 mL of free water

three times per day. The patient would also need to be taking a multivitamin to meet 100% of the

RDIs for vitamins and minerals with the Jevity 1.5 prescription.

The patient was not provided with any education about a low sodium diet for

hypertension or a low saturated and trans fat diet for dyslipidemia, because the RD wanted to

encourage the patient to eat anything by mouth that she could. Her dyslipidemia may have been

related to her history of hypothyroidism, and not necessarily the composition of her diet. During

her radiation and chemotherapy patients, the RD wanted the patient to focus on maintaining her

weight and not those other dietary restrictions. If the patient had been able to take anything by

mouth, the RD may have recommended liberalizing the patient’s diet to a regular soft diet to

encourage oral intake. An oral nutritional supplement such as Resource Breeze or a Resource

Health Shake could have been added to the patient’s diet order depending on whether or not she

preferred a clear liquid supplement over a milky liquid supplement.

*Name changed to protect patient’s identity.

Summary:

The chance of being diagnosed with thyroid cancer is now more than twice what it was in

the year 1990. This is due in part to the increased use of thyroid US which can detect small

nodules that may not have been found in the past, but the increase is also due to the finding of

more large tumors as well. Most thyroid cancers are very treatable if caught early. The 5-year

relative survival rates for Stage I and II papillary and follicular cancer, and Stage I medullary

cancer are near 100%. My case study patient was discharged home with a continuous tube

feeding pump from case management, and the knowledge that she needed to adequately feed and

hydrate herself using her PEG. She would continue to see the outpatient RD once a week at her

radiation therapy treatments for follow-up.

Table 2: Patient’s Laboratory

Table 3: Patient’s Urinalyses

Table 4: Patient’s Laboratory on Day of Discharge

Pertinent Medication Bibliography16

(includes patient’s home & hospital medications)

Medication

(brand name and

generic name) Drug Action Side Effects Food/Drug Interactions

Symbicort

budesonide &

formoterol

Antiasthma (not for acute

symptoms), COPD

treatment, long acting

bronchodilator, Beta-2

agonist

↑appetite, ↑ wt,

N/V, dyspepsia,

enteritis,

diarrhea,

candidiasis,

throat irritation

Ca/Vit D supplement

recommended, rinse

mouth after using inhaler,

avoid grapefruit/related

citrus with capsule,

Advair

fluticasone &

sameterol

Antiasthma (not for acute

symptoms), COPD

treatment, long acting

bronchodilator, Beta-2

agonist

N/V, diarrhea,

stomach ache,

candidiasis, ↓

salivation, throat

irritation

none noted

Synthroid

levothyroxine

Thyroid hormone (T4) for

hypothyroidism

appetite changes,

↓ wt, nausea,

diarrhea

Take on empty stomach

before breakfast to ↑

absorption, take drug 2-3

hours before soy

Ecotrin

aspirin

(acetylsalicylic

acid)

Analgesic, antipyretic,

antiarthritic, non-steroidal

anti-inflammatory drug

(NSAID), to prevent

myocardial infarction (MI),

or cerebrovascular accident

(CVA), platelet aggregation

inhibitor

anorexia, N/V,

dyspepsia, black

tarry stools,

Take w/ 8 oz water or

milk, after meals or with

food to ↓ GI irritation,

avoid alcohol, limit

caffeine, garlic, ginger,

gingko, & horse chestnut,

food ↓ rate of absorption

Oscal + D

calcium

carbonate

vitamin D

Antacid, mineral supplement,

phosphate binder

Anorexia, chalky

taste, dry mouth,

↓ diarrhea

Take w/ meals as

supplement/phosphate

binder, take 1-3 hours

after meals as antacid,

Vit D ↑ Ca absorption

Ativan

lorazepam

Antianxiety, antipanic, sleep

aid

Dry mouth, ↑

thirst, N/V,

constipation,

diarrhea,↑

appetite

Avoid alcohol, limit

caffeine (↓ sedative

effect), may take w/ food

if GI distress occurs

Apresoline

hydralazine

Antihypertensive,

vasodilator

Anorexia, ↓or ↑

wt, ↑ thirst,

unpleasant taste,

N/V, diarrhea,

GI distress

Take consistently w/ or

w/out food, avoid natural

licorice

Tylenol

acetaminophen Analgesic, antipyretic No GI bleeding

Do not mix with hot

drink, causes bitter taste.

Avoid alcohol, may take

w/out regard to food

Zofran

odansetron

Antiemetic, antinauseant,

serotonin 5HT3 receptor

agonist

Dry mouth, abd

pain,

constipation,

diarrhea

Take initial dose ½ hour

before chemotherapy

Protonix

pantoprazole AntiGERD, antisecretory

Nausea, abd

pain, diarrhea, ↑

gastric pH

Take w/out regard to

food, avoid alcohol

Zocor

simvastatin

Antihyperlipidemic, HMG-

CoA Reductase Inhibitor

Nausea, abd

pain, diarrhea,

dyspepsia,

constipation,

flatulence

Take w/out regard to

food, avoid

grapefruit/related citrus

& St. John’s wort

Pepcid

famotidine

Antiulcer, antiGERD,

antisecretory, Histamine H2

Receptor Antagonist

↑ gastric pH,

N/V, diarrhea,

constipation

Avoid alcohol, limit

caffeine, take w/out

regard to meals, a bland

diet may be

recommended

Magic Swizzle

lidocaine,

diphenhydramin,

magnesium

hydroxide/alumi-

num hydroxide

Topical mucositis agent

Unpleasant taste,

burning mouth

sensation

Do not swallow

mouthwash, avoid eating

for at least 1 hour after

use

Sancuso Patch

granisetron

Antiemetic, antinauseant,

serotonin 5HT3 receptor

agonist

Taste disorder,

dyspepsia, abd

pain,

constipation,

diarrhea

Transdermal patch can be

worn for 7 days

Hexadrol

dexamethasone

Anti-inflammatory,

immunosuppressant,

corticosteroid

Esophagitis,

N/V, bloating,

↑ wt, ↑ appetite

Take w/ food and limit

caffeine to decrease GI

effects, avoid alcohol

Ca/Vit D supplement

recommended with long-

term use

Compazine

prochlorperazine

Antiemetic, antinauseant,

antipsychotic

Dry mouth,

constipation, ↑

wt, ↑ appetite

Limit caffeine, may take

w/ food, milk, water to ↓

GI distress, avoid alcohol

Vitamin C

ascorbic acid

Vitamin, antiscurvy,

antioxidant

N/V, dyspepsia,

gastric cramps

Take w/ Fe supplement to

↑ Fe absorption

K-Dur

potassium

chloride

Electrolyte, potassium

supplement

GI irritation,

N/V, abdominal

pain, diarrhea,

flatulence

Do not take salt

substitutes with K-Dur,

take w/ meals and 8 oz

liquid

Neutra Phos

potassium

Urinary acidifier, phosphorus

supplement

↑ wt, ↑ thirst,

N/V, stomach

Avoid Ca & Vit D

supplements or salt

phosphate and

sodium

phosphate

pain, diarrhea substitutes, take w/ meals

to ↓ GI irritation &

laxative action

MagOx

magnesium

oxide

Mineral supplement, antacid,

laxative

Chalky taste,

cramps, diarrhea,

N/V

As antacid, take after

meals, as laxative, take

with 8 oz water, take

fiber, folate, or iron

supplement separately by

at least 2 hours

Prinivil

lisinopril

Antihypertensive,

angiotensin converting

enzyme inhibitor

Dry mouth, N/V,

abd pain,

constipation,

diarrhea,

anorexia, ↓ wt

Take without regard to

food, limit alcohol, avoid

natural licorice & salt

substitutes

Platinol

cisplatin antineoplastic

Anorexia, ↓ wt,

severe prolonged

N/V, diarrhea,

altered taste,

stomatitis

Insure adequate fluid

intake/hydration to

produce 100-200 mL

urine/hr for ≥ 24 hours

after infusion

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