Transcript File - wei Yuan

Recurrent Oropharyngeal
Squamous Cell Carcinoma
Wei Yuan
Sodexo Mid-Atlantic Intern
02/04/2013
Objectives
• Identify three risk factors of oropharyngeal cancer.
• Identify one major nutrition impact of oropharyngeal cancer.
• Identify three major treatments for oropharyngeal cancer.
General Information
EA

59 YOM

African American

Admitted to SGAH 01/04/2013 on Med-Surg floor

D/C to home 01/10/2013

Readmitted to SGAH 01/15/2013 in ICU

Plan to d/c to hospice
Social & Family History
Social History
• Occupation: Not employed
• Education: High school
• Marital status: Single w/ a significant other
• Religion: Baptist
• Pt currently resides with son in Frederick.
• History of tobacco, alcohol, cocaine, and other drug abuse. EA
just quit smoking a few months ago.
Family History
• His mother died in her 40s because of alcohol abuse. His
father died in his 70s due to unknown cause.
Past Medical History
Past Medical History

Oropharyngeal cancer diagnosed in 2007, status post chemo and radiation therapy.

Fungal ball in his left upper lobe of the lung status post antifungal treatment
Past Surgery History

Gastrostomy tube placement in 2007

The feeding tube was removed 5 months after the placement.

Left superficial parotidectomy, left modified radical neck dissection, and wide local
excision of recurrent carcinoma on the left side of the face, 08/20/2012.
Outpatient medication

Fentanyl patch 50 mcg every 72 hrs

Ambien 10 mg PO daily
Anatomy of the Pharynx
Oropharyngeal Cancer Etiology

Oropharyngeal cancer is a disease in which cancer cells are
found within the anatomical borders of the oropharynx. The
majority of oropharyngeal cancers are squamous cell
carcinomas.

Major risk factors: tobacco and alcohol abuse.

Other risk factors
Being infected with human papillomavirus (HPV)-especially
HPV-16.
Chewing betel quid and drinking mate.
Age, gender, poor nutrition, weakened immune system, and
genes.
Oropharyngeal Cancer Complications

Airway obstruction

Dysphagia

Disfigurement of the neck or face

Hardening of the skin of the neck

Loss of voice and speaking ability
The Major Nutrition Related Problem

DYSPHAGIA
Treatment and Nutrition Impact
Treatment
Nutrition Impact
Surgery
Changes the ability to swallow, eat, talk
Radiation Therapy
Sore throat and difficulty swallowing,
damage to the salivary glands and/or the
thyroid gland
Chemotherapy
Poor appetite, N/V, diarrhea, mouth and
lip sores
Targeted Therapy
Tiredness, fever, diarrhea
Palliative Treatment
Nutrition is important!
Stages of Oropharyngeal Cancer
The TNM Staging System
T: The size of primary tumor and which
T0, T1, T2, T3, T4a, T4b
tissues in oropharynx it has spread to
N: The extent of spread to nearby lymph N0, N1, N2a, N2b, N2c, N3
nodes
M: If the cancer has spread to other
M0, M1
organs
No actual stage for recurrent cancer in the TNM system.
EA's Recurrent Cancer
Pathology report, August 2012

Present throughout the parotid gland

Moderately differentiated


Consistent with recurrent/metastatic carcinoma from primary
tumor at the base of the tongue.
No carcinoma was identified in eleven lymph nodes.
Admission 1: 01/04-01/10
Admission 1 - Dx & Present Medical Problems
Admission Dx
• Dysphagia secondary to oropharyngeal cancer
• Oropharyngeal cancer, status post surgery
• Anemia
• Hyponatremia
Present medical problems
• Difficulty swallowing x 2 months
• Finished 7 radiation treatments
• Significant wt loss (10% in 3 months)
Admission 1-Physical Exam
Vital Signs
Temperature 36.7, blood pressure 130/79, heart rate 72,
respiratory rate is 20
Neck
On the left side, he has multiple surgical wounds
Chest
Clear to auscultation bilaterally
Abdomen
Soft. Positive bowel sounds
Extremities
No edema
Admission 1-Labs (01/04/2013)
Labs
Normal Range
01/04
Sodium
135-145 mEq/L
128 mEq/L
Potassium
3.5-5.1 mEq/L
4.6 mEq/L
Chloride
98-107 mEq/L
91 mEq/L
BUN
7-20 mg/dL
12 mg/dL
Creatinine
0.6-1.3 mg/dL
1.1 mg/dL
Glucose
74-105 mg/dL
78 mg/dL
Albumin
3.4-5.0 g/dL
3.3 g/dL
Calcium
8.4-10.6 mg/dL
9.6 mg/dL
H/H
13.5-18 g/dL, 39-52%
11.9 g/dL, 37.3%
Admission 1 - Procedure
• Percutaneous Endoscopic
Gastrostomy (PEG) on
01/05
• Preferred route for head
and neck ca patients
• A lower rate of
hospitalization for
dehydration
• A higher therapy
completion rate
• Weight gain or maintenance
Admission 1-Nutrition History




Previously having regular diet with good appetite.
Soft diet after neck surgery in August, 2012; still good
appetite.
Swallowing difficulty 2 months ago. Only drinking 3-4 cans
Ensure/Boost and 1/2 cup of blenderized soup daily (Estimated
energy: 1200 kcal, protein 47 g).
Wt loss from 155 lb in Sept. 2012 to 137 lb in Jan. 2013.
Admission 1-Medications
Medication
Usage
Nutrition Impact
Cefazolin
Antibiotic
Anorexia
Miralax
Laxative
Nausea, bloating, cramps, flatulence
Dilaudid
Pain management
Anorexia, wt loss, thirst, dehydration
Milk of Magnesia
Laxative
Chalky taste, nausea, cramping, diarrhea
MVI
Supplement
NS 0.9%
Hydration
Admission 1-Nutrition Assessment
Anthropometic

Ht: 178 cm

Wt: 63 kg

BMI: 19.9

IBW: 75.5 kg

% IBW: 83.4%

UBW: 70 kg

% UBW: 90%

Wt change: 10% in 3 months
Subjective/Objective
• Soft diet and good appetite until
having dysphagia
• On Osmolite 1.2 at 40 ml/hr
when visiting
• Complaining watery stool x2
Admission 1-Estimated Needs

Energy needs range: 30-35 kcal/kg
Estimated energy: 1890-2205 kcal

Protein needs range: 1.3-1.5 g/kg
Estimated protein: 82-95 g

Fluid needs range: 1 ml/kcal
Estimated fluid needs: 1890-2205 ml
Admission 1-Nutrition Dx (01/09)
PES
• Swallowing difficulty r/t recurrent head and neck ca AEB TF
osmolite 1.2 at 40 ml/hrx24 hrs via PEG
• Involuntary wt loss r/t dysphagia secondary to recurrent head
and neck ca AEB 10% wt loss within 3 months.
Another possible one
• Malnutrition r/t dysphagia secondary to recurrent head and
neck ca AEB 10% wt loss within 3 months and 1200 kcal po
intake before PEG placement.
Admission 1- Goals, Interventions, M/E
Nutrition Goals

Pt will get adequate nutrition to meet needs from TF with good tolerance

Pt will maintain current wt during hospital stay, no further wt loss.
Intervention


Rec to change TF to Jevity 1.5 at goal rate 60 mlx24 hrs, starting from 35
ml/hr with auto flush water (25ml/hrx24hrs) and extra water 120 ml/every
6 hrs, providing 2160 kcal, 92 g protein, and 2170 ml water.
Rec to d/c Miralax and MOM
Monitoring & Evaluation

TF formula change, rate, tolerance, bowel movement
Admission 1-Follow up (01/10)
• TF of Jevity 1.5 at 50 ml/hr when visiting
• Pt reported no N/V, no watery stool, one formed stool since
changing formula
• RN reported no residual
• A home TF plan needed due to D/C order
Nutrition Goal,Intervention, M/E
Goal
• Pt will understand home TF schedule including formula, rate, and time
frame.
Intervention
• Home TF plan: Jevity 1.5, 6 cans per day, one can every 3 hours at 800,
1100, 1400, 1700, 2000, 2300; 178 ml extra water (3/4 cup) to flush the
tube every time w/ 1 can of formula (2133 kcal, 91 g protein, and 2149 ml
water). If pt tolerates well, TF can be gradually increased to 2 cansx3
times per day. Use an IV pole for gravity TF.

Speak w/ case manager regarding TF formula, volume, and the need for
an IV pole.
Monitoring & Evaluation

Understanding of home TF plan
Admission 2: 01/15-
Admission 2
Readmitted on 01/15/2013
Readmitted dx:
• Acute respiratory failure due to upper airway obstruction
• Supraglottic edema secondary to radiation therapy
• Squamous cell carcinoma
• Anemia
• Hyponatremia
Admission 2-Physical Exam (01/15/2013)
General
Alert and agitated
Vital Signs
Blood pressure 140/103, heart rate 90, oxygen sat dropped to the
80s.
Neck
Surgical wounds at the left side of the neck
Chest
Wheezes bilaterally
Cardiovascular S1, S2
Abdomen
Soft with positive bowel sounds and PEG intact.
Extremities
No edema
Admission 2-Labs (01/15/2013)
Labs
Normal Range
01/15
Sodium
135-145 mEq/L
131 mEq/L
Potassium
3.5-5.1 mEq/L
4.2 mEq/L
Chloride
98-107 mEq/L
89 mEq/L
BUN
7-20 mg/dL
15 mg/dL
Creatinine
0.6-1.3 mg/dL
0.9 mg/dL
Glucose
74-105 mg/dL
75 mg/dL
Albumin
3.4-5.0 g/dL
Calcium
8.4-10.6 mg/dL
8.7 mg/dL
H/H
13.5-18 g/dL, 39-52%
10.4 g/dL, 33.4%
Admission 2-Procedure
• Tracheostomy (01/16/2013)
• EA still wished to continue with
radiation therapy for ca
• An alternative airway
• After the surgery, EA was sent to
ICU, sedated and intubated
Admission 2-Medications
Medication
Usage
Nutrition Impact
Albuterol inhalation solution
Preventing reversible obstructive airway disease
Peculiar taste
Sore/dry throat
Pepcid
Stress ulcer prophylaxis
Decrease gastric acid secetion
Increase gastric pH
N/V, diarrhea, constipation
Dilaudid
Pain management
Anorexia, thirst, wt loss, dehydration,
Atrovent
Preventing reversible obstructive airway disease
N/A
Fentanyl Patch
Pain management
N/A
NS 0.9%
Hydration
Propofol
ICU sedation for intubated adults
Fat, 1.1 kcal/ml
Colace
Stool softener
Bitter taste, throat irritation, nausea,
cramps, diarrhea, rash
Dulcolax
Stimulant laxative
Nausea, belching, abd cramps, diarrhea
Admission 2-Nutrition Assessment
(01/18/2013)
Anthropometric

Ht: 178 cm

Wt: 64.4 kg (1.4 kg wt gain since
last admission)

BMI: 20.3

IBW: 75.5 kg

% IBW: 85.3%

UBW: 70 kg

% UBW: 92%
Subjective/Objective
• Pt was vented, without propofol
• Abdomen soft, non-tender, nondistended, bowel sounds positive
• Surgical wounds at the left side of
his neck
• Jevity 1.5 at rate 30 ml/hr (MD
order)
Admission 2- Estimated Needs (01/18/2013)
Estimated Needs: ~1482 kcal (23 kcal/kg)
• Penn State equation for critically ill, vented, non-obese
patients (Ht: 178cm, Wt: 64.4 kg, age 59 y, ventilation in liter
per minute 4L/min, the maximum temperature during the
previous 24 hours 36.9 degrees Celsius)
RMR=Mifflin (0.96)+ventilation per minute (4)x31+Tmax
(36.9)x167-6212=1482 kcal
Estimated protein range 1.3-1.5 g/kg
• Estimated protein needs: 84-97 g
Fluid need is per MD order in ICU
Admission 2-Nutrition Diagnosis (01/18/2013)
PES statement
• Inadequate TF intake r/t infusion volume not reached AEB TF
intake (1080 kcal/day)< estimated energy needs (1482
kcal/day)
Admission 2-Nutrition Goal, Intervention, M/E
Nutrition Goal
• Pt will have adequate nutrition via TF during hospital stay
Intervention
• Rec to change TF w/ Jevity 1.5, goal rate 35 ml/hr x 24 hrs,
Prostat 1 pkt TID via PEG, fluid per MD, providing 1476 kcal
(1260 kcal from Jevity 1.5, 216 kcal from Prostat), 99 g protein
(54g from Jevity 1.5, 45g from Prostat). Fluid is per MD.
Monitoring and Evaluation
• TF rate change, TF tolerance, wt change
Admission 2-Reassessment (01/21/2013)
• EA was agitated and fought against ventilation during the
weekend.
• Intubated and sedated w/ propofol at 23.3 ml/hr.
• Per RN, pt tolerated TF well with 80ml residual in 12 hr shift.
Nutrition Reassessment (01/21/2013)
Energy needs: ~1516 kcal (23.5 kcal/kg)
• Penn State: RMR=Mifflin (0.96)+ventilation per minute
(4)x31+Tmax (37.1)x167-6212=1516 kcal.
• Since propofol was running at 23.3 ml/hr, the calories from
propofol (23.3x24x1.1=615 kcal) needed to be subtracted.
Calories from TF should be 901 kcal.
Estimated protein needs range: 1.3-1.5 g/kg
• Estimated protein needs: 84-97g
Fluid is per MD
Admission 2-Nutrition Diagnosis (01/21/2013)
PES
• Excessive intake from enteral nutrition r/t propofol use at
23.3 ml/hr AEB tube feeding, prostat, and propofol provide
2091 kcal while patient needs 1516 kcal.
Admission 2-Intervention & M/E
Intervention
• Rec to change TF w/ Jevity 1.5, goal rate 20 ml/hr x 18 hrs,
Prostat 5 pkt via PEG, fluid per MD, providing 1515 kcal (540
kcal from Jevity 1.5, 360 kcal from Prostat, and 615 kcal from
propofol), 98 g protein (23g from Jevity 1.5, 75g from Prostat).
Monitoring and Evaluation
• TF rate change
• TF tolerance
• Propofol rate change
The story continues ...
• 01/25: Pt was extubated, rec to change TF back to Jevity 1.5
at 60 ml/hrx24 hrs, d/c prostat.
• 01/30: Carotid blowout due to tumor encasing a carotid
artery.
• Plan to d/c to hospice
Nutrition and Wound Care
• 3 significant wounds
• Unhealed surgical incisions since radical neck dissection
surgery in August, 2012.
• Wounds deteriorated since radiation therapy
Antioxidants and Radiation Therapy
• Radiation therapy is used to eradicate cancer and as a
palliative measure to relieve pain associated by increasing
DNA damage in tumor cells.
• Antioxidants protect normal cells by reducing the oxidative
modification of DNA, while providing same benefits for cancer
cells.
• High-dose antioxidant supplementation: decreasing local
tumor control and shortening the survival of ca pts.
• Only topical wound care was provided for EA.
Nutrition Role
Nutrition intervention benefits EA by:

Improving kcal and protein intake

Maintaining anthropometric measurements

Improving the quality of life
References
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2013.
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References
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Questions?