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Base of the Tongue Cancer CASE STUDY KERRY BARBERA PRIORITY NUTRITION CARE DIETETIC INTERN Behavioral Objectives You will be able to name the two leading risk factors for head and neck cancer. You will be able to identify at least 2 symptoms of head and neck cancer. You will be able to recall 2 nutritional problems that can result from treatment intervention. BOT Cancer Head and neck cancer Incidence Risk factors Treatment and their side effects and their impact on nutrition Prognosis Research Patient B PMH, labs, meds Diagnosis Medical treatment Nutritional ADIME Summary and questions Head and Neck Cancer o Oral cavity o Pharynx o Larynx Incidence Head and neck cancer accounts for approximately 3% of all cancer diagnosis with Squamous cell carcinoma being the most prevalent.1 Oropharyngeal cancer patients are typically between the ages of 50-70 years old and is more common in men than women. 2 Human Papillomavirus infection can affect the tonsils and back of throat during oral sex and has been linked to the increase in the number of oral cancer diagnoses in the younger population.3 Base of the Tongue Cancer Tobacco and alcohol are among the strongest risk factors of these cancers. 7 of 10 patients dx with this type of cancer are heavy drinkers.1 Signs & Symptoms Speech and swallowing Pain Dysphagia Weight loss Otalgia Treatment Main goal preserving speech and swallowing • Surgical resection • Radiotherapy • Chemotherapy –adjunct therapy Procedures • Tracheostomy for preservation of the airway • NG or PEG tube for nutritional support Enteral Nutrition NG tubes PEG Tubes Smoking sensation Nutritional Implications Inability to eat Dysphagia NPO post surgery Pain Mucositis Nausea and vomiting Malnutrition and cachexia are very common Mucositis Frequent complication of cancer treatment Painful and debilitating inflammation and ulceration Patients unable to speak, eat or tolerate treatments Lead to reduction and even cessation of radiation or chemotherapy Treatment Good oral hygiene- brush teeth 2-3 times a day with mild tasting toothpaste Avoid acidic or spicy foods Sucking on ice chips during chemotherapy Magic Mouthwash Prognosis 5 year survival rate: • 75% local occurrence –stage l, ll, or lll • 38% regional cancer – stage lll or lV that has spread to the nearby tissue or lymph node • 20% distal occurrence- metastasis Screening Research TROS Transoral robotic surgery has been utilized to improve access to tumors during surgery. Positive outcomes and disease control maybe achieved with TORS as a primary therapy Prophylactic versus reactive PEG tube Placement Reactive PEG tube placement was found to provide a shorter duration of usage without incurring greater weight loss or poorer oncology outcomes.9 Higher rate of unnecessary PEG placement were found when done prophylactically.10 Patient B 45 y/o female who presented to the emergency department with complaints of difficulty with swallowing and tongue swelling. She described her difficulty swallowing as a foreign body sensation. Reported that she has been having dysphagia over the last three weeks. Presents with a 40-pound unintentional weight loss. CT Scan BOT squamous cell carcinoma with bilateral subglottic and glottic involvement Left worse than right sided mass in the BOT extends into hypoglossal and genioglossus muscle. Second mass supraglottic region involving the false and true vocal cords Multiple necrotic enlarged lymph nodes CT with contrast negative for METs Medical and Social History Admitted to the hospital 10/12/15-BOT cancer with laryngeal and necrotic lymph node involvement. Pack a day smoker > 10 years. Alcohol abuse in past No medical insurance & no previous medical care Unemployed, widowed, adult niece lives with patient Labs HGB & HCT low-common with cancer BUN low ( 6) creatinine was WNL Anion Gap ( 14) High All electrolytes and other lab results were WNL Admit Medications IVF: Dilaudid for pain- can cause increase thirst/dehydration Methylpredisone- Corticosteroid- monitor labs Can decrease Ca, Vit D, Vit A, Vit K, Vit C, P, and Zn. Can increase Na. Ondansetron for nausea- can increase thirst Nutrition Assessment Nutrition assessment on admission for unintended weight loss. Patient reports normal appetite until ~ 1 month ago. Poor intake > 1-month r/t difficulty in swallowing. Did not eat > 1 week prior to admission r/t severe pain with eating. Patient reports usual weight of 115-120 lb, wt loss of > 35 lb (29%) over the last 4 weeks. Nutrition Assessment Patient is currently NPO. RN reports patient to have a speech evaluation, pt diagnosed with oropharyngeal dysphagia. Patient B underwent surgery for a tracheotomy to protect her airway, biopsy and the placement of a PEG tube. Estimated Energy Needs Anthropometrics: Height: 64 in. Adm Weight: 37.8 kg BMI: 14.3 kg/m2 UBW: 115-120 lb (52.27-54.55kg) UBW% 69% Clinical nutrition weight: 37.8 kg Estimated Energy Needs: MSJ 1008 X 1.2-1.3 + 250 Kcal/day for wt gain = 1460-1560 Kcal/day Estimated Protein Needs: 53-60 Gm/day ( 1.4-1.6 Gm/kg) Estimated fluid Needs: 1.4L-1.6L/day (1mL/Kcal) Nutrition therapy: NPO Nutrition Diagnosis Patient B meets the criteria for diagnosis of severe malnutrition of chronic illness as evidenced by 29% weight loss X 4 weeks, meeting <75% of estimated nutrition needs for > 1 month, and evidenced of muscle wasting at temples. 1.Malnutrition r/t chronic disease, dysphagia AEB 29% wt loss X 4weeks, meeting <75 of estimated nutrition needs > 1 month, and evidence of muscle wasting at temples. 2. Inadequate PO intake r/t dysphagia AEB inability to take oral intake. Nutritional Intervention/Analyses Tube feeding regimen of 4 cans of Osmolite 1.5 Cal + 60 mL H20 before/after each feeding + 100 mL H2O BID. This provides 1440 Kcal (98% of estimated needs) 60 Gm of protein (1.2 Gm/kg) 193 Gm CHO, 0 fiber, 730 mL of free water (1410 mL free water with H2O flushes), 96 % of recommended daily allowance (RDI). Patient B is meeting 98% of her estimate energy needs and 96% of her RDI. Per SLP, Frazier water protocol Monitoring Throughout Medical course monitor • TF tolerance • Weights • Intake and Outputs • Labs Treatment Medical: Patient B underwent a laryngoscopy, biopsy, tracheostomy and PEG tube placement. MNT: Emphasis on initiating PEG Tube bolus regimen and monitoring Patient B‘s weights, input and outputs, and labs closely for tube feeding tolerance. Patient B was independent with tube feedings upon discharge. Modified barium swallow -Patient B was diagnosed with oropharyngeal dysphagia. SLP-initiated the Frazier Water Protocol and worked with patient on how to utilize a communication board Discharge plan Patient was discharged to a rehabilitation facility. Discharge follows up with : Otolaryngologist Radiation Oncologist Medical Oncologist. Summary Head and neck cancer accounts for approximately 3% of all cancer diagnosis with Squamous cell carcinoma being the most prevalent.1 Tobacco and alcohol are among the strongest risk factors of these cancers. Symptoms include pain, difficulty talking, dysphagia, weight loss, Otalgia Treatment significantly impacts nutrition, malnutrition and cachexia are common. Screening can save lives Behavioral Objectives You will be able to name the two leading risk factors for head and neck cancer. You will be able to identify at least 2 symptoms of head and neck cancer. You will be able to recall 2 nutritional problems that can result from treatment intervention. BOT Cancer Bibliography 1.Schoeff S, Barrett DM, Gress CD, Jameson MJ. Nutritional Management For Head And Neck Cancer Patients. Practical Gastroenterology.2013; (121):43-51. 2.National Cancer Institute. Oropharyngeal Cancer Treatment. Updated in 2015. Available at: http://www.cancer.gov/types/head-and-neck/hp/oropharyngealtreatment-pdq#link/_303_toc19 Oct. 2015. Accessed on October, 19, 2015. 3.National Cancer Institute. Head And Neck Cancers. Available at: http://www.cancer.gov/types/head-and-neck/head-neck-fact-sheet. Accessed October 18, 2105. 4.Emedicine.medscape.com. Malignant Tumors Of The Base Of Tongue: Background, Etiology, Pathophysiology.2015. Available at: http://emedicine.medscape.com/article/847955-overview.Accessed October 16, 2015. 5.Oralcancerfoundation.org. Treatment - The Oral Cancer Foundation. Available at: http://www.oralcancerfoundation.org/cdc/cdc_chapter6.php. Accessed:24 Oct. 2015. Bibliography 6.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage. Available at: http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavityand-oropharyngeal-cancer-survival-rates1. Accessed on November 1, 2015. 7.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage. 2015. Available at: http://www.cancer.org/cancer/oralcavityandoropharyngealcancer/detailedguide/oral-cavityand-oropharyngeal-cancer-survival-rates. Accessed on: November 1, 2015. 8.Moore E J, Olsen SM, Laborde RR, Garcia JJ, Walsh FJ, Price DL, Janus JR, Kasperbauer JL, and Olsen, KD. Long-Term Functional And Oncologic Results Of Transoral Robotic Surgery For Oropharyngeal Squamous Cell Carcinoma. Mayo Clinic Proceedings. 2012; (87): 219-225. 9.Kramer, S. et al. Prophylactic Versus Reactive PEG Tube Placement In Head And Neck Cancer'. Otolaryngology - Head and Neck Surgery.2013; 150 (3): 407-412. 2015. 10.Madhoun, Mohammad F. Prophylactic PEG Placement In Head And Neck Cancer: How Many Feeding Tubes Are Unused (And Unnecessary)? World Journal of Gastroenterology. 2011;17 (8): 1004.