Esophageal Cancer
A CASE STUDY BY RAQUEL REDMOND
Agenda
I.
Discussion of Disease
II. Medical Nutrition Therapy
III. Presentation of the Patient
IV. Critical Comments
Statistics
2014
18,170 new cases
15,450 deaths
12,450 male deaths
5-year survival rate
Discussion of
Disease
Anatomy of
the
Esophagus
25 cm long
Three sections
Four layers
Types of Esophageal Cancer
Squamous cell carcinoma
Heavy alcohol consumption
Smoking tobacco
Adenocarcinoma
Chronic acid reflux
Barretts esophagus
Obesity
Lymphomas, melanomas, sarcomas
Nonmodifiabl
e
Risk Factors
Alcohol
use
Over 55
Squamous cell
carcinoma
Adenocarcinoma
Modifiabl
e
Male
Tobacco
use
Obesity
Obesity
H. pylori
leptin
adiponectin
GERD
Barretts
esophag
us
adenocarcino
ma
Signs and Symptoms
Dysphagia
Excessive mucus production
Chest pain
Weight loss
Hoarseness or chronic cough
Indigestion or heartburn
Diagnosis
Upper
gastrointestinal
series
CT scan
PET scan
Endoscopy
Biopsy
MRI
Labs
Complete blood count
White blood cells
Red blood cells
Platelets
Tumor marker tests
HER2
VEGF
Esophageal
Cancer
Staging
TNM staging
Histological grade
Treatment
Chemotherapy
Radiation therapy
Surgical resection
Photodynamic therapy
Radiofrequency ablation
Esophageal stent
Targeted therapy
Esophagectomy
Complications: anastomotic leaks, fistulas, strictures, bilious gastroesophageal
reflux, dumping syndrome
Treatment Symptoms
Chemotherapy
Radiation
Postoperative
Anorexia
Xerostomia
Gastroparesis
Nausea
Mucositis
Indigestion
Vomiting
Sore mouth and throat
Acid reflux
Fatigue
Dysphagia
Dysphagia
Odynophagia
Decreased motility
Alterations in taste and Anastomotic leak
smell
Fatigue
Loss of appetite
Medical Nutrition
Therapy
Assessment
Food and nutrition-related
history
Anthropometrics
Biochemical data and medical
tests
Nutrition-focused physical
findings
Social history
Monitoring
Assessment
& Evaluation
Intervention
Diagnosis
Estimated Nutrient Needs
Condition
Weight gain
Normometabolic
state
Hypermetabolic
state
Sepsis
Condition
Obese
Stressed
Non-stressed
Energy Needs
30-40 kcal/kg
25-30 kcal/kg
35 kcal/kg
25-30 kcal/kg
Protein
Needs
21-25 kcal/kg
1.2-1.5 g/kg body
weight
1-1.2 g/kg body
weight
Diagnosis
Inadequate oral intake (NI-2.1)
Unintended weight loss (NC-3.2)
Underweight (NC-3.1)
Malnutrition (NI-5.2)
Unintended weight gain (NC-3.4)
Food and nutrition knowledge deficit (NB-1.1)
Undesirable food choices (NB-1.7)
Intervention
Weight loss
Fatigue
Sore mouth and throat
Xerostomia
Altered taste or smell
Postoperative intervention
Enteral and Parenteral Nutrition
Indications for enteral nutrition
Inadequate oral intake
Esophageal obstructions
Dysphagia
Perioperative malnutrition
Enteral formulas
EPA
DHA
Parenteral nutrition
Monitoring and Evaluation
Indicators to measure success
Measureable goals
Monitor
Weight
Diet intake
Symptoms
Labs
Medications
Skin integrity
Presentation of the
Patient
Patient: Mr. JL
37 year old male
Caucasian
PMH: gastroesophageal reflux
disease
20 years of heavy drinking
25 years smoking 1 pack/day
Initial weight: 277 lbs
BMI 37.6
Course of Disease
Jan
2014
Weight: 277 lbs
Difficulty swallowing
May
2014
Emergency room visit
Dysphagia
July
2014
EGD: esophageal stricture down to
gastroesophageal junction
Biopsy: poorly differentiated adenocarcinoma
Course of Disease
July
2014
PET: intense uptake in lower third of esophagus; no
metastasis
US: mass extending into the muscularis propria
Aug
2014
Chemotherapy port
Jejunostomy tube
Sep
2014
Begin chemotherapy: five week course of
carboplatin and taxol
Begin radiation therapy
Initial Assessment
October 17, 2014
A) WEIGHT: 208#
DIET HX: mechanical soft diet and thin liquids
PO INTAKE: poor; tries to drink enough water, eats soups, drinks
3 Ensures/day
GI: weight loss, dysphagia, anorexia, and heartburn, + J-tube
LABS: within normal limits
MEDS: Oxycodone, Roxicodone, Zofran, Compazine, Carafate,
Esomeprazole
SKIN: no documented wounds
Initial Assessment
D) Inadequate energy intake (NI-1.4) related to esophageal
cancer and treatment as evidenced by unintentional weight loss
of >5% in one month or >10% in six months.
I) Isosource 1.5 at 110 milliliters per hour for 16 hours. This
provides 2,625 calories, 118 grams of protein, and 1,358
milliliters of free water.
M/E) GOAL: Weight maintenance and tube feed regimen to
provide 80-100% of estimated nutrient needs. Will monitor
weight, PO intake, GI symptoms, labs, and meds. Follow-up in 35 days.
Patient Labs
Chem
Profile
Lab
Values
CBC
Lab
Values
Differenti
al
Lab
Values
Glucose
85
WBC
3.5
Neutrophi 82
ls
BUN
RBC
4.6
Basophils
Creatinine 0.74
Hemoglob 12.3
in
Lymphocy 10
tes
Sodium
Hematocri 36.6
t
Monocyte
s
142
Potassium 4.5
MCV
90
Chloride
103
MCH
30.3
CO2
26
MCHC
33.6
Calcium
9.5
RDW
14.2
Estimated Nutrient Needs
Energ
y
Protei
n
TF provides: 2,625 kcal
28 kcal/kg
Normometabolic state: 25-30
kcal/kg
TF provides: 118 g protein
1.2 g/kg body weight
Stressed: 1.2-1.5 g/kg body weight
Follow-Up Assessments
October 21, 2014
Weight: 208#
Nausea/vomiting
Dysphagia
Eating soup; drinking Ensure
Shakes
Boost High Protein @ 80 mL/hr
Jevity 1.0 and Vital 1.5 to trial
Encouraged PO intake
October 24, 2014
Weight: 207#
Nausea improved
Excessive saliva production
Eating soup; refusing Ensure
Shakes
Refused tube feeds; Ensure Active
to trial
Consider Reglan
Encouraged use of Isosource 1.5 @
110 mL/hr x 16 hours and PO
intake
Follow-Up Assessments
December 9, 2014
Weight: 188#
Nausea improved
Better PO intake
Tube feeds still not well tolerated
No longer interested in CXT and
RXT
Encouraged use of Isosource 1.5
@ 110 mL/hr x 16 hours and PO
intake
Weight History
Date
Weight
January 2014
277 lbs
July 28, 2014
247 lbs
August 14, 2014
245 lbs
August 28, 2014
233 lbs
September 18, 2014
225 lbs
October 3, 2014
216 lbs
October 17, 2014
208 lbs
November 20, 2014
199 lbs
December 1, 2014
188 lbs
Total weight
loss:
89 lbs
Course of Disease
Dec
2014
Weight: 188 lbs
Eating better; appetite better
Jan
2015
Metastasis: liver and lung lesions
Begin new chemotherapy
Future
Continue to meet with outpatient oncology team
and Registered Dietitian
Critical Comments
Critical Comments
Team work
Goals not met:
Meet estimated nutritional needs
Weight maintenance
Manage symptoms affecting nutrition
Encourage PO intake
Psych/social work consult
More diet education
Thank you!
QUESTIONS?
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
National Cancer Institute. SEER Stat Fact Sheets: Esophageal Cancer. http://seer.cancer.gov/statfacts/html/esoph.html.
Accessed December 14, 2014.
American Cancer Society. Cancer Facts and Figures 2014.
http://www.cancer.org/acs/groups/content/@research/documents/webcontent/acspc-042151.pdf. Published 2014. Accessed
December 14, 2014.
Medscape. Esophagus Anatomy. http://emedicine.medscape.com/article/1948973-overview. Updated October 14, 2011.
Accessed December 14, 2014.
American Cancer Society. What are the risk factors for cancer of the esophagus?
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophagus-cancer-risk-factors. Updated November 6, 2014.
Accessed December 14, 2014.
National Cancer Institute. Alcohol and Cancer Risk. http://www.cancer.gov/cancertopics/factsheet/Risk/alcohol. Updated June
24, 2013. Accessed December 14, 2014.
Long E and Beales ILP. The role of obesity in oesophageal cancer development. Ther Adv Gastroenteral. 2014;7(6):247-268.
Alexandre L, Long E, and Beales ILP. Pathophysiological mechanisms linking obesity and esophageal adenocarcinoma. World J
Gastrointest Pathophysiol. 2014;5(4):534-549.
Mayo Clinic. Barretts Esophagus.
http://www.mayoclinic.org/diseases-conditions/barretts-esophagus/basics/definition/con-20027054. Published August 7,
2014. Accessed December 14, 2014.
American Cancer Society. Signs and symptoms of esophagus cancer.
http://www.cancer.org/cancer/esophaguscancer/detailedguide/esophagus-cancer-signs-and-symptoms. Updated November 6,
2014. Accessed December 14, 2014.
Kosovec JE, Zaidi AH, Komatsu Y, Kasi PM, Cothron K, Thompson DV, Lynch E, and Jobe BA. Establishing magnetic resonance
imaging as an accurate and reliable tool to diagnose and monitor esophageal cancer in a rat model. PLOS.
2014;9(4):e93694.
Medscape. Esophageal Cancer Staging. http://emedicine.medscape.com/article/2003224-overview. Updated September 6,
References
14.
Tew WP, Kelsen DP, and Ilson DH. Targeted therapies for esophageal cancer. Oncologist. 2005;10(8):590-601.
15.
Nutrition Care Manual. Esophageal. http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=145164. Accessed January 19,
2015.
16.
Evidence Analysis Library. Oncology.
https://www.andeal.org/topic.cfm?cat=2959&conclusion_statement_id=250683&highlight=esophageal%20cancer&home=1.
Updated 2007. Accessed January 19, 2015.
17.
Ligthart-Melis GC, Weijs PJM, te Boveldt ND, Buskermolen S, Earthman CP, Verheul HMW, de Lange-de Klerk ESM, van
Weyenberg SJB, van der Peet DL. Dietician-delivered intensive nutritional support is associated with a decrease in severe
postoperative complications after surgery in patients with esophageal cancer. Diseases of the Esophagus. 2013;26:587-593.
18.
Wu J MD PhD, Huang C MHS, Xiao H MD PhD, Tang Q MD, Cai W MD PhD. Weight loss and resting energy expenditure in male
patients with newly diagnosed esophageal cancer. Nutrition. 2013;29:1310-1314.
19.
Mahan KL, Escott-Stump S, Raymond JL. Krauses Food and Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders;
2012:842-854.
20.
Miller KR, Bozeman MC. Nutrition therapy issues in esophageal cancer. Current Gastroenterology Reports. 2012;14:356-366.
21.
Ryan AM, Reynolds JV, Healy L, Byrne M, Moore J, Brannelly N, McHugh A, McCormack D, Flood P. Enteral nutrition enriched
with eicosapentaenoic acid (EPA) preserves lean body mass following esophageal cancer surgery: results of a double-blinded
randomized controlled trial. Annals of Surgery. 2009;249(3):355-363.
22.
American Society of Parenteral and Enteral Nutrition Board of Directors and the Clinical Guidelines Task Force. Guidelines for
the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN J Parenter Enteral Nutr. 2002;26(suppl 1):1SA138SA.
23.
Seike J, Tangoku A, Yuasa Y, Okitsu H, Kawakami Y, Sumitomo M. The effect of nutritional support on the immune function in
