Esophageal Cancer Treated with Surgery and Radiation

FSHN 450 Andrea Rapp

Assessment:

58 y/o male

Admission Hx: 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

Food allergies: NKA

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

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.

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)

Case Report Questions:

1. What does the term adenocarcinoma mean?

Adenocarcinoma is a term used to classify cancer by means of tissue origin. If a patient has this diagnosis, it means that the cancer had originated in the mucus-secreting glands of the body. In this particular patient, the cancer is in his esophagus.

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

There are a lot of risk factors that may lead to the development of esophageal cancer, however there are some that are more common. One risk factor would be having acid reflux (or GERD), especially if that leads to the development on Barrett esophagus. This is a condition in which the lining of the esophagus becomes damaged by stomach acid and is frequently coupled with heartburn. The patient seems to have these symptoms and conditions as he has been experiencing heartburn episodes and has reported regurgitation of foods with a sore throat upon swallowing. This condition is also more common in males, which he also meets the criteria for. Another common risk factor would be the use of tobacco. This patient is excessively smoking every day and has been for a long time. His alcohol consumption also increases the risk for this type of cancer.

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

This patient was staged using the TNM system. With his particular stage diagnosis, it means that he had stage 2 cancer in the primary tumor, with no nodes and no mets. In this system, T stands for the original tumor, the N stands for nodes, meaning whether or not the cancer has spread to any nearby lymph nodes, and the M represents metastasis, or whether or not the cancer has spread to other parts in the body. If someone has T1 that means the primary tumor is in stage one. The higher the T number is, the larger the tumor is or the more it has grown in nearby tissues. The N1 staging means that it has spread to nearby lymph nodes, but probably not too many. The higher the N number is, the more the cancer has spread to nearby lymph nodes. Finally, M0 means that there was no distant cancer spread found. If it is listed as M1, then the cancer has spread.

4. Why is cancer therapy multi-modality?

A multi-modality therapy means that it is a therapy type that involves a bunch of regimens. Having this kind of treatment is usually more effective as it decreases side effects, decreases tumor resistance, and they can target different stages of cancer cell division, increasing the effectiveness. From my own personal run in with cancer, I know this treatment works very well as I was on the multi-modality treatment of ABVD chemotherapy.

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

Height: 6’3”

Usual Body Weight: 220 BMI: 27.5

Current Body Weight: 190 BMI: 23.7

The patient has unintendedly lost 30lbs which is about 13.6% of his usual body weight which does put him at risk for malnutrition. Some of the other risk factors for malnutrition this patient has would be his regurgitation of foods and also that he is not eating due to heartburn, pain upon swallowing, and foods getting stuck in throat. Also, looking at his 24 hour diet recall, this patient currently may not be meeting

his DRI’s for certain nutrients. He does not seem to be consuming any fruits, and the acidity of the tomatoes could be causing some GI discomfort.

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.

Kcal: 2700 kcal/d à 31 kcal/kg Found by BEE x 1.5 (due to weight loss) Protein: 1.5 g/kg of BW 126 g/d 126 x 4 = 504 kcal 19% of total daily kcal Source: 10% Freamine III (Amino Acids) Fat: 30% of total kcal Goal: 810 kcal/day 20% concentration IVFE Glucose: Remaining Kcal: 1,386 51% total Kcal D70W 70%

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.

Transition: To start, it would want to be ensured that the patient is absorbing adequate nutrients from TPN. Once that is achieved, then enteral nutrition can begin. However, it should be starting at a very low rate and coupled with TPN to ensure that the patient can tolerate the EN product and the gut is working as it should. The TPN amount should also be decreased to make sure you are not overfeeding. Once the patient begins to tolerate more of the EN feeding, then TPN can be discontinued.

Product for post-operative period: Isosource 1.5

Product for long term: Jevity 1.2

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).

a) Product: Isosource 1.5 Method of administration: Continuous Volume: 75ml/hr for a total of 1800 ml/day b) Product: Jevity 1.5 Method of administration: cyclic Volume: 180 ml/hr over 10 hour period

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

Patients Fluid Requirements: 35 ml/kg of body weight for a total of 3,010 ml

a) Amount of free water: 1386 ml b) Amount of free water: 1356 ml

Water requirements will be met by using a water flush in the tube. This will help with cleaning the tube and preventing blockages as well as meeting the needs for the patients free water.

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

PES: Unintended weight loss r/t heartburn and difficulty swallowing foods aeb diet recall and admission hx.

Goals: Increase weight by atleast 10% within the next 6 months. Increase lab values to be within normal range within the next 6 months. Ensure full tolerance to tube feeding. Monitor: Tube feeding tolerance Lab values (ex: albumin, hgb, hct, electrolytes, etc..) Weight gain/loss Adequate fluid intakes/physical conditions (ex: mucous membranes) Followup: Lab values Appetite Esophagus conditions (swallow improvements)

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

When receiving radiation, some things that could occur would be Esophagitis , Stomatitis, Mucositis, and Dysphagia. These could be an issue because it could affect whether or not the patient can consume food or even absorb it in the body. Other possibly problems could be N&V or smell changes that could lead to possible anorexia. It would be best to monitor this patient to be sure nutrient needs are being met and fluid intake and weight changes are in healthy ranges.