Supraglottic Squamous Cell Laryngeal Carcinoma

Brikeda JazexhiuSodexo Mid-Atlantic Dietetic InternshipFebruary 7, 2010

General Information DP83 year old African-American femaleAdmitted to Maryland General Hospital

12/15/10◦ Dx: difficulty breathing and swallowing◦ ICU s/p tracheostomy

Discharged to nursing home on 12/28/10◦ Dx: supraglottic squamous cell laryngeal

carcinoma, adenocarcinoma of the right upper lobe, healthcare-acquired pneumonia, pulmonary edema w/ possible dx of CHF, thrombocytopenia, normocytic anemia, Clostridium difficile colitis

Social History Occupation: housekeeper at St. Agnes

Hospital until retirementEducation: 9th grade high school Marital Status: legally married,

separatedLiving Arrangements: lives with her son

and his family Religious Group: Baptist Smoker: 2PPD x 30 years, quit 5 years

ago◦MD suspected COPD dx in the past

Past Medical History HypothyroidismHypertensionHysterectomy Tubal Ligation Admitted to St. Agnes Hospital 2o

dysphagia on 9/10St. Agnes: MBS showed aspirationFamily History: mother with cancer

Outpatient Medications

Diovan Antihypertensive: Works by blocking angiotensin II receptor blockers, decreasing the effectiveness of angiotensin II. Causing blood vessels to dilate, which lowers blood pressure.

Hydrochlorothiazide Antihypertensive, Diuretic: Works by increasing the amount of salt and water that the kidneys remove from the blood. Causes a decrease in blood volume, decreasing blood pressure.

Synthroid Synthetic T4 thyroid hormone

Present Medical Problem Coughing episodes after meals

and during the middle of the night x 4 mos

Difficulty swallowing x 4 mos 12/10/10- visited outpatient

Otolaryngologist for dysphagia12/15/10- admitted to MGH 2◦

difficulty breathing/swallowingICU following tracheostomy procedure

Procedures Flexible fiberoptic bronchoscopy

Conducted through trach tube. Results showed secretions, no signs of endobronchial lesions

Rigid esophagoscopy Conducted using a Jesberg esophagoscope. No signs of esophageal lesions

Direct suspension microlaryngoscopy

Conducted using a Dido laryngoscope. Found a 3 cm papillary tumor attached to the laryngeal surface of the epiglottis and to the left of the midline involving the left aryepiglottic fold, as well as the left vocal fold and extending slightly to the left lateral glossoepiglottic fold.

Imaging-CT scan Mass identified within the left aryepiglottic fold with extension to the pharyngoepiglottic fold and epiglottis.

Laryngeal Carcinoma Etiology

Statistics◦2007-2nd most common malignancy of the

head and neck ◦2007-11th most common form of cancer

among men worldwide◦2010-10,110 men and 2,610 women

diagnosed◦2010-3,600 mortalities

Polulations at risk: African-American males over the age of 55 years old ◦Rare in individuals under the age of 30 (1%)

Laryngeal Carcinoma Etiology

Primary risk factor◦Tobacco use: constitutes 85% of

laryngeal malignancies ◦Smokers:10-20 times higher risk◦Smoking cessation: reduces risk by

60% in patients who have not smoked in 10-15 years

◦Smoking history: 14% increased chance in developing second head and neck carcinoma

Laryngeal Carcinoma Etiology

Co-risk factor◦Alcohol use: synergistic risk factor

Additional risk factors◦Asbestos, nickel compounds, wood

dust, leather products, paint diesel fumes and glass wool

◦Chronic GERD and HPV-16 suspected risk factors, however no causal link

Anatomy of the Larynx

Supraglottis

Glottis

Subglottis

Anatomy of the LarynxSupraglottis: extends from the tip of the

epiglottis to the laryngeal ventricle◦1. Epiglottis◦2. False vocal cords◦3. Aryepiglottic folds◦4. Arytenoids

Glottis:1 cm below the vocal cords◦1. True vocal folds◦2. Anterior and posterior commissure

Subglottis: expands to the inferior margin of the cricoid cartilage

Normal Swallowing Function

Three stages:

◦ oral

◦ pharyngeal

◦ esophageal

Supraglottic CarcinomaVarious diagnosis

◦95% are squamous cell carcinomas

◦Remainder 5% consist of: Salivary gland tumors Mesenchymal tumors Benign neoplasms

Pathophysiology Begins at the cellular level with

mutations in the DNA, caused either form genetic, environmental or lifestyle factors

Supraglottic and subglottic:◦More likely to metastasize due to

locationGlottic:

◦Less likely to metastasize due to anatomic barriers

PathophysiologyAnatomical

concepts:◦ Pre-epiglottic

space: filled with fat between the epiglottis and hyoid bone. Epiglottic cartilage allows the tumor to have access to the soft tissues around the neck.

PathophysiologyAnatomical

concepts:◦ Paraglottic space:

filled with fat laterally within the supraglottis. Allows transglottic tumor formation through mucosa access

Survival Rates/TreatmentMost recurring

malignancies occur 2 years post primary treatment

65% of patients diagnosed with laryngeal cancer live ~5 years

RadiationChemotherapyLaryngectomyCombination of

chemoradiotherapy

DP’s Supraglottic TumorSurgeon removed ~90% of tumor

with the cup-biting forcepsTumor was large enough to block

view of vocal cordsSuspected probable squamous

cell carcinomaTumor stage: T2, N0, MX

◦Could be M1 if lung mass was metastatic cancer from the larynx

Laryngeal Tumor Staging TNM staging:

◦Divided into three subgroups of the supraglottis, glottis and subglottis.

Influence on Nutritional Status

Supraglottic laryngeal cancer often leads to nutritional depletion causing:◦Dysphagia◦Odynophagia◦Dysgeusia◦Fatigue leading to decreased po intake ◦Further contribution to wt loss

The main nutrition related problem resulting from head and neck cancer is dysphagia

Physical Assessment (12/16)

Asymptomatic bradycardiaBP of 118/56 mm HgTemperature: 97.1◦ FPulse rate: 50 BPM Respiratory rate: 16 BPMChest: bilateral breath sounds

without wheezes/crackles/murmurs

Physical Assessment (12/16)

HEENT: atraumatic and normocephalicOral: upper and lower denturesSkin: intact, no signs of jaundice Abdomen: soft, non-tender with

present bowel sounds Extremeties: no signs of

clubbing/cyanosis/edema CNS: alert and oriented x 3Appearance: nourished, yet noted w/

wt loss

Admission Medications (12/16)

AlbuterolDiovanHydrochlorothiazideOxycodoneProtonixSimvastatinSynthroid

Lab Values-Initial Assessment (12/16)

Na:139 mEq/LK: 3.7 mEq/LCl: 108 mEq/LCO2: 26 mEq/LBUN: 15 mg/dLCreat: 0.74

mg/dLGluc: 136mg/dL

HMCV: 93.7 fL Ketones: 5 mg/dL

Ca: 8.2 mg/dL LMg:1.9 mEq/LPhos: 2.7 mg/dLWBC: 7,500 mcLRBC: 3.51 Mi

l/mm3 LH/H: 10.1/32.9%

LTSH: 0.023 LFree T4: 1.69 H

Nutrition History (12/16)Decreased appetite x 4 mosNever finished meals and

stopped eating after several bitesCoughing episodes after each

mealUrged by family to increase oral

intake

Nutrition Assessment (12/16)

NKADiet order: NPOOral intake: poor PTAComplained of mostly nausea at

timesComplained of pain affecting oral

intake near throat area and behind ears

Nutrition Assessment (12/16)

Anthropometrics◦Ht: 63”◦BMI: 25◦Wt: 134#, 61 kg ◦IBW: 115#, 52 kg ◦% IBW: 127#, 58 kg◦UBW: 146#, 66 kg ◦% UBW: 92%◦Adjusted BW: 123#, 56kg◦% wt change: 8.2% x 4 mos

Nutrition Assessment (12/16)

Estimated Needs◦Kcals: 30-35 kcal/kg

~1,680-1,960 kcal

◦Protein: 1.5-2 g protein ~84-112 g protein/kg

◦Fluids: 30 ml/kg ~1,680 ml/kg

Nutrition Diagnosis (12/16)

PES Statement

◦Swallowing difficulty related to mechanical causes, as evidenced by pt with coughing episodes during meals

◦Unintended weight loss related to decreased oral intake 2◦ difficulty swallowing, as evidenced by 8.2% weight loss x 4 mos

Intervention/Recommendations (12/16)

Rec: as medically safe to eat, consistency per SLP evaluation/recommendation

Rec: begin TF if FEES failed◦ Initiate at low infusion rate to prevent

refeeding syndrome: Infuse @10 ml/hr and increase 10 ml every 8 hours Provides 77 g of CHO initially

◦Fibersource HN 65 ml/hr, 100 ml flushes q6h Provides 1,872 kcal, 82 g protein and 1,679 total

fluids Provides 33 kcal per kg of body weight

Monitoring and Evaluation (12/16)

Weight◦Maintain weight◦Monitor for fluctuation

Protein-energy needs◦Pt to meet ~75-100% of estimated

nutritional needs

SLP Evaluation (12/17) Bedside evaluation-done with

applesauce to rule out aspiration◦No signs of penetration or aspiration◦Silent aspiration suspected

FEES◦Showed silent aspiration on own

secretions◦Pt lacked reflexive cough and presented

decreased sensation◦Recommendation for PEG tube

Regimen of Therapies PEG tube placed to improve

nutritional status and prevent further weight loss, as DP planned to undergo radiation and chemotherapy

PEG tube is preferred for head and neck cancer 2◦ radiation induced oral and esophageal ulcerations

Nutrition RoleNutrition intervention benefits

the patient by:◦ preventing nutritional deterioration◦ improving kcal/protein intake◦ maintaining anthropometric

measurements◦ improving the quality of life

Enteral NutritionEN is recommended if the patient is

malnourished or po intake has declined for more than 7-10 days

Standard formula recommended ◦Glucose tolerance may be impaired in

cancer patients EN recommended in patients

undergoing radio-chemotherapy◦Helps prevent therapy associated wt loss ◦Helps limit interruption of radiation

therapy

Enteral Nutrition According to the EAL, intensive

nutrition therapy of 40 kcals/kg minimized weight loss and preserved fat-free body mass in patients with head and neck cancers◦Radiation therapy: outpatient EN improved

weight status, increased calories and protein and improved tolerance of therapy for better outcomes

◦Recommendations begin with 30-35 kcal/kg and 1.0-1.5 g protein/kg and increase per patient needs

EN Initiated (12/18)Fibersource HN @ 65 ml/hr, 100

ml flushes q6h-Rec begin @ 10 ml/hr◦Initiated @ 40 ml/hr

Provided: 1,152 kcal, 61 g protein

Refeeding syndromePotassium Magnesiu

mPhosphate

Initial Assessment 12/16/10

3.7 mEq/L 1.9 mEq/L 2.7 mg/dL

Day 2 TF 12/19/10

3.5 mEq/L 1.7 mEq/L 1.3 mg/dL

Refeeding SyndromeRepleted with:

◦Potassium Phosphate◦Magnesium Sulfate◦Potassium Chloride

Guidelines:◦Don’t advance nutrition until

electrolytes are WNL◦Thiamine: 100 mg daily for 5-7 days◦Folate: 1mg/day 5-7 days

Follow Up (12/21) Temperature: 101.1◦ F

◦Suspected pneumonia 2◦ to febrile state-X-ray completed Results positive for healthcare-acquired pneumonia

2◦ improper suctioning of trach tube Treated with Vancomysin, Zosyn and Levaquin

Complains of persistent diarrhea◦Suspected C.diff.-stool sample checked

Treated with Flagyl

◦Recommended d/c Docusate

Follow Up Medications (12/21)

BisacodylCalcium with Vit. DDocusate SodiumFerrous SulfateLevoxyl

Follow Up Tube Feeding Rate (12/21)

TF upon admit (12/16): Fibersource HN @ 65 ml/hr, 100 ml flushes q6h◦Provided: 1,872 kcal, 82 g protein and

1,679 total ml◦Provided: 33 kcal per kg of body wt

MD prescribed TF: Fibersource HN @100ml/hr, 100 ml flushes q6h◦Provided: 2,880 kcal, 127 g protein,

2,344 ml total fluids ◦Provided: 51 kcal per kg of body wt

Follow Up Labs (12/21) Na:140 mEq/LK: 4.4 mEq/LCl: 107 mEq/LCO2: 27 mEq/LBUN: 16 mg/dLCreat: 0.64

mg/dLGluc: 150mg/dL

HMCV: 94.3 fL

Ca: 8.2 mg/dL LMg:1.7 mEq/L LPhos: 1.3 mg/dL

LWBC: 8,400 mcLRBC: 3.31 Mi

l/mm3 LH/H: 9.7/31.5% LPrealbumin: 6.9

LKetones:

negative

Electrolytes

Potassium Magnesium Phosphate

Initial Assessment 12/16Rec: infusion rate 10 ml/hr

3.7 mEq/L 1.9 mEq/L 2.7 mg/dL

Day 2 TF 12/18Infusion rate 40 ml/hr

3.5 mEq/L 1.7 mEq/L 1.6 mg/dL

Day 5 TF 12/21Infusion rate 100 ml/hr

4.4 mEq/L 1.7 mEq/L 1.3 mg/dL

Follow Up Nutrition Assessment (12/21)

Estimated Needs (based on actual body weight 61 kg)◦35-40 kcal/kg

~2,135-2,440 kcal

◦1.5-2.0 g protein/kg ~92-122 g protein

◦25 ml/fluid-decreased fluid needs- pt developed pulmonary edema 1,525 ml fluid

Follow Up Nutrition Diagnosis (12/21)

PES◦Excessive enteral nutrition infusion

related to current diet order, as evidenced by pt receiving ~2,880 kcal per TF formula, 135% of estimated kcal needs.

Follow Up Recommendations (12/21)

Rec: Change TF to Resource 2.0 @ 55 ml/hr, water flushes at 150ml q6h◦Provides: 2,640 kcal, 110 g protein,

1,524 ml total fluids ◦Provides: 43 kcals per kg of body

weight◦

Needs Kcals Protein Fluids

35-40 kcal/kg

1.5-2.0 g/pro

25 ml/fl

2,135-2,440

92-122 1,525

Monitoring/Evaluation (12/21)

Indicator Criteria

TF Monitor tolerance, residuals < 200 ml

GI function Monitor GI status, diarrhea

Electrolytes Monitor electrolytes/replete

Weight Monitor weight/promote weight gain

Pre-albumin Monitor pre-albumin levels

DischargeDischarged to nursing home on 12/28/10Follow up with chemotherapy and

radiationDischarge dx:

◦Squamous cell laryngeal carcinoma◦Adenocarcinoma of lung◦Healthcare-associated pneumonia◦Hypothyroidism, HTN ◦Pulmonary edema◦Thrombocytopenia ◦Normocytic anemia◦Clostridium difficile colitis

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