Renal Cell Carcinoma Case Study

Renal Cell Carcinoma Renal Cell Carcinoma Case StudyCase Study

Presented by Erin McLean

OverviewOverview• Patient information

• Disease background

• Nutrition care process

• Conclusion

• Review of key points

• Personal impressions

Patient ProfilePatient Profile• Gender: Male• Age: 70• Ethnic background: Hispanic• Household situation: Lives with wife, has 2

grown children living elsewhere• Education: Not disclosed• Occupation: Retired heavy equipment operator• Religion: Not disclosed• Admit date, discharge date: 09/03/13, 09/14/13

Reason for Hospital Reason for Hospital AdmissionAdmission

• The patient was admitted to the hospital for reparative surgery of a fractured right hip due to a nonsyncopal fall.

• Shortly before the patient fractured his hip, he was diagnosed with metastatic RCC.

• A x-ray exam found metastatic lesions in the area of the fracture.

Medical/Health/Family Medical/Health/Family HistoryHistory

• Past medical history:– Stage IV RCC s/p 2 chemotherapy treatments– Type 2 diabetes with neuropathy– Hypertension– Hyperlipidemia– Peripheral vascular disease– Benign prostatic hyperplasia– Chronic kidney disease stage III

Medical/Health/Family HistoryMedical/Health/Family History

• Home medications:– Enalapril, Megace, metformin, Norco, Reglan,

iron, omeprazole, tamsulosin, fluoxetine

• Quit smoking 9 months prior to admission

• No history of alcohol or illicit drug abuse

• Poor appetite

• Family history positive for type 2 diabetes

Medical DiagnosisMedical Diagnosis• Pathologic fracture in the right femoral

neck 2° metastatic RCC

• Pathologic fracture in the right proximal humerus 2° metastatic RCC

• Acute-on-chronic renal failure

RCC DefinedRCC Defined• RCC:

– Most common form of kidney cancer– 14th most common form of cancer in US– Highly vascularized malignancies– Originates in lining of proximal convoluted

tubules – Termed metastatic RCC when its spreads

RCC DefinedRCC Defined

Pathophysiology Pathophysiology • RCC consists of various tumor groups:

– Clear cell, 60-70% – Papillary, 5-15%– Chromophobe, 5-10%– Oncocytic, 5-10%– Collecting duct, <1%

PathophysiologyPathophysiology• RCC affects calcium homeostasis:

Symptoms/Clinical Symptoms/Clinical ManifestationsManifestations

• RCC often presents with symptoms unrelated to renal cancer.

• The 3 classical RCC symptoms include:– Abdominal pain, hematuria, palpable mass

• Metastatic RCC presents with:– Bone pain, pulmonary issues, adenopathy, GI

bleeds

EtiologyEtiology• Risk factors for RCC:

– Tobacco smoking– Obesity– Hypertension– Chemical exposure– Analgesic drug use– Hepatitis C infection– End-stage renal disease

Hypertension and Risk of Renal Cell Hypertension and Risk of Renal Cell Carcinoma Among White and Black Carcinoma Among White and Black

AmericansAmericans

• Purpose:– To determine the association between high blood

pressure and RCC risk for black and white Americans

• Methods:– 358 black and 843 white case participants– 519 black and 707 white control participants– HTN history and antihypertensive drugs reported– ORs and CI calculated utilizing unconditional logistic

regression • Adjusted for smoking, BMI, family history of RCC,

demographic characteristics

(Colt et al., 2011, p. 1-4)


AmericansAmericans

• Results:– In study population, HTN doubled risk of RCC – Whites had lower incidence of developing

RCC (P=0.11)– RCC risk ↑ with passing years after initial dx

of HTN with an OR of 4.1 (CI=2.3-7.4) for blacks and an OR of 2.6 (CI=1.7-4.1) for whites (P for trend <0.001)

(Colt et al., 2011, p. 1, p. 4-5)


AmericansAmericans

• Conclusion:– Among blacks and whites, HTN is a risk factor

for RCC.– Due to the increased prevalence of high blood

pressure in blacks than whites, HTN may explain the racial disparity of RCC incidence seen more commonly in the former rather than the latter group.

(Colt et al., 2011, p. 1, p. 5-7)

TreatmentTreatment• Treatment depends on:

– Type of RCC– Stage of RCC– Tissue or organs affected– Preexisting conditions or comorbidities– Nutritional status– Age

TreatmentTreatment• Surgical interventions:

– Nephron-sparing partial nephrectomy– Radical nephrectomy– Laparoscopic nephrectomy

TreatmentTreatment• Immunotherapy:

– Interleukin-2 – Interferon

• Tumor ablation therapy:– Cryoablation – Interstitial radio frequency

ablation

TreatmentTreatment• Targeted therapy:

– Sorafenib, pazopanib, sunitinib, everolimus

• Chemotherapy and radiotherapy

TreatmentTreatment• Treatment specific to patient:

– Repair of right femoral neck fracture• Right hip long stem hemiarthroplasty with cement

– Repair of right proximal humerus fracture• Intramedullary fixation

TreatmentTreatment• Medications:

– Amlodipine, cefazolin, enalapril, fluoxetine, heparin, insulin, Megace, omeprazole, pantoprazole

• Patient had received 2 chemotherapy treatments prior to admission

TreatmentTreatment• Drug-nutrient interactions:

– Fluoxetine — if taken with tryptophan supplements, can ↑ drug side effects

– Omeprazole — can ↓ calcium absorption by 61%; if taken with gingko and St. John’s wort, can ↓ drug effectiveness

(Pronsky & Crowe, 2010, p. 140, p. 260).

Nutrition InterventionNutrition Intervention• Interventions implemented to combat following

side effects associated with advanced cancer:– Nausea/vomiting– Weight loss– Early satiety– Anorexia– Xerostomia– Altered taste– Bloating – Constipation– Dysphagia

Fruit, Vegetables, Fibre and Micronutrients Fruit, Vegetables, Fibre and Micronutrients and Risk of US Renal Cell Carcinomaand Risk of US Renal Cell Carcinoma

• Purpose:– To determine if an association existed

between the risk of RCC and the intake of fruit, vegetables, fiber, and certain micronutrients

• Methods:– 323 case participants– 1,827 control participants– Questionnaires with dietary intake of

participants mailed to researchers for analysis

(Brock et al., 2011, p.1077-1078)


• Results:– Intake of vegetables ↓ RCC risk

• (P for trend =0.002)

– Vegetable fiber associated with ↓ RCC risk• (P<0.001)

– Grain and fruit fiber had no association with ↓ RCC risk

– β-cryptoxanthin ↓ RCC risk• (P for trend =0.01)

– Lycopene nonsignificantly ↓ RCC risk(Brock et al., 2011, p.1077, p.1079)


• Results cont.:– Association between RCC risk and intake of

vegetable fiber and β-cryptoxanthin stronger in those ≥65 years of age

• (P for interaction =0.001)

– Nonsmokers with low intake of fruit fiber and cruciferous vegetables had ↑ RCC risk

• (P for interaction =0.03)

• Conclusion:– Further research necessary to identify additional

nutritional compounds that ↓ RCC risk

(Brock et al., 2011, p.1077, p. 1079, p.1082-1083)

PrognosisPrognosis• Prognosis dependent on cancer stage and

method of treatment

RCC StageRCC Stage 5-Year Survival 5-Year Survival RateRate

Stage IStage I 81%81%

Stage IIStage II 74%74%

Stage IIIStage III 53%53%

Stage IV, metastaticStage IV, metastatic 8%8%

PrognosisPrognosis• Survival predictors that indicate a ↓ life

expectancy include:– ↑ serum calcium– ↑ lactate dehydrogenase – Anemia– Stage IV RCC– ↓ activities of daily living– Systemic treatment <1 year after diagnosis

Preoperative Nutritional Status Is an Preoperative Nutritional Status Is an Important Predictor of Survival in Patients Important Predictor of Survival in Patients

Undergoing Surgery for Renal Cell Undergoing Surgery for Renal Cell CarcinomaCarcinoma

• Purpose:– To determine whether nutritional deficiency is

a critical factor in determining survival after surgery

• Methods:– 369 patients who had either a partial or radial

nephrectomy– 85 patients considered nutritionally deficient

preoperatively

(Morgan et al., 2011, p. 923-924)



• Methods cont.: – Considered nutritionally deficient if:

• ≥5% body weight lost preoperatively• BMI of <18.5 kg/m2• Albumin <3.5 gm/dL

– Primary outcomes included overall mortality and disease-specific mortality

(Morgan et al., 2011, p. 923-924)



• Results:– 3-year overall survival was 58.5% and

disease-specific survival was 80.4% in experimental group

– 3-year overall survival was 85.4% and disease-specific survival was 94.7% in control group

– (P<0.001)

(Morgan et al., 2011, p. 924-926)



• Conclusion:– Addressing poor nutritional status in RCC

patients undergoing surgery is essential since it remains a significant predictor of overall and disease-specific mortality.

(Morgan et al., 2011, p. 923, p. 927)

Nutrition Care ProcessNutrition Care Process

AssessmentAssessment• Anthropometric data:

– Height: 5’11”– Weight: 72.3 kg– IBW: 78.2 kg ±10%– BMI: 22.2 kg/m2, normal

AssessmentAssessment• Biochemical labs:

Renal ProfileRenal Profile

Date 09/04 09/08 09/09 09/10 09/11 09/12 09/13

Glucose (mg/dL)

119, High 177, High Normal 112, High Normal 134, High 139, High

BUN(mg/dL)

Normal Normal Normal Normal Normal Normal Normal

Creatinine (mg/dL)

Normal 1.55, High 1.35, High 1.26, High Normal Normal Normal

Potassium (mEq/L)

Normal Normal 3.1, Low Normal Normal 3.3, Low Normal

Chloride (mEq/L)

113, High 116, High 118, High 118, High 114, High 112, High 111,High

CO2(mEq/L)

14, Low 12, Low 13, Low 16, Low 16, Low 17, Low 17, Low

Calcium (mg/dL)

6.8, Low 6.8, Low 6.8, Low 6.6, Low 6.4, Low 6.3, Low 6.2, Low

Albumin (gm/dL)

1.6, Low 1.5, Low 1.5, Low 1.5, Low 1.5, Low 1.4, Low 1.5, Low

Phosphorus (mg/dL)

2.1, Low 2.1, Low Normal 1.7, Low 2.0, Low 2.1, Low 2.0, Low

GFR (mL/min/1.73 m2)

Normal 45, Low 52, Low 57, Low Normal Normal Normal

AssessmentAssessment• Biochemical labs cont.:

Basic Metabolic Panel (BMP)Basic Metabolic Panel (BMP)

Date 09/05 09/06 09/07 09/08

Glucose(mg/dL)

173, High 154, High Normal 166, High

BUN(mg/dL)

Normal Normal Normal Normal

Creatinine(mg/dL)

1.42, High 1.47, High 1.55, High 1.56, High

Sodium(mEq/L)

135, Low Normal Normal Normal

Potassium(mEq/L)

3.4, Low 3.4, Low 3.0, Low Normal

Chloride(mEq/L)

114, High 119, High 121, High 120, High

CO2(mEq/L)

14, Low 13, Low 15, Low 12, Low

Calcium(mg/dL)

7.0, Low 6.9, Low 7.3, Low 6.9, Low

GFR(mL/min/1.73 m2)

49, Low 47, Low 45, Low 44, Low

AssessmentAssessment• Biochemical labs cont.:

Comprehensive Metabolic Panel (CMP)Comprehensive Metabolic Panel (CMP)

Date 09/14

Glucose (mg/dL)

207, High

CO2(mEq/L)

17, Low

Calcium(mg/dL)

7.3, Low

Total Protein (gm/dL)

5.9, Low

Albumin(gm/dL)

1.8, Low

AssessmentAssessment

Complete Blood Count (CBCComplete Blood Count (CBC)

Date 09/04 09/05 09/07 09/08 09/09 09/10 09/11 09/12 09/13 09/14

Red Blood Cell (m/ul)

3.70, Low 4.32, Low 4.33, Low 4.14, Low 4.09, Low 3.89, Low 3.90, Low 3.85, Low 4.04, Low Normal

Hemoglobin (gm/dL)

7.8, Low 9.9, Low 10.3, Low 10.0, Low 9.7, Low 9.2, Low 9.2, Low 9.1, Low 9.4, Low 10.5, Low

Hematocrit (%)

25.0, Low 30.4, Low 30.9, Low 29.6, Low 29.4, Low 27.6, Low 27.8, Low 27.4, Low 28.5, Low 31.9, Low

• Biochemical labs cont.:

Other LabsOther Labs

Date 09/04 09/05 09/06 09/07 09/09

Ionized Calcium (mmol/L)

1.00, Low 0.98, Low 0.98, Low 1.06, Low No lab drawn

PTH, Intact(pg/mL)

No lab drawn No lab drawn No lab drawn No lab drawn 101, High

Vit D, 25-OH(nmol/L)

No lab drawn No lab drawn No lab drawn No lab drawn 17, Low

AssessmentAssessment• Diet history:

– Poor appetite– General diet at home– No swallowing difficulties– No issues with digestion/elimination

AssessmentAssessment• Dietary consult #1:

– Sent by MD to address patient’s malnutrition status before initial surgery

– Consult sent based on patient’s low albumin labs (1.5-1.8 gm/dL throughout stay)

– Per daughter, patient consumed <50% of each meal

AssessmentAssessment• Calculated needs:

– Calories • 2170-2530 kcal (30-35 kcal/kg ABW)

– Protein• 94-108 gm/day (1.3-1.5 gm/kg ABW)

– Fluid• 2170-2530 ml/day

• Level 2 nutritional compromise:– Limited PO intake (<50%)– Unintentional weight loss PTA

Nutrition DiagnosesNutrition Diagnoses• PES statements:

– Inadequate energy intake related to current condition as evidenced by intake record.

– Increased nutrient needs related to metabolic stressors as evidenced by albumin.

Nutrition InterventionNutrition Intervention• Nutrition intervention:

– Glucerna Snack Shake TID (420 kcal)– Mighty Shake TID (384 kcal)– Encouraged to order from room service menu– Request to MD to liberalize diet – Continue Megace (400 mg BID) and calcium

gluconate

Monitoring & EvaluationMonitoring & Evaluation• Monitoring and evaluation:

– Patient’s serum albumin labs would trend towards normal limits

– Patient would meet >75% of estimated nutritional needs from oral food intake

– Lean body mass would remain intact

AssessmentAssessment• Dietary consult #2:

– Sent by MD to address increasing calcium in the patient’s diet

– Consult sent based on patient’s low ionized calcium labs (0.98-1.06 mmol/L)

– Per daughter, patient consumed ~50% of each meal

AssessmentAssessment• Calculated needs remained the same

• Level 2 nutritional status remained the same

• Nutrition diagnoses remained the same

Nutrition InterventionNutrition Intervention• Nutrition intervention:

– Continue Glucerna Snack Shake TID – Discontinue Mighty Shake TID– Propass with mousse BID– Request to MD for vitamin D and PTH labs – Continue Megace (400 mg BID), calcium

gluconate, vitamin C (500 mg/day), and multivitamin (1 tablet per day)

Monitoring & EvaluationMonitoring & Evaluation• Monitoring and evaluation:

– Patient’s ionized calcium labs would trend towards normal limits

– Patient’s serum albumin labs would trend towards normal limits

– Patient would meet >75% of estimated nutritional needs from oral food intake

– Weight would remain stable– Lean body mass would remain intact– Promotion of surgical wound healing

AssessmentAssessment• Follow-up/reassessment:

– Patient reported improvement in appetite– Per patient, consuming 50-75% of each meal

• Calculated needs remained the same

• Level 2 nutritional status remained the same

• Nutrition diagnoses remained the same

Nutrition InterventionNutrition Intervention• Nutrition intervention remained the same

but with two additions: – Vitamin D supplementation – Re-instate calcium supplementation

Monitoring & EvaluationMonitoring & Evaluation• Monitoring and evaluation remained the

same but with one addition: – Patient’s vitamin D labs would trend towards

normal limits

ConclusionConclusion• Patient admitted for surgical repair of right

hip fracture• Additional fracture found in right proximal

humerus• Patient developed AoCRF which resolved

upon discharge• Medical diagnosis: Pathologic fractures• Nutritional diagnoses: Inadequate energy

intake and increased nutrient needs

ConclusionConclusion• Nutrition interventions:

– ↑ overall food intake– Treating nutrient deficiencies

• Upon discharge, albumin increased slightly

• Calcium supplementation not re-instated• Vitamin D supplements ordered • Weight could not be monitored after 2nd

consult

Review of Key PointsReview of Key Points• RCC most common form of kidney cancer

• Highly vascularized malignancies

• Affects calcium homeostasis

• Classic symptoms include:– Abdominal pain– Hematuria– Palpable mass

Review of Key PointsReview of Key Points• Most prominent risk factors include:

– Smoking– Obesity– Hypertension

• Many treatments available including:– Surgical interventions– Immunotherapy– Tumor ablation therapy– Targeted therapy

Review of Key PointsReview of Key Points• Nutrition interventions typically combat

nutrition-related side effects

• Prognosis dependent on cancer stage and method of treatment

Personal ImpressionsPersonal Impressions

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