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Diagnosed Esophageal Cancer

Major Case Study



Elizabeth Haley
University of Maryland Diete;c Internship

Outline
! Overview of Esophageal Cancer
! Meet the Pa;ent
! Nutri;onal Considera;ons
! Nutri;on Assessment & Therapy
! Conclusions & Summary

Overview of Esophageal Cancer

Types of Esophageal Cancer

! Adenocarcinoma
! Most common in United States
within the past 2 years

! Squamous cell carcinoma

! Most common worldwide

Signs & Symptoms

! Dysphagia
! Vomi;ng and regurgita;on
! Gastroesophageal reux and heartburn
! Odynophagia
! Weight loss

Detection
! No screening for average person at risk
! Pre-cancer screening for those at high risk
! BarreRs esophagus
! Signs of dysplasia

! Endoscopic tes;ng with biopsy

Treatment Options
! Esophageal resec;on
! If caught in early stage
! Esophagoastrectomy

Treatment Options
! Mul;modal therapy
! For more advanced stage
! Chemotherapy and radia;on treatments
! Chemotherapy treatments include 5-uorouracil and cispla;n or
taxane
! Targeted drug therapy include Hercep;n and Cyramza

Treatment Options
! Balloon dila;on, bougienage,
thermocoagula;on, photodynamic
therapy, or expandable metal
prothesis or stent
! Pallia;ve measures

Metastatic Disease
! Trachea
! Spine
! Chest wall
! Lungs

Meet the Patient

General Information
! 59 y.o caucasian male
! AdmiRed to BWMC 11/11/15 with c/o abdominal pain, chest wall
pain, diculty swallowing, urinary reten;on, ascites with laboratory
evidence of hyponatremia, hypomagnesemia, metabolic acidosis,
and RLL pneumonia
! Final diagnosis of metasta;c esophageal cancer to chest wall, Type 2
Diabetes Mellitus, Hypertension, Iron deciency anemia, RLL
Pneumonia, sepsis with Acute Respiratory Failure
! DV expired on November 20, 2015

Social History
! DV married living with wife, son, and daughter-in-law
! Unknown family history
! Employed by automobile dealership working in the parts
department
! Grade level of educa;on unknown
! History of alcohol abuse drinking about 6 drinks daily
! Pa;ent denied use of tobacco, smokeless tobacco, or illicit drug use

Past Medical History

! Seizure disorder
! Type 2 Diabetes Mellitus
! Hypertension
! Cirrhosis
! Anemia
! Alcohol abuse
! CVA
! High cholesterol

Nutritional History
! Diet History
! DV followed a regular diet at home previous to admission (PTA)
! He ate breakfast, no lunch, and very limited food at dinner. For a snack he would have ice cream at
night
! Pa;ent reported he was experiencing early sa;ety and had a limited appe;te

! Physical Ac;vity
! Limited
! Pa;ent reported shortness of breath going up and down stairs

! Weight History
! UBW: 210lbs
! May 2015: 160lbs (50lb weight loss in 1 month, -23%)
! November 2015: 180lbs (20lb weight gain since may, -14% of UBW)
*Note since the pa;ent was admiRed with ascites, this was masking an even greater loss of lean
body mass.

Hospital Stay
! Day 1: AdmiRed with c/o diculty swallowing, diculty breathing, ascites,
and signicant weight loss. A CT chest/pelvis, US abdomen, and CXR was
ordered.
! Day 2: Dieren;al primary diagnosis Esophageal Cancer in the context of
alcohol abuse versus primary Hepatocellular Cancer (HCC) secondary to liver
cirrhosis that was metasta;c to the esophagus.
! CT showed mass
! US showed hepatomegaly, faRy inltrate, thick walled gallbladder, and mild
perihepa;c ascites
! CXR showed a mass in the right upper anterolateral lung, emphysema

Hospital Stay
! Day 3 Suspected:
! esophageal malignancy (r/t esophageal mass, reported 50lb wt. loss)
! second lung/chest wall malignancy (metasta;c disease versus lung cancer)
! hepatomegaly with LFTs (ETOH disease related versus metasta;c liver cancer
versus primary liver cancer)
! iron deciency anemia (suspected blood loss from esophageal mass)
! Paracentesis, chest wall mass biopsy, colonoscopy completed with diagnosis of
colonic diver;culi;s, EGD completed with biopsy of mass and decision made to
place stent.

! Day 4: Thoracic surgery determined no surgery was necessary at this ;me

but will follow biopsy results. Thoracic surgery suspected the diagnosis
would be stage 4-esophageal cancer.

Hospital Stay
! Day 5: Mild increase in WBC. Glucose controlled, no longer needing
medica;on. Magnesium repleted.
! Day 6: Pathology pending for suspected stage 4 esophageal cancer.
Surgery determined the pa;ent not a surgical candidate due to metasta;c
disease.
! Day 7: EGD for stent placement. Esophageal and chest wall biopsy results
were pending.
! Day 8: Repeat paracentesis. On nasal cannula for new respiratory distress.

Hospital Stay
! Day 9: DV was found unresponsive and obtunded by nursing sta; he had
developed hypoxia and became hypotensive. Again responsive but remained
lethargic and confused. Started on bicarbonate drip. New RLL inltrate.
Started on IV an;bio;cs. Foley catheter placed. Pathology reports came
back posi;ve for adenocarcinoma. Pallia;ve measures in place.
! Day 10: Pa;ent placed on comfort measures. Pa;ent expired at 11:18 am.
Family was present.

Diet & Intake

Nutritional Considerations

Nutritional Indicators
! Dysphagia
! Vomi;ng and regurgita;on
! Gastroesophageal reux and heartburn
! Odynphagia
! Weight loss
! Obstruc;on
! Tracheoesophageal stula
! Gastrointes;nal bleed

Nutrition Interventions
! Iden;fy symptoms impac;ng pa;ents nutri;on
! Emphasize on adequate protein and energy
! Consider vitamin and/or mineral supplementa;on if needed
! Adjust food texture if needed
! If pa;ent has a stent, have pa;ent drink liquids before solid foods
and con;nually drink liquids while ea;ng
! If pa;ent is showing con;nual poor nutri;onal status, enteral feeds
should be considered. Omen seen in post-surgical pa;ents
! Dumping syndrome may be seen in pa;ents post-esophagectomy

Nutrition Assessment & Therapy

Nutrition Diagnosis
Inadequate oral intake related to early sa;ety as evidence
by signicant -13% weight change in the past 6 months.
May 2015 weight was 210lbs, admission weight 180lbs.

Nutrition Prescription
!Calorie Needs: 2072-2487kcal/day (25-30kcal/kg for
diabetes maintenance)
!Protein Needs: 82.9-99.48g/day (1-1.2g/kg)
!Fluid Needs: 2487mL/day (30mL/kg)

Nutrition Intervention
Ini;ate PO diet beyond clear liquids vs. nutri;on support
within 72 hours.

Monitoring & Evaluation

!Meals and Snacks: Con;nue clear liquid diet. Advance to
consistent CHO high when medically appropriate and as
tolerated.
!Medical Food Supplement: Pa;ent currently receiving Ensure
Clear with CLD, pa;ent does not like the mixed berry avor,
would suggest trying apple. As diet advances, RD to order
Glucerna (chocolate) as pa;ent reports drinking at home and
appropriate for consistent CHO diet.
!IDNT Other: Con;nue to monitor glucose control, PO intake,
weights, GI func;on, and lytes/labs.

Conclusions & Summary

Key Points
! Rapid spreading disease
! Signs of weight loss is crucial
! Relieve symptoms (pre-treatments, during treatments)
! Texture modica;ons
! Food preferences

! Adequate protein and energy

Thank you!

Ques;ons?

References
!

Absi, A. Esophageal Cancer. Cleveland Clinic: Center for Con;nuing Educa;on. hRp://www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/hematology-oncology/esophageal-cancer/. Accessed: May 3, 2016.

Almhanna, K., Hoe, S. (2015). Esophageal cancer 2015, more ques;ons than answers. Journal of Gastrointes;nal Oncology.

Esophagus Cancer Overview. The American Cancer Society. hRp:/www.cancer.org/acs/groups/cid/documents/webcontent/003049-

pdf.pdf. Accessed: May 2, 2016.

Esophageal Cancer: Treatment Op;ons: Cancer.net hRp://www.cancer.net/cancer-types/esophageal-cancer/treatmentop;ons.

Updated October 20, 2015. Accessed March 22, 2016.

Hanna, W.C., Sudarshan, M., Roberge, D., David, M., Waschke, K.A., Mayrand, S., Alcindor, T., Ferri, L.E. (2012). What is the op;mal
management of dysphagia in metasta;c esophageal cancer? Current Oncology

Lagergren, J., (2014). Advances in cura;vely intended treatment. Nature Reviews: Gastroenterology & Hepatology.

Oncology Cancer Sites: Esophageal. Online Nutri;on Care Manual. Academy of Nutri;on and Diete;cs. hRps://
www.nutri;oncaremanual.org/topic.cfm
ncm_category_id=1&ncm_toc_id=145164&ncm_heading=References&ncm_content_id=92733. Accessed: May 3, 2016.

Stahl, M., MarieRe, C., Haustermans, K., Cervantes, A., & Arnold, D., (2013). Oesophageal cacner: ESMO Clinical Prac;ce Guidelines
for diagnosis, treatments and follow-up Annals of Oncology

Targeted Therapy for Cancer of the Esophagus. The American Cancer Society. hRp://www.clevelandclinicmeded.com/medicalpubs/
diseasemanagement/hematology-oncology/esophageal-cancer/. Accessed: May 3, 2016.