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?

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