1. Case Study # 33 Esophageal Cancer
Adrienne Grogan
Mariah Guthrie

2. Esophageal Cancer 20% 5 year survival rate Two types Squamous
Adenocarcinoma

3. Adenocarcinoma
Cancer found in the secretory cells of the body. These type of cells secrete mucus, digestive juices, or other fluids into the body. Common adenocarcinoma cancers are found in the breast, prostate, esophagus, pancreas, lungs, and colon.

4. Etiology of Esophageal Cancer
Smoking
Heavy Drinking
Male
Poor diet
Obesity
GERD
Barrett’s Esophagus
Poor Diet
According to his medical record, Mr. Seyer has had heartburn for about a year, has smokes two packs a day, and drinks a moderate amount of alcohol, all of which are risk factors for esophageal cancer.
Barrett’s esophagus:
Barrett’s esophagus is a condition in which the tissue lining the esophagus—the muscular tube that carries food and liquids from the mouth to the stomach—is replaced by tissue that is similar to the intestinal lining.
People with Barrett’s esophagus are at increased risk for a rare type of cancer called esophageal adenocarcinoma.

5. Patient Description Mr. Seyer, 58 y.o. male
After undergoing chest x-ray, endoscopy with brushings and biopsy, and CT scan, diagnosed with Stage IIB (T1, N1, M0) adenocarcinoma of esophagus
Dysphagia and Odynophagia
Smokes 2ppd/ drinks 1-2 drinks/1-2 x week

6. Staging of Cancer Mr. Seyer’s Diagnosis= Stage IIB (T1, N1, M0)
T- how far the tumor has grown
N- nearby lymph nodes
M- metastasized to other organs
Stage IIB of the esophagus is described as the cancer that has grown into layers below the epithelium and has been found in 1 or 2 of the nearest lymph nodes, but has not yet spread to lymph nodes far away to the esophagus (NCI).

7. Patient History Height: 6’3” Weight: 198lbs. Current BMI: 24.7
Normal Weight: 228lbs.
%UBW: 86.8%
14% weight loss= severe
Mr. Seyer as experiencing a severe weight loss since he has lost more than 10% of his UBW in a short timeframe. There are a few factors that could have contributed to this significant weight loss. He has not been wanting to eat due to pain and heartburn, and now he is experiencing difficulty swallowing foods of certain texture. Additionally, Mr. Seyer’s diagnosis of cancer increases his caloric needs in order to maintain his body weight due to the fact that cancer cells cause increased energy demands and change the metabolism of fat, protein and carbohydrate in the body

8. Nutritional Effects of Cancer
Nausea and Vomiting
Cachexia
Metabolic Changes
protein (increased protein metabolism, decreased protein synthesis, depletion of lean body mass)
fat (increase of lipid metabolism, depletion of total body fat)
carbohydrate (increased gluconeogenesis, glycose synthesis, increased cori cycle activity)

9. Diet Usual Dietary Intake 24 Hour Recall AM: Eggs, bacon, toast
Lunch: cold lunch, with sandwich, deli meat, leftovers, fruit, cookies, tea
PM: All meats, rice or pasta, 2-3 vegetables, 1-2 beers
24 Hour Recall
Am: 1 packet oatmeal, coffee
Lunch: 6oz. tomato soup, 2-4 crackers
Dinner: Macaroni and Cheese (½ cup)
Bedtime: 1 scoop chocolate ice cream

10. Abnormal Lab Results

11. Transhiatal Esophagectomy
Removes diseased part of esophagus
Stomach is attached to remaining part
A problem often seen in patients who undergo this type of operation is that after eating meals they experience regurgitation, or backwash of stomach contents. The solution to this problem is keeping the patient from laying down for a period of time after a meal

12. Radiation Therapy Side Effects: Dysgeusia Delayed wound healing
mucositis
dysphagia
xerostomia
Kill cancer cells by sending high doses of radiation to the cancer cells of the tumor
Targeted to affect just the tumor whereas chemo treats the whole body
Administered from a machine outside of the body or from objects put inside of the body
These side effects often will require the placement of a jejunal feeding tube, in order for the patient to receive an adequate supply of nutrients.

13. Potential Nutritional Complications of Radiation Therapy
xerostomia
anorexia
dysphagia
dysgeusia
mucositis
xerostomia- dry mouth
dysphagia- difficulty swallowing
dysgeusia- alterations in taste (metalliac taste, and meats disliked→ using plastic utensils and other types of high protein foods such as pb, cottage chese, cheese, and soy meat subsititues)

14. Nutrition Assessment REE Energy Requirements (30-35 kcal/kg)
(10 x 90kg) + (6.25 x 190.5cm) – (5 x 58yrs) + 5= 1,805 kcal
Energy Requirements (30-35 kcal/kg)
30 kcal x 90kg= 2,700 kcal
35 kcal x 90kg=3,150 kcal
Protein Requirements (extreme wasting g/kg)
1.5g x 90kg=135g
2.5g x 90kg=225g
Fluid Requirements (30-35 mL/kg)
30mL x 90kg=2,700 mL
35mL x 90kg=3,150mL
** Stress importance of calorie and protein intake due to correlation between weight loss and prognosis of cancer
Research tells us that there is a strong correlation between significant weight loss and prognosis of patients with cancer. In patients who are malnourished, there is an increased risk of morbidity and mortality and an overall decreased quality of life. Additionally, weight loss is often an indicator of a poor prognosis. Patients who get adequate nutrition should better maintain their weight and nutrition stores as well as get relief from nutrition impact symptoms and a better quality of life. However in patients who do not get adequate nutrition, treatment side effects tend to be more severe, and they also will have an increased risk of infection and lower chances for survival

15. Isosource HN Formula Isosource HN: 1.2 kcal/mL 18% Protein 53% Fat
29% Carbohydrate
*high in omega fatty acids & protein
Best option for our client compared to other forms of isosource

16. Isosource HN Formula Current Nutrient Breakdown of Enteral Formula:
Kcals= 75 mL/hr x 24 hr=1,800 mL x 1.2kcal/mL= 2,160 kcal
Protein=2,160 kcal x .18 protein= 388.8kcal from protein / 4 kcal/g protein= 97.2g protein
*Recommended 2,700-3,150kcal and 135-2,25g protein
Energy Requirements (30-35 kcal/kg)
30 kcal x 90kg= 2,700 kcal
35 kcal x 90kg=3,150 kcal
Protein Requirements (extreme wasting g/kg)
1.5g x 90kg=135g
2.5g x 90kg=225g

17. PES Statements
PES 1:
Malnutrition related to decreased appetite and pain while eating as evidenced by weight loss of 30# over past several months.
PES 2:
Inadequate protein intake related to changes in metabolism due to cancer state as evidenced by weight loss and low total protein, prealbumin, and albumin levels.

18. Intervention
Change formula to Isosource HN 1.2kcal at 105 mL/hr x 24 hours.
Kcals= 105 mL/hr x 24 hr=2,520 mL x 1.2kcal/mL= 3,024 kcal
Protein=3,024 kcal x .18 protein= 544 kcal from protein / 4 kcal/g protein= 136 g protein
** even though currently at what is considered “healthy weight” according to BMI, and previous was overweight, out primary concern is getting him adequate nutrients, so it is OK and GOOD for him to be getting his many calories and to gain weight

19. Intervention Once off enteral nutrition formula…
Clear liquids (no caffeine)
High calorie/high protein beverage (ex: Ensure or Boost)
small meals 6-8 times a day
Multivitamin and mineral supplement

20. Intervention Clear liquid diet Thickened or thick liquid diet
Soft and pureed foods
Foods softened with gravy or water

21. Monitoring/Evaluation
Weight (3x week)
Signs of edema (daily)
Signs of dehydration (daily)
fluid intake and output (daily)
nitrogen balance (weekly)
stool output and consistency (daily)
urine glucose (weekly)
serum electrolytes, BUN, creatinine, and blood count (weekly)
chemistry profile such as proteins, calcium, magnesium, phosphorus, LFT’s (weekly)

22. Resources
American Cancer Society. Treatment Types. (n.d.). Retrieved October 2, 2014, from
Definition of adenocarcinoma - NCI Dictionary of Cancer Terms. (n.d.). Retrieved September
22, 2014, from
Esophageal cancer treatment. (2014). National Cancer Institute. Retrieved from
National Cancer Institute, (NCI). What You Need To Know About" Cancer of the Esophagus.
(2013, April 4). Retrieved September 22, 2014, from
Nelms, M. (2011). Nutrition therapy and pathophysiology (2nd ed., p. 48. Belmont, CA:
Wadsworth, Cengage Learning.

23. Resources
Nutrition in Cancer Care (PDQ®). (2014, September 3). Retrieved October 1, 2014, from
age1.
Transhiatal Esophagectomy (THE). (2012, May 8). Retrieved October 2, 2014, from
Types of Esophageal Cancer. (2013, April 4). Retrieved September 22, 2014, from
Witte, S., & Mahan, L. (1996). Krause's food, nutrition and diet therapy(9th ed.). Philadelphia:
Saunders.