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Case Study: Esophageal Cancer treated with surgery and radiations

Patient Summary: After undergoing chest X-ray, endoscopy with brushings and biopsy, and CT
scan, Mr. Seyer was diagnosed with Stage IIB (T1, N1, MO) adenocarcinoma of the esophagus.
What does the term adenocarcinoma mean?
A malignant gland tumor. Aden=gland, oma=tumor, carcin=cancerous/malignant,
carcinoma=epithelial. Essentially a cancerous/malignant tumor originating from a
gland/glandular structures in epithelial tissue of the esophagus.
Define and describe these therapies: surgical resection, radiation, chemotherapy, biological
response modifier therapy, and immunotherapy. Briefly describe the mechanism for each.
In general, how do they act to treat a malignancy?
Surgical resection: The most effective and involves the removal of a tumor and/or lymph node.
Often chemotherapy or radiation is used prior to surgery to shrink the tumor, making it smaller
and easier to remove. Surgery can allow adjuvant therapy to be more effective. Reconstructive
and plastic surgery is also used to restore function and appearance.
Radiation: Localized treatment using electromagnetic rays and charged particles. It can control
the growth of a tumor when it cannot be removed, or prophylactically to protect the brain and
spinal cord from leukemic infiltration. This process works by altering the cancer cells cellular
and nuclear material; mainly the DNA. Similar to chemotherapy, radiation also targets rapidly
dividing cells. Its commonly given in combination with surgery and/or chemotherapy, and can
also be a form of palliative care.
Chemotherapy: Systemic treatment with a relatively narrow therapeutic index; chemo drugs
drugs circulate throughout the body via an IV. Four broad categories of what the drug targets:
DNA replication, small molecules/biologicals (ex: cytokines), hormonal therapy,
macromolecules. It targets rapidly dividing cells, and in doing that unfortunately healthy host
cells may also fall victim to the drugs along with the cancer cells.
Biological Response Modifier Therapy: Aim is to reinforce or restore the immune systems
ability to fight off the cancer, without directly targeting cancer cells.
immunotherapy- monoclonal antibodies (MAbs) stimulate immune response to
attack cancer cells
cytokines- administered to help mediate and regulate immune response, the types
used are interferons (INF), interleukins (IL), and hematopoietic growth factor.
hematopoietic stem cell transplantation- stem cells are from either donor, identical
twin, or the actual patient themselves. most often for hematological cancers (ex:
lymphoma).
Briefly describe the potential effect of cancer on nutritional status

Common medical problems related to cancer include nausea/vomiting, early satiety, dysgeusia,
diarrhea, mucositis, xerostomia, constipation, weight loss/ cancer cachexia, anemia, anorexia,
and fatigue. These are a result of the disease itself and/or the side effect of therapies. These
affect nutrition status because they can cause a decrease in oral energy intake, which is major
because nutrition support (enteral or parenteral) is generally only advised in some cases
depending on the individual and type of treatment. Inadequate energy intake can put the patient
at risk for being malnourished. The main goal for MNT in cancer is to prevent malnourishment,
because it can be difficult to reverse.
Describe potential nutritional and metabolic effects of both surgery and radiation.
Radiation and surgery can affect the nutritional status of cancer patients. Radiation can cause
nausea and vomiting as well as impact the patients sense of taste and smell making food less
palatable. Other adverse effects of radiation therapy, particularly in the head and neck, include
xerostomia, dysphagia, odynophagia, and severe esophagitis, all which would cause a decrease in
both fluid and energy intake. Surgery can promote swallowing disorders. All of these issues can
lead to insufficient intake and negatively impact treatment outcomes without nutritional
intervention.
Calculate and evaluate Mr. Seyers %UBW and BMI
UBW% = 90 kg x 100 = 86.9% BMI= 90 kg = 24.9
103.6kg
1.9 m2
Summarize your findings regarding his weight status. Classify the severity of his weight
loss. What factors may have contributed to his weight loss? Explain.
Mr. Seyers BMI is 24.9, which indicates he is at the borderline of normal and overweight. He
reported that he has lost 30 lbs in the last several months, a 13% weight reduction, which
indicates he is at severe nutritional risk.
Estimate Mr. Seyers energy and protein requirements based on his current weight.
Mr. Seyers protein needs were calculated as follows: .8g x 90 kg x 1.5 (for wasting)=108
His energy requirements are: 2777= 66.5 + (13.8x 90 Kg. ) + (5 x 187.5 cm) - (6.8 X58
yrs)(including a 1.5 for wasting).
Estimate Mr. Seyers fluid requirments based on his current weight.
Fluid intake should be in the range of 30-35 mL/kg of body weight. Mr. Seyers current weight is
90 kg. His fluid intake should be 90kg x 35 mL/kg = 3,150 mL= 3.15 L
What factors noted in Mr. Seyers history and physical may indicate problems with eating
prior to admission?

Prior to admission Mr. Seyers intake had been declining. He was finding difficulty and pain in
swallowing. He was experiencing heartburn, regurgitation and fullness regardless of intake. Mr.
Seyers 24 hour recall when compared to his usual meals was very telling. Adequate protein and
a full varied diet was replaced with a sparse diet of soft, easy to swallow foods.
Review the patients chemistries upon admission. Identify any that are abnormal and
describe their clinical significance for this patient, including the likely reason fore each
abnormality and its nutritional implications.
Upon admission Mr. Seyers labs confirmed nutritional issues. His Hemoglobin and Hematocrit
lab values were both below the normal range. His protein, albumin and pre-albumin were also
below normal. These below normal lab values could be indicative of microcytic anemia due to
protein deficiency and his chronic disease state. The nutritional concerns with microcytic anemia
relate to the functions iron performs in the cell, including the role of iron as a cofactor,
transporter, and promoter. With anemia the outcomes could be exhaustion and poor
concentration. For Mr. Seyers, adequate protein intake is critical to his post operative healing.
This could very well be an anemia of chronic disease.
Select two high priority nutrition problems after Mr. Seyers surgery and complete the Pes
statement for each.
Dehydration due to decreased fluid intake, dysphagia, and odynophagia as evidenced by
xerostomia and dry mucous membranes.
Inadequate energy intake due to dysphagia and odynophagia, as evidenced by significant weight
loss (13%) in the past month and 24 hour recall.