Francis Anthony B.

Losloso
MAN-AHN
Oncology Nursing
September 24, 2019

Case Analysis: Nasopharyngeal Carcinoma

1. Gathering thorough history taking and physical assessment is the key in

determining risks in developing cancer. In the field of head and neck oncology, it is
very important to determine patient’s family history because it plays a significant role
in NPCA. Risks in NPCA in a first-degree family member could be as high as 8 times
that of the general population (Cummings). Lifestyle such as tobacco smoking/
chewing, alcohol intake and sedentary lifestyle, diets high in preservatives such as
salted fish, eggs, vegetables, nitrosamines and vitamin deficiency, dental and oral
routine/ care, occupation that may expose them chronically to certain carcinogen and
environmental factors such as chemical fumes, woods, industrial cement/dust etc. It
is also associated with Epstein-Barr Virus. Significant history of NPCA patients may
reveal presence of unilateral or bilateral cervical masses (87%), epistaxis, hearing
loss and cranial nerve deficits (Pontejos, A. 2019)

2. Cetuximab
It is a monoclonal antibody (a man-made version of an immune system protein)
that targets the epidermal growth factors receptor. EGFR is a protein found on the
surface of cells. It normally receives signals telling the cells to grow and divide.

Action: it is an epidermal growth factor receptor inhibitor used to treat head and
neck cancer
:in nasopharyngeal carcinoma, cells sometimes have more than normal
amounts of EGFR, which can help them grow faster, by blocking EGFR, cetuximab
may slow or stop this growth.
 Class: Antineoplastic
Dose: 2mg/ml (50mg/100ml single use vials)
: Initial dose of 400mg/m^2 IV infuse over 2 hours
Frequency: usually once a week
Indications: epidermal growth factor receptor
-in combination with radiation therapy for initial treatment of locally or
regionally advanced SCCA
-in combination with platinum-based therapy with 5-FU for first-line
treatment of patients
-monotherapy in patients with recurrent or metastatic SCCA for whole prior
platinum-based therapy failed

3. Side effects and Adverse Effect of Cetuximab

Side effects:
-Skin problems (itchiness, -Constipation
acne-like rash on the -Stomatitis
face/chest -Hypomagnesemia
-Headache -Neutropenia
-Tiredness and weakness -Difficulty Breathing
-Fever -Cough
-Diarrhea -Peripheral Neuropathy
-Nausea/ vomiting -Hepatotoxicity
-Weight loss and poor -Infection
appetite -Nail Changes
-Abdominal pain

Adverse Reaction:
-Anaphylactic Shock
-Cardiac Arrest
4. Current treatment and Management to control vomiting
He is currently undergoing his chemo-radio therapy which causes him to
experience nausea and vomiting. Ways to reduce incidence of nausea and vomiting
is by giving the following medications:
• Ondansetron 4-8mg every 12 hours IV as needed
• Metoclopramide 10mg every 8 hours IV as needed
• Granisetron 0.01mg/kg/dose infused over 5 minutes or direct injected over 30
seconds
• Positioning the patient upright
• Offer dry foods
• Bland, soft, easily-digestible food for main meals
• Oral care
• Monitoring fluid and electrolyte balance, Input and Output

5. Explanation of need for external beam radiation

External beam radiation therapy is the most common form of radiation therapy for
nasopharyngeal carcinoma. It uses a method of delivering a beam or several beams of
high-energy x-rays to a patient’s tumor. Beams are generated outside the patient usually
by a linear accelerator and are targeted at the tumor site. It doesn’t hurt and the machine
does not touch the patient.

The team will take careful measurements to determine correctness of angles for
aiming the radiation beams and the proper dose or radiation. It will last only a few minutes
but the set-up time takes longer. Most often, radiation treatments are given 5 days a week
for about 7 weeks.

It is most often given using a technique called intensity-modulated radiation

therapy. It focuses the radiation better and lowers the radiation exposure to nearby
healthy tissues further reducing side effects.
 Encouraging MP to undergo external beam radiation may provide a significant
difference in managing his case focusing mainly on its benefits but of course, mentioning
the risks of the procedure. Emphasizing that most studies say that chemotherapy
nowadays in combination with radiation therapy helps patients live longer than just
radiation therapy alone. However, adding chemo leads to more side effects, which can
affect his quality of life.

6. Computation of Absolute Neutrophil Count (ANC) and its significance

ANC measures the percentage of neutrophils in white blood count. It is significant
since cancer patients undergoing chemo-radiation therapy experience side effects such
as neutropenia wherein there is a significant reduction in neutrophils. It is essential since
it is the first line of defense against infection, hence this decrease may increase their risk
for acquiring infection.
ANC= WBC x total neutrophils (segmented neutrophils % + segmented bands %)
x 10
Normal result: >1000
31,200 cumm= 6,000 cumm x 0.52 x10

7. Implications of current blood counts

Low RBC, Hgb, Hct := Patient is already experiencing signs of malnutrition
(anemia) that is probably caused by poor appetite, nutrition, possibly bleeding or
worst, metastasis in the bone. Low levels of red cells require blood transfusions in
which patient may be at risk for developing infections.
ANC: 31,200 cumm= Patient still have normal levels of ANC preventing him from
acquiring infection.
Platelet count: 80, 000= Patient is at risk for bleeding since it is difficult for the
blood to clot.

8. Granisetron is classified as an anti-emetic drug. It is a selective 5-HT3 receptor

antagonist; granisetron binds to 5-HT3 receptors both in the peripheral and central
nervous system with primary effect in tract. It is used to prevent nausea and vomiting
 caused by chemo and radiation therapy. It works by blocking one the body’s natural
serotonin that can cause nausea and vomiting. It will definitely help the patient further
preventing complications specially being at risk for aspiration.

9. When is Granisetron administered

It is administered 30 minutes to 1 hour before chemotherapy. Second dose may
be given after 12 hours. It can be administered through oral and IV for 30 seconds up
to 5 minutes. Giving it prior to chemotherapy since its effect is more on preventing
nausea and vomiting.

10. Prioritization of nursing problem

a. Ineffective airway clearance- dyspnea/ orthopnea
b. Impaired tissue perfusion- anemia/ pallor of mucosa and nail beds/ capillary refill
<3s/ cold extremities
c. Risk for allergic reaction- rashes
d. Risk for aspiration- symptoms of nausea and vomiting
e. Risk for fluid and electrolyte imbalance- symptoms of nausea and vomiting
f. Risk for bleeding- low platelet count
g. Risk for Infection- undergoing chemo-radiotherapy
h. Imbalance body nutrition less than body requirement- poor appetite and weight
loss
i. Social Isolation- constantly withdrawing from people
11. Key nursing interventions to implement
a. Maintain patent airway, suctioning and positioning patient
b. Facilitating blood transfusions as ordered to prevent bleeding and resolve
anemia
c. Monitoring signs and symptoms of allergic reaction. Have diphenhydramine/
anti-histamine or worst epinephrine pen ready for anaphylactic shock
d. Administration of anti-emetic medications to prevent nausea vomiting. Still
positioning patient to prevent aspirations.
 e. Administration of appropriate intravenous fluids and other means of nutritional
support to prevent electrolyte imbalance and malnutrition.
f. Isolating patient to prevent acquisition of infection. Maintaining aseptic technique
and ensuring that patient wears mask.
g. Encouraging patient to eat. Give his preferred food to increase his appetite.
Provide parenteral nutrition if necessary.
h. Provide psychosocial support to patient

12. Importance of nutrition in care of cancer patients

It is important for patients diagnosed with nasopharyngeal carcinoma or other head
and neck cancer in general to receive adequate nutrition. According to an article by
Healio, 2017, an estimated of 30-50% of patients experience malnutrition before
treatment begins. Even those who are not malnourished at the time of diagnosis remain
highly susceptible to malnutrition. Passageway of food is compromised since most of
them experience symptoms of dysphagia often results from obstruction of the tumor,
odynophagia or other factors. Supportive management such as nasogastric/orogastric
tube for short term use may be facilitated. On the other hand, gastrostomy/jejunostomy
tubes may be inserted for long-term nutritional support and it may provide the best route
of artificial nutrition support. It is associated with better quality of life with greater mobility
and higher satisfaction in appearance and functionality of the tube. Patients undergoing
chemotherapy or radiation therapy may also experience poor appetite, encouraging them
to increase their food intake and providing them their food preference may be helpful.

References:
1. Krause, C. et.al. (2015) Cummings Otorhinolaryngology- Head and Neck Surgery,
6th Ed. Philadelphia, PA: Saunders
2. Pontejos, Jr., A.(2019) Manual for the Management of Head and Neck
Malignancies, Manila, University of the Philippines
3. https://www.healio.com/hematology-oncology/head-neck-
cancer/news/online/%7B0373231c-9676-47ff-9d04-46cc0eaf9a73%7D/nutrition-
is-essential-component-of-care-for-patients-with-head-neck-cancers
 4. https://www.cancer.org/cancer/nasopharyngeal-cancer/treating/radiation-
therapy.html
5. https://www.cancer.org/cancer/nasopharyngeal-cancer/treating/targeted-
therapy.htm

NOTES:
Case Analysis: Nasopharyngeal Carcinoma

CC: Dysphagia, nasal twang

Sx: Withdrawal, timid, poor appetite, vomiting, weight loss 10 kg in 1 year
regression (no longer talks), dyspnea when standing or walking, mouth breather
low rbc, hgb hct, WBC 6,000 cumm neutrophil 0.52, PC 80k
pallor mucosa and nail beds, cap refill 3 sec
cold extremities, pinpoint rashes over areas of the arm where bp is taken

Management: ongoing 3rd cycle of chemotherapy (Cisplatin, Paclitaxel, Cetuximab)

(+) vomiting despite Ondansetron
external beam radiation post 4 mos chemo

Common in Southeast Asia

Diagnosed with advanced disease
Progression of time, survival of these patients improved due to combined treatment of chemotherapy
and radiation therapy
Due to advancement in techniques, side effects can be reduced

>99% are symptomatic

<1% are asymptomatic
diagnosed incidentally which may occur when imaging is performed
EBV serology

palpable neck lump-most common presentation

blood stained saliva/ sputum- 2nd most common
epistaxis not common-tumor is located in postnasal space 23.1%
deafness more common 30.2% because of otitis media with effusion secondary to eustachian tube
dysfunction (conductive in nature)
other presenting complaints:
-nasal obstruction
-unilateral tinnitus
-persistent headaches- common with intracranial extension or clival erosion
cranial nerve palsies 10%
-common nerves affected (5,6,9,10,12)

patients with dermatomyositis have a risk of 10% to develop npca-screened regularly

examination reveals exophytic mass may occupy whole postnasal space (+) ulceration (+) contact
bleeding
10% submucosal lesion

diagnosis
NP BIOPSY- gold standard
-transnasally under local anesthesia using rigid endoscopy
-may also be performed under GA (deep biopsy) Rosenmuller fossa and vault of NP
immunohistochemical markers (cytokeratin, epithelial cell marker, EBER)
CT/ MRI
-primary tumor and regional disease
-delineation of clival and skull base erosion
-to determine distant metastasis

PET
-used if CT is indeterminate
Audiogram/ Tympanogram- baseline level, patient undergoes radiation that might worsen the hearing
(cisplatin may cause sensorineural hearing loss)

EBV serology titers

assisting diagnosis of new NPC patients

histology
2. keratinizing carcinoma - SCCA
3. nonkeratinizing carcinoma-lack of keratin pearls + presence of syncytial sheets of cohesive cells
with large nuclei

Treatment
1. Pre treatment planning
-multidisciplinary approach (surgeon, rad onco, med onco, patho, audiologist, dental)

-for chemo (hematologic and biochemical investigation with creatinine clearance)

-dental (oral hygiene d/t radiation) any decaying, unhealthy teeth are extracted to prevent
osteomyelitis from setting in during postradiation period
no evidence prophylactic extradion will reduce osteoradionecrosis

2. Radiation
stage I-II radiation only
stage III-IV concurrent chemo-radiation
stage IV -may be better controlled with neoadjuvant cisplatin followed by chemoRT
-administered by linear accelerator dose 60-70Gy in NP and both sides of neck
-given daily up to 2Gy in 35-40 fractions
-side effects mucositis (up to 3 months after last day of treatment to heal), xerostomia (may be
permanent), sinusitis, crusting, blood stained nasal discharge, otitis media, sensorineural hearing loss,

-late side effects- cranial nerve palsies-difficulties in distinguising trismus from recurrent
disease

3. Chemotherapy
-cisplatin-may give rise to idiosyncratic sensorineural hearing loss and peripheral neuropathy
-paclitaxel combined with 5FU and hydroxyurea— to avoid SE of cisplatin toxicities
-5-fluorouracil
-,ocal and regional control but it increases both acute and late toxicities

4. Surgery
-contraindicating factors
1. internal carotid artery involvement
 2. skull base erosion
3. intracranial involvement
-approaches
1. open- transnasal, transmaxillary, midfacial degloving, transpalatal
2. endoscopic
-radical neck dissection/ modified neck dissection
-spinal accessory nerve and SCM muscle are not spared
-IJ vein is not commonly preserved
-if brachytherapy is considered- PMMF is harvested to reduce likelihood of cutaneous necrosis
and to protect carotid artery

a, local recurrence- nasaopharyngectomy

b. endoscopic and robotic approach-centrally placed on the posterior wall of NP
c. Lateral rhinotomy and medial maxillectomy approach- for tumors slightly larger tht those
indicated for endoscopic approach. may be used for recurrent or residual tumors
d. maxillary swing- wide access for resecting NP tumors
e. lateral inratemporal
f. le-fort 1

References:
3. https://www.healio.com/hematology-oncology/head-neck-cancer/news/online/%7B0373231c-9676-
47ff-9d04-46cc0eaf9a73%7D/nutrition-is-essential-component-of-care-for-patients-with-head-
neck-cancers
4. https://www.cancer.org/cancer/nasopharyngeal-cancer/treating/radiation-therapy.html
https://www.cancer.org/cancer/nasopharyngeal-cancer/treating/targeted-therapy.htmll