Case study – ENT Oncology patient

70 years old man with an oropharyngeal carcinoma, receiving chemoradiation

 Introduction

A70 year old man is admitted to the hospital as an emergency  with a bleeding of the tongue basis. He is admitted to an oncology ward specializing in diseases of the ear, nose and throat. Initially he had unintentionally lost 6 kg body weight before diagnosis, but had regained 3 kg in the past month. He is recently diagnosed with a tongue basis carcinoma. The oncologists proposed chemo radiation therapy, with a preventive placement of a Percutaneous Endoscopic Gastrostomy (PEG). The dietitian is consulted to determine and improve his nutritional status and to start enteral nutrition.

Diagnostics

The nurse of the oncology ward screens the patient with SNAQ and scored 4 (malnourished). According to the screening protocol the dietitian is consulted and performs the nutritional status diagnostics. Based on the laboratory (inflammatory) values, VAS appetite, percentage of involuntary weight loss, BMI, FFM index and WHO performance status, he is classified as suffering from cancer cachexia. In the  process of staging the tumor process a CT scan is performed. The skilled dietitian selects the slide at L3 level and ‘analyzes’ the scan accordingly to determine the skeletal muscle area, muscle attenuation radiation and skeletal muscle index (figure). According to the known cutoffs for SMI in oncology patients, this patient is depleted in muscle mass. Using a food diary/24h recall, his nutritional intake is found to be reduced to approximately 75% of his energy and protein needs.

Figure: CT slice at L3 level of this patient

Somatic factorsCollected data based on targeted diagnostics
70 yr, male

Recently diagnosed tong basis carcinoma right, with extension to the left side T4N2cM0, with involvement of the extrinsic tongue muscles which requires (intentional curative) chemo and radiotherapy treatment
COPD gold class 2

Decreased appetite, swollen tongue, pain with swallowing, difficulty with chewing and swallowing, hematemesis, only able to eat a smooth and liquid diet, normal stools black coloured
Smokes cigarettes 25/d, 46 pack years

Height 1.70 m,
Current weight 60 kg  BMI 20.8 kg/m2
Weight 1 month ago 57 kg
Normal weight 63 kg
Weight loss 4 months was 9.5%
Weight loss relative to normal weight 4.8%
SNAQ: 4 points

Rx:
Cisplatin 7 weeks a 40 mg/m2/week
PCM
Fentanyl blaster
Movicolon 1 x dd
PPI
Anthropometrics:
Bioelectric impedance analysis:
FM 23 %
FFM 77%/46 kg
FFMI 15.9 kg/m2 (

Estimated resting energy expenditure WHO: 1385 kcal
Estimated TEE = REE + 30% activity/disease factor ~ 1800 kcal/d

Food intake: (dietary history) ~ 1300 kcal, 40 g protein, 55 g fat, 130 g carbs, 2 tins of beer/d

VAS appetite: 5

Other:
CT imaging at L3:
Skeletal muscle area: 123.1 cm2 (N; ref 108.8)
Mean Hounsfield Units: 22.6
SMI 42.6 cm2/m2 (L)

Laboratory test results:
HB 7.5 g/dl (L)
CRP 10 g/dl (H)
Albumin 28 g/L (L)
eGFR >90 ml/min/1.73 m2 (N)
Functional factors
Hand grip strength left 30-22-24 kg and right (dominant) 32.5-32-34 kg: (P25)
ADL: WHO performance score 2; unable to work and >50% of the day out of bed
Psychological factorsSocial factors
Limited disease insight
Feeling depressed
Married
Retired construction worker
Hobby: playing billiards with friends
1 adult home living son, no grandchildren

Dietetic diagnosis

70 year old male patient, hospitalized via ER at the oncological ward with a tongue basis bleeding. He is diagnosed with tongue basis carcinoma (T4N2cM0) and will be treated with chemo-radiation (Cisplatin) and a PEG has been placed preventively per protocol. He is malnourished, with cancer. He has muscle mass depletion based on a decreased skeletal muscle mass index,  FFMI (15.9 kg/m2 (<P5)) and handgrip strength (32.5 kg (P25)), 5% weight loss, moderate inflammation (CRP 10), and a decreased appetite (VAS 5).  He is suffering from a swollen tongue, swallowing and chewing difficulties and has a decreased nutritional intake (~ 75% of normal intake/ 60-75% of nutritional needs). Enteral nutrition will be started to meet his nutritional energy and protein needs. He is married, retired, a heavy smoker, has a WHO-performance status of 2, limited disease insight and sometimes feels depressed.

Treatment goals

  • Retention of weight, FFMI, hand grips strength and SMI during chemo radiation treatment
  • Weight gain of 1-2 kg/month and restore FFMI (P25-P50) and handgrip strength (P50) in 6 months subsequently
    • Energy goal including 1800 kcal/d
    • Protein goal 1.5 /kg FFM is 70 g/d

Treatment plan

  • Diet: Oral nutritional supplements (ONS)and start enteral nutrition at night via PEG, oral intake as needed/possible
  • Physical training: to obtain an anabolic state: physiotherapist

 Evaluation

Three weeks after the hospitalization and tongue basis bleeding, the chemoradiation therapy started. During the final 6 weeks of this treatment, eating orally was impossible. His weight decreased to 56 kg (BMI 19.4 kg/m2), FFMI to 15.1 kg/m2, hand grip strength to a mean 29 kg (dominant hand). For 2.5 months enteral nutrition was his sole source of nutrition. Due to increased depressionand sleeping problems, he started sleep medication and antidepressants. Six months after finishing chemoradiation he was able to eat normally again to meet his energy and protein needs. He is visiting his physiotherapist once a week. On review, his weight is 62 kg, FFMI 16.0, hand grip strength dominant arm is 35 kg and SMI based on CT L3 is 44.1 cm2/m2.

Dietetic diagnostic toolkit

Dietetic diagnostic toolkit

Calculations

Calculations

Nutritional Assessment Platform

Nutritional Assessment Platform

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