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January 28, 2014 Presented by Natalie Frison,

Head and Neck Cancer with Fibula Free-Flap Surgery and Provision of Immuno -Enhanced Enteral Nutrition Support . January 28, 2014 Presented by Natalie Frison, Sodexo Mid-Atlantic Dietetic Internship, Class of 2014 . Outline . Introduction Discussion of Disease Current Research

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January 28, 2014 Presented by Natalie Frison,

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  1. Head and Neck Cancer with Fibula Free-Flap Surgery and Provision of Immuno-Enhanced Enteral Nutrition Support January 28, 2014 Presented by Natalie Frison, Sodexo Mid-Atlantic Dietetic Internship, Class of 2014

  2. Outline • Introduction • Discussion of Disease • Current Research • Medical Interventions • Nutrition Interventions • Patient History • Social History • Medical History • Nutrition History • Objective Data • Discussion of Treatment and Hospital Course

  3. Learning Objectives • Describe the surgical procedure for the resection of head and neck cancer. • Name two nutrients commonly included in immune-enhancing enteral nutrition formulas and explain their functions in post-surgical patients.

  4. Introduction • S.M. is a 79 yo male • Admitting diagnosis: squamous cell carcinoma of the right retromolartrigone • Admitted to GWUH on 12/2/13 for tumor resection • Discharged to hospice care on 1/1/14 • Discharge diagnosis: dermal metastasis of squamous cell carcinoma

  5. http://www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral-cavity/Patient/page1/AllPages/Printhttp://www.cancer.gov/cancertopics/pdq/treatment/lip-and-oral-cavity/Patient/page1/AllPages/Print

  6. Discussion of Disease

  7. Oral Squamous Cell Carcinoma (SCC) • Oral cancer: 6th most common cancer globally1 • SCC accounts for 90% of all oral cancers1,2 • Associated with tobacco use, alcohol consumption, and low intake of fruits and vegetables1,2,3 • Also may be linked to HPV, genetic markers3 • More prevalent in men than in women1,2 • Average age at diagnosis: 62 years2

  8. Oral Squamous Cell Carcinoma (SCC) • Treatment: surgery, radiation, chemotherapy • 5-year survival: about 50%1 • About 2/3 of patients present with advanced stage and metastatic growth2 • Prognosis associated with TNM stage2,3

  9. Oral Squamous Cell Carcinoma (SCC) • Prognosis also associated with surgical margins2,3 • Even with “successful” surgery, margins may contain pre-cancerous keratinocytes • Local recurrence: about 30% • SCC has high incidence of metastasis:2,3 • Lymph node • Perineural • Vascular

  10. Dermal Metastasis • Dermal metastasis is rare4 • Survival: 1 to 65 weeks4 • Considered terminal stage of disease4 • Palliative care4

  11. Free-Flap Reconstruction • Tumor is resected from head/neck • Bone, tissue, and vasculature are taken from a donor site on the patient and transferred to the site of resection • Osteocutaneous free-flap tissue transfer is preferred surgery for mandibular defect reconstruction5 • Well-vascularized, thick tissue6 • Restore mandible form and function

  12. A-B) Before surgery. C-D) 60 days after surgery.7

  13. A-B) Frontal and lateral view of the patient after surgery. C-D) 3D-CT 6 months after surgery.7

  14. Free-Flap Reconstruction • Success rate: 90-99%8,9 • Considered safe, effective procedure for elderly patients8,9 • 5-year survival: 51%5 • Return of oral function: 89%5

  15. Nutrition in Head & Neck Cancer • High risk for malnutrition due to dysphagia10 • Obstruction due to tumor • Effect of chemo/radiation • Result of surgery • Use of enteral nutrition support • PEG is preferred route10 • Pretreatment/home EN10 • Prevent weight loss, dehydration, nutrient deficiencies, treatment interruptions10

  16. Immuno-Nutrition • Surgery -> inflammatory response -> immunosuppression -> infections 11,12, 13 • Supplementation of nutrients in addition to energy and protein • Modulate inflammatory response • Boost immune system • Decrease risk for infection

  17. Immuno-Nutrition • Nutrients include: • Arginine • Glutamine • Omega-3 fatty acids • Antioxidants • Trace elements

  18. Immuno-Nutrition • Arginine • Essential component of immune cells, especially lymphocytes (T cells)11,12,13,14 • Precursor of cells used for collagen synthesis and tissue repair13,14 • Glutamine • Increased production of immune cells11,12,14 • Improved gut barrier function11,12 • Increased protein synthesis12,14

  19. Immuno-Nutrition • Omega-3 fatty acids • Decreased production of inflammatory mediators11,12,13,14 • Antioxidants and trace elements11,14 • Zinc, copper, selenium, vitamin E, vitamin C, N-acetyl cysteine • Anti-inflammatory properties • Reduce oxidative stress

  20. EAL Recommendation • Pre-operative and post-operative use of arginine-containing EN15,16,17,18,19 • Not recommended • Research shows no significant impact • Fair • Imperative

  21. Immuno-Nutrition: Consensus • Sources: ESPEN,11 SCCM,12 A.S.P.E.N.12 • Good efficacy in surgical patients11,12,13 • Reduction in rate of infections11,12,13 • Decreased length of hospital stay11,12,13,14 • No significant effect on mortality11,12,13 • More benefits seen in malnourished patients13 • Should be initiated pre-operatively12

  22. Case Study: Oral SCC, Free-flap Reconstruction, and Provision of Immuno-enhancing EN

  23. Patient Social History • S.M. was a 79 yomale • Muslim • Retired • Widowed • Supportive family • Speaks English and Urdu • Former smoker (risk factor) • Does not drink alcohol

  24. Medical and Nutrition History • PMH: GERD, BPH • 10/8/13: Diagnosed at MFA Otolaryngology clinic • Squamous cell carcinoma of the right retromolartrigone • 11/17/13: Presented to ED for jaw pain • Followed by ENT team • PEG placement pre-operatively on 11/22 • Scheduled tumor resection • 11/25/13: Discharged

  25. Nutrition History • Use of EN at home via PEG • Pivot 1.5 (immuno-enhanced) • 1.2 L per day • Usually 400 mL bolus TID • Family support • No complaints • Food recall: broth, water

  26. Pivot 1.5 Cal • Sole-source enteral nutrition formula • Produced by Abbott Nutrition • “Very-high-protein, calorically dense, immune-supporting, hydrolyzed, peptide-based enteral formula for use in metabolically stressed, immunosuppressed patients, such as those with…head and neck cancer”20 • Includes arginine, glutamine, omega-3 fatty acids, vitamin C, vitamin E, zinc, copper, selenium20

  27. Patient Data (Admission) • Ht = 178 cm (5’10”) • Wt = 56.7 kg (125 lb) • BMI = 17.9 (underweight) • Physical findings: muscle wasting, appears debilitated

  28. Home Medications • Percocet analgesic • Colace stool softener • Tamsulosin BPH treatment • Gabapentin anti-epileptic • Oxycodone analgesic

  29. Hospital Course • 12/2: Admitted to GWUH for tumor resection • 12/3: Tumor resection and reconstruction with fibula free flap and right pectoralis muscle flap and awake tracheotomy • Involvement of mandible, extension to base of skull • 12/4: ICU to monitor post-surgery

  30. Lab Values (12/4) • Na 130 L • Cl 95 L • Mg 1.5 • Phos 4.6 H • K 4.6 • Glu 138 H • H/H 11.1 L/32.2 L

  31. Medications (Post-surgery) • Clindamycin antibiotic • Pantoprazole anti-GERD • Electrolyte repletion: • Magnesium sulfate • Potassium chloride • Potassium phosphate

  32. Initial Nutrition Assessment • Performed on 12/4 • Weight history: • Weight at previous admission (11/22) was 129 lb • Admission weight was 125 lb • Weight loss: 4 lb in about one week • At previous admission, reported weight of 145 lb about 6 months ago • >10% weight loss in 6 months: severe weight loss

  33. Initial Nutrition Assessment • Assessment • No N/V, mild constipation • Muscle mass wasting, temporal wasting, edema in abdominal area, severe protein-calorie malnutrition • Calorie needs: 1985 kcal (35 kcal per kg) • Protein needs: 113 g (2 g per kg) • Fluid needs: 2000 mL (1 mL per kcal)

  34. Initial Nutrition Assessment • Diagnoses: • Inadequate intake R/T inability to take nutrition by mouth, secondary to head and neck cancer with composite resection of tumor, AEB dependence on EN support, underweight BMI • Increased nutrient needs R/T catabolic state, oncologic processes, and recent surgery AEB patient with elevated energy, protein, and micronutrient needsand weight loss

  35. Initial Nutrition Assessment • Intervention: • EN via PEG: Pivot 1.5 via continuous administration with daily goal volume of 1.325L (60mL/hr), water flushes 30mL q4h • 1988 kcal, 125 g, 1120 mL free water • Monitoring and Evaluation • S/S of tolerance to EN administration

  36. Hospital Course • 12/5-12/7: ICU, vent management and flap checks • 12/9: Transitioned to bolus feeds • 220mL q4h with water flushes • 12/11: Nutrition reassessment • 12/12: Transitioned back to continuous feeds due to diarrhea

  37. Hospital Course • 12/15: Confirmation of pneumonia • 12/19: • Transferred to ARU • Transitioned to bolus feeds • Removal of remaining staples • SLP: excellent response to PMV

  38. Hospital Course • 12/24: • Patient complaint of painful abscess on right cheek; also noted nodule on right cheek • Exploration of surgical wound of the neck for infection • Biopsy of nodule to confirm dermal metastasis of SCC • Penrose drain placement

  39. Hospital Course • 12/26: • Transferred to medical unit • Right facial swelling and pain with pitting edema • 12/29: • Evidence of expanding dermal metastasis • Family meeting planned

  40. Hospital Course • 12/30: • Wound exploration and washout • Confirmation of dermal metastasis • No further interventions possible to control tumor • 12/31: • Family meeting • Decision made to transition to palliative care • Plans to transfer to inpatient hospice care

  41. Hospital Course • 1/1/14: • Pain Management: Recommendation for med regimen for pain control • Palliative Care: Patient knows he is at end of life and desires optimal pain control, does not want further treatment • Discharged to inpatient hospice care for pain control with plans to then discharge home with family and nursing support • Continue EN support

  42. References • Zini A, Czerninski R, Sgan-Cohen HD. Oral cancer over four decades: epidemiology, trends, histology, and survival by anatomical sites. J Oral Pathol Med [serial online]. 2010;39:299-305. Available from: PubMed. Accessed January 18, 2014. • Feller L, Lemmer J. Oral squamous cell carcinoma: epidemiology, clinical presentation and treatment. Journal of Cancer Therapy [serial online]. 2012;4:263-268, Available from: Scirp.org. Accessed January 18, 2014. • Jadhav KB, Gupta N. Clinicopathological prognostic implicators of oral squamous cell carcinoma: need to understand and revise. N Am J Med Sci[serial online]. 2013;5(12):671-679. Available from: PubMed. Accessed January 19, 2014. • Sesterhenn AM, Albers MB, Timmesfeld N, Werner JA, Wiegand S. Dermal metastasis in squamous cell carcinoma of the head and neck. Head Neck [serial online]. 2013;35(6):767-771. Available from: PubMed. Accessed January 19, 2014. • Dean NR, Wax MK, Virgin FW, Magnuson JS, Carroll WR, Rosenthal EL. Free flap reconstruction of lateral mandibular defects: indications and outcomes. Otolaryngol Head Neck Surg[serial online]. 2012;146(4):547-552. Available from: PubMed. Accessed January 17, 2014.

  43. References • Hill JL, Rinker B. Microsurgical reconstruction of large, locally advanced cutaneous malignancy of the head and neck. Hindawi Publishing Corporation: Internal Journal of Surgical Oncology. Available at: http://www.hindawi.com/journals/ijso/2011/415219/cta/. Accessed January 17, 2014. • Pellini R, Mercante G, Spriano G. Step-by-step mandibular reconstruction with free flap fibula modeling. ActaOtorhinolaryngologicaIItalica[serial online]. 2012;32:405-409. Available from: PubMed. Accessed January 19, 2014. • Turra F, La Padula S, Razzano S, et al. Microvascular free-flap transfer for head and neck reconstruction in elderly patients. BMC Surgery [serial online]. 2013;13(Suppl 2):S27. Available from: BioMed Central. Accessed January 17, 2014. • Tarsitano A, Pizzigallo A, Sgarzani R, Oranges CM, Cipriani R, Marchetti C. Head and neck cancer in elderly patients: is microsurgical free-tissue transfer a safe procedure? ActaOtorhinolaryngologicaItalica [serial online]. 2012;32:371-375. Available from: PubMed. Accesssed January 18, 2014. • Raykher A, Russo L, Schattner M, Schwartz L, Scott B, Shike M. Enteral nutrition support of head and neck cancer patients. NutrClinPract [serial online]. 2007;22:68. Available from: Sage Journals. Accessed January 15, 2014.

  44. References • Calder PC. Immunonutrition in surgical and critically ill patients. British Journal of Nutrition[serial online]. 2007;98(Suppl. 1):S133-S139. Available from: PubMed. Accessed January 17, 2014. • McClave SA, Martindale RG, Vanek VW, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr [serial online]. 2009;33:277. Available from: Sage Pub. Accessed January 20, 2014. • Braga M, Wischmeyer PE, Drover J, Heyland DK. Clinical evidence for pharmaconutrition in major elective surgery. JPEN J Parenter Enteral Nutr [serial online]. 2013;37:66S. Available from: Sage Pub. Accessed January 20, 2014. • Rodera PC, de Luis DA, Gomez Candela C, Culebras JM. Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a systematic review. NutrHosp [serial online]. 2012;27(3):681-690. Available from: PubMed. Accessed January 18, 2014.

  45. References • de Luis DA, Izaola O, Cuellar L, Terroba MC, Aller R. Randomized clinical trial with an enteral arginine-enhanced formula in early postsurgical head and neck cancer patients. Eur J ClinNutr [serial online]. 2004;58:1505-1508. Available from: PubMed. Accessed January 17, 2014. • de Luis DA, Aller R, IzaolaO, Cuellar L, TerrobaMC. Postsurgery enteral nutrition in head and neck cancer patients. Eur J ClinNutr [serial online]. 2002;56:1126-1129. Available from: PubMed. Accessed January 17, 2014. • Riso S, Aluffi P, Brugnan M, Farinetti F, Pia F, D’Andrea F. Postoperative enteral immunonutrition in head and neck cancer patients. ClinNutr[serial online]. 2000;19(6):407-412. Available from: PubMed. Accessed Janurary 17, 2014. • van Bokhorst-de van der Schueren MAE, Quak JJ, von Blomberg-van der Flier BME, et al. Effect of perioperative nutrition, with and without arginine supplementation, on nutritional status, immune function, postoperative morbidity, and survival in severaly malnourished head and neck cancer patients. Am J ClinNutr [serial online]. 2001;73:323-332. Available from: PubMed. Accessed January 17, 2014. • The Evidence Analysis Library. ADA Oncology Evidence-based Nutrition Practice Guideline page. Available at: http://andevidencelibrary.com/topic.cfm?cat=3250. Accessed January 17, 2014. • Abbott Laboratories Inc. 2012 Abbott Nutrition Pocket Guide. Concord, NH: Litho in USA; 2011.

  46. Thank you!

  47. Free-Flap Reconstruction: Video • Free Fibula for Mandible Reconstruction by Prof RidaFranka • http://www.youtube.com/watch?v=apviekOUMng

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