1. Base of the Tongue Cancer
Case Study
Kerry Barbera
Priority Nutrition Care Dietetic Intern

2. Behavioral Objectives
You will be able to name the two leading risk factors for head and neck cancer.
You will be able to identify at least 2 symptoms of head and neck cancer.
You will be able to recall 2 nutritional problems that can result from treatment intervention.

3. BOT Cancer Patient B Head and neck cancer PMH, labs, meds Diagnosis
Incidence
Risk factors
Treatment and their side effects and their impact on nutrition
Prognosis
Research
Patient B
PMH, labs, meds
Diagnosis
Medical treatment
Nutritional ADIME
Summary and questions

4. Head and Neck Cancer
Oral cavity
Pharynx
Larynx

5. Incidence
Head and neck cancer accounts for approximately 3% of all cancer diagnosis with Squamous cell carcinoma being the most prevalent.1
Oropharyngeal cancer patients are typically between the ages of years old and is more common in men than women. 2
Human Papillomavirus infection can affect the tonsils and back of throat during oral sex and has been linked to the increase in the number of oral cancer diagnoses in the younger population.3

6. Base of the Tongue Cancer
Tobacco and alcohol are among the strongest risk factors of these cancers.
7 of 10 patients dx with this type of cancer are heavy drinkers.1

7. Clinical and pathological symptoms weight loss is the primary
Picture

8. Signs & Symptoms Speech and swallowing Pain Dysphagia Weight loss
Otalgia

9. Treatment Main goal preserving speech and swallowing Procedures
Surgical resection
Radiotherapy
Chemotherapy –adjunct therapy
Procedures
Tracheostomy for preservation of the airway
NG or PEG tube for nutritional support
Enteral Nutrition
NG tubes
PEG Tubes
Smoking sensation
Enteral nutrition plays a central role in recovery process. This can be a double edged sword because patients may rely on the PEG tube if swallowing is painful further delaying the ability to take in oral intake.1

10. Nutritional Implications
Inability to eat
Dysphagia
NPO post surgery
Pain
Mucositis
Nausea and vomiting
Malnutrition and cachexia are very common

11. Mucositis Frequent complication of cancer treatment
Painful and debilitating inflammation and ulceration
Patients unable to speak, eat or tolerate treatments
Lead to reduction and even cessation of radiation or chemotherapy

12. Treatment
Good oral hygiene- brush teeth 2-3 times a day with mild tasting toothpaste
Avoid acidic or spicy foods
Sucking on ice chips during chemotherapy
Magic Mouthwash

13. Prognosis 5 year survival rate:
75% local occurrence –stage l, ll, or lll
38% regional cancer – stage lll or lV that has spread to the nearby tissue or lymph node
20% distal occurrence- metastasis

14. Screening
Good oral health

15. Research
TROS
Transoral robotic surgery has been utilized to improve access to tumors during surgery.
Positive outcomes and disease control maybe achieved with TORS as a primary therapy
Where current surgical intervention tends to significantly alter the anatomy of the mouth to access the tongue during surgery this may lead to less disfiguring of the tongue and mouth post surgery having positive affect on the patients recovery time and outcome.

16. Prophylactic versus reactive PEG tube Placement
Reactive PEG tube placement was found to provide a shorter duration of usage without incurring greater weight loss or poorer oncology outcomes.9
Higher rate of unnecessary PEG placement were found when done prophylactically.10
Patient B PEG tube was inserted because of dysphagia and the possible length of her treatment. Patient B had lost forty pounds in just 1 month related to her inability to eat and having the PEG tube placement with in a few days of her admission, I believe, was key on her ability to survive her future surgery and treatment.

17. Patient B
45 y/o female who presented to the emergency department with complaints of difficulty with swallowing and tongue swelling. She described her difficulty swallowing as a foreign body sensation.
Reported that she has been having dysphagia over the last three weeks.
Presents with a 40-pound unintentional weight loss.

18. CT Scan
BOT squamous cell carcinoma with bilateral subglottic and glottic involvement
Left worse than right sided mass in the BOT extends into hypoglossal and genioglossus muscle.
Second mass supraglottic region involving the false and true vocal cords
Multiple necrotic enlarged lymph nodes
CT with contrast negative for METs

19. Medical and Social History
Admitted to the hospital 10/12/15-BOT cancer with laryngeal and necrotic lymph node involvement.
Pack a day smoker > 10 years.
Alcohol abuse in past
No medical insurance & no previous medical care
Unemployed, widowed, adult niece lives with patient

20. Labs HGB & HCT low-common with cancer BUN low ( 6) creatinine was WNL
Anion Gap ( 14) High
All electrolytes and other lab results were WNL
No signifigant findings There were no significant findings. Her BUN and Anion Gap were slightly elevated but her creatinine is normal. I would monitor kidney function. All other lab results were WNL.

21. Admit Medications IVF:
Dilaudid for pain- can cause increase thirst/dehydration
Methylpredisone- Corticosteroid- monitor labs
Can decrease Ca, Vit D, Vit A, Vit K, Vit C, P, and Zn.
Can increase Na.
Ondansetron for nausea- can increase thirst

22. Nutrition Assessment
Nutrition assessment on admission for unintended weight loss.
Patient reports normal appetite until ~ 1 month ago.
Poor intake > 1-month r/t difficulty in swallowing. Did not eat > 1 week prior to admission r/t severe pain with eating.
Patient reports usual weight of lb, wt loss of > 35 lb (29%) over the last 4 weeks.

23. Nutrition Assessment Patient is currently NPO.
RN reports patient to have a speech evaluation, pt diagnosed with oropharyngeal dysphagia.
Patient B underwent surgery for a tracheotomy to protect her airway, biopsy and the placement of a PEG tube.

24. Estimated Energy Needs
Anthropometrics: Height: 64 in. Adm Weight: 37.8 kg BMI: 14.3 kg/m2 UBW: lb ( kg) UBW% 69%
Clinical nutrition weight: 37.8 kg
Estimated Energy Needs: MSJ 1008 X Kcal/day for wt gain = Kcal/day
Estimated Protein Needs: Gm/day ( Gm/kg)
Estimated fluid Needs: 1.4L-1.6L/day (1mL/Kcal)
Nutrition therapy: NPO

25. Nutrition Diagnosis
Patient B meets the criteria for diagnosis of severe malnutrition of chronic illness as evidenced by 29% weight loss X 4 weeks, meeting <75% of estimated nutrition needs for > 1 month, and evidenced of muscle wasting at temples.
1.Malnutrition r/t chronic disease, dysphagia AEB 29% wt loss X 4weeks, meeting <75 of estimated nutrition needs > 1 month, and evidence of muscle wasting at temples.
2. Inadequate PO intake r/t dysphagia AEB inability to take oral intake.

26. Nutritional Intervention/Analyses
Tube feeding regimen of 4 cans of Osmolite 1.5 Cal + 60 mL H20 before/after each feeding mL H2O BID.
This provides 1440 Kcal (98% of estimated needs) 60 Gm of protein (1.2 Gm/kg) 193 Gm CHO, 0 fiber, 730 mL of free water (1410 mL free water with H2O flushes), 96 % of recommended daily allowance (RDI).
Patient B is meeting 98% of her estimate energy needs and 96% of her RDI.
Per SLP, Frazier water protocol

27. Monitoring Throughout Medical course monitor TF tolerance Weights
Intake and Outputs
Labs

28. Treatment
Medical: Patient B underwent a laryngoscopy, biopsy, tracheostomy and PEG tube placement.
MNT: Emphasis on initiating PEG Tube bolus regimen and monitoring Patient B‘s weights, input and outputs, and labs closely for tube feeding tolerance. Patient B was independent with tube feedings upon discharge.
Modified barium swallow -Patient B was diagnosed with oropharyngeal dysphagia.
SLP-initiated the Frazier Water Protocol and worked with patient on how to utilize a communication board
This is where a patient with dysphagia has free access to water. Water is considered neutral pH and the aspiration of water is considered a benign event. Focus is not on preventing aspiration but on preventing dehydration.
so that patient B could communicate her needs.

29. Discharge plan Patient was discharged to a rehabilitation facility.
Discharge follows up with :
Otolaryngologist
Radiation Oncologist
Medical Oncologist.

30. Summary
Head and neck cancer accounts for approximately 3% of all cancer diagnosis with Squamous cell carcinoma being the most prevalent.1
Tobacco and alcohol are among the strongest risk factors of these cancers.
Symptoms include pain, difficulty talking, dysphagia, weight loss, Otalgia
Treatment significantly impacts nutrition, malnutrition and cachexia are common.
Screening can save lives

31. Behavioral Objectives
You will be able to name the two leading risk factors for head and neck cancer.
You will be able to identify at least 2 symptoms of head and neck cancer.
You will be able to recall 2 nutritional problems that can result from treatment intervention.
Intro-background, etiology, incidence
Specifically about BOT cancer

32. BOT Cancer

33. Bibliography
1.Schoeff S, Barrett DM, Gress CD, Jameson MJ. Nutritional Management For Head And Neck Cancer Patients. Practical Gastroenterology.2013; (121):43-51.
2.National Cancer Institute. Oropharyngeal Cancer Treatment. Updated in Available at: Oct Accessed on October, 19, 2015.
3.National Cancer Institute. Head And Neck Cancers. Available at: Accessed October 18, 2105.
4.Emedicine.medscape.com. Malignant Tumors Of The Base Of Tongue: Background, Etiology, Pathophysiology Available at: October 16, 2015.
5.Oralcancerfoundation.org. Treatment - The Oral Cancer Foundation. Available at: Accessed:24 Oct

34. Bibliography
6.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage. Available at: Accessed on November 1, 2015.
7.Cancer.org. Survival Rates For Oral Cavity And Oropharyngeal Cancer By Stage Available at: Accessed on: November 1, 2015.
8.Moore E J, Olsen SM, Laborde RR, Garcia JJ, Walsh FJ, Price DL, Janus JR, Kasperbauer JL, and Olsen, KD. Long-Term Functional And Oncologic Results Of Transoral Robotic Surgery For Oropharyngeal Squamous Cell Carcinoma. Mayo Clinic Proceedings. 2012; (87):
9.Kramer, S. et al. Prophylactic Versus Reactive PEG Tube Placement In Head And Neck Cancer'. Otolaryngology - Head and Neck Surgery.2013; 150 (3):
10.Madhoun, Mohammad F. Prophylactic PEG Placement In Head And Neck Cancer: How Many Feeding Tubes Are Unused (And Unnecessary)? World Journal of Gastroenterology. 2011;17 (8): 1004.