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, 2014Presented by Natalie Frison, Sodexo Mid-Atlantic Dietetic Internship, Class of 2014

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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

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Learning Objectives 1. Describe the surgical procedure for the

resection of head and neck cancer.2. Name two nutrients commonly

included in immune-enhancing enteral nutrition formulas and explain their functions in post-surgical patients.

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Introduction S.M. is a 79 yo male Admitting diagnosis: squamous cell

carcinoma of the right retromolar trigone

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

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

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Discussion of Disease

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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

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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

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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

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Dermal Metastasis Dermal metastasis is rare4

Survival: 1 to 65 weeks4

Considered terminal stage of disease4

Palliative care4

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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

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

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

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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

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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

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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

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Immuno-Nutrition Nutrients include:

Arginine Glutamine Omega-3 fatty acids Antioxidants Trace elements

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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

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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

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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

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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

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

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

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Medical and Nutrition History PMH: GERD, BPH 10/8/13: Diagnosed at MFA Otolaryngology

clinic Squamous cell carcinoma of the right retromolar

trigone 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

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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

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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

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

appears debilitated

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

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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

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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

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Medications (Post-surgery) Clindamycin antibiotic Pantoprazole anti-GERD Electrolyte repletion:

Magnesium sulfate Potassium chloride Potassium phosphate

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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

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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)

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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 needs and weight loss

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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

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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

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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

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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

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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

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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

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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

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References 1. 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.

2. 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.

3. 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.

4. 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.

5. 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.

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References 6. 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.

7. Pellini R, Mercante G, Spriano G. Step-by-step mandibular reconstruction with free flap fibula modeling. Acta OtorhinolaryngologicaI Italica [serial online]. 2012;32:405-409. Available from: PubMed. Accessed January 19, 2014.

8. 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.

9. 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? Acta Otorhinolaryngologica Italica [serial online]. 2012;32:371-375. Available from: PubMed. Accesssed January 18, 2014.

10. Raykher A, Russo L, Schattner M, Schwartz L, Scott B, Shike M. Enteral nutrition support of head and neck cancer patients. Nutr Clin Pract [serial online]. 2007;22:68. Available from: Sage Journals. Accessed January 15, 2014.

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References11. 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.

12. 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.

13. 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.

14. Rodera PC, de Luis DA, Gomez Candela C, Culebras JM. Immunoenhanced enteral nutrition formulas in head and neck cancer surgery: a systematic review. Nutr Hosp [serial online]. 2012;27(3):681-690. Available from: PubMed. Accessed January 18, 2014.

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References 15. 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 Clin Nutr [serial online]. 2004;58:1505-1508. Available from: PubMed. Accessed January 17, 2014.

16. de Luis DA, Aller R, Izaola O, Cuellar L, Terroba MC. Postsurgery enteral nutrition in head and neck cancer patients. Eur J Clin Nutr [serial online]. 2002;56:1126-1129. Available from: PubMed. Accessed January 17, 2014.

17. Riso S, Aluffi P, Brugnan M, Farinetti F, Pia F, D’Andrea F. Postoperative enteral immunonutrition in head and neck cancer patients. Clin Nutr [serial online]. 2000;19(6):407-412. Available from: PubMed. Accessed Janurary 17, 2014.

18. 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 Clin Nutr [serial online]. 2001;73:323-332. Available from: PubMed. Accessed January 17, 2014.

19. 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.

20. Abbott Laboratories Inc. 2012 Abbott Nutrition Pocket Guide. Concord, NH: Litho in USA; 2011.

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Thank you!

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Free-Flap Reconstruction: Video Free Fibula for Mandible Reconstruction

by Prof Rida Franka http://www.youtube.com/watch?v=apvie

kOUMng