Khairallah Aoucar M.D

Otolaryngology department

Eye & Ear Hospital

Introduction Most patients of head and neck malignancy are

malnourished at diagnosis.

1. Mechanical obstruction

2. Sensory impairment

3. Odynophagia

4. Trismus

5. The co-existent alcohol abuse and long term tobacco

Carol Rees Parrish Nutritional Management for Head and Neck Cancer Patients.; Practical Gastroenterology, September 2013; pp43-51

1. Surgery

2. Radiotherapy (RT)

3. Chemotherapy

lead to changes that further complicate and challenge oral intake

aggressive intervention and focus towards the nutritional status of the patients.

Hunter KU, Jolly S. Clinical review of physical activity and functional considerations in head and neck cancer patients. Support Care Cancer 2013;21:1475-1479.

Second most important factor in predicting long term prognosis.

No comprehensive evidence based guidelines for the nutritional management of this complex patient population.

=>inconsistencies in practice and currently no uniform model of care.

Brookes GB. Nutritional status--a prognostic indicator in head and neck cancer. Otolaryngol Head Neck Surg 1985 Feb;93(1):69-74

Relationship: malnutrition &outcome of the patient

Factors contributing to malnutrition

Factors Contributing to MalnutritionUpon location of malignancy:

1. Anorexia

2. Nausea

3. Inadequate mastication

4. Xerostomia

5. Dysgeusia

6. Dysphagia or odynophagia.

=>Diminished oral intake and avoidance of firm solids correlated with malnutrition

Cancer cachexia“state of maladaptation to the fasting state with ongoing

mobilization of energy reserves”

In normal subjects, a forced reduction in caloric intake leads to a reduction in caloric expenditure

In cancer patients, this normal adaptation may be blunted or blocked

William D. DeWys. Pathophysiology of Cancer Cachexia: Current Understanding and area for Future Research. Cancer Res 1982;42:721s-725s.

Cancer cachexia Glucose is metabolized in tumor tissue predominantly

via anaerobic glycolysis, even if tumor cells are well oxygenated in tissue culture

lactic acid ----------glucose by the liver and kidney 10% increase in energy expenditure in tumorbearing individuals

Cori cycle

Young, V. R. Energy metabolism and requirements in the cancer patients. Cancer Res., 37. 2336-2347, 1977.

Cancer cachexia Proinflammatory cytokines: tumor or the host

Exuberant systemic inflammatory response

Increased production of acute-phase proteins in the liver further depleting essential amino acids

Robert L. Ferris. Cancer cachexia syndrome in head and neck cancer Patients: part i. Diagnosis, impact on quality of life and survival, and treatment. HEAD & NECK—DOI 10.1002/hed April 2007: 401 – 411.

Cancer cachexia Toxohormones (tumor derived factors ):

1. Lipid Mobilising Protein (LMP)

2. Proteolysis Inducing Factor (PIF).

These hormones further mediate the lipolysis and proteolysis

Robert L. Ferris. Cancer cachexia syndrome in head and neck cancer Patients: part i. Diagnosis, impact on quality of life and survival, and treatment. HEAD & NECK—DOI 10.1002/hed April 2007: 401 – 411.

Surgery Post Treatment undernutrtion may be due to various

factors.

Surgery:

1. depending on the tumour site

2. procedure, and approach

may significantly alter the anatomy and lead to scarring that negatively impacts swallowing

Radiotherapy The acute reaction of the aerodigestive tract as a result

of undergoing radiotherapy (RT):

diverse gastrointestinal symptoms and decreased food intake

Develop mucositis and side effects

Chemotherapy adjuvant or neoadjuvant chemotherapy:

1. enhances the negative effects of radiation.

2. causes nausea and vomiting and reduces the desire to eat

Impact of Malnutrition on Outcome of Patient studies :correlations between malnutrition and

increased postoperative

1. Morbidity

2. Mortality

3. Length of hospitalization

4. Decreased survival at two years

Goodwin WJ Jr, Torres J. The value of the prognostic nutritional index in the management of patients with advanced carcinoma of the head and neck. Head Neck Surg 1984; 6:932-937.

A specialist dietitian should be part of the MDT for treating head and neck cancer patients throughout the continuum of care.

Frequent dietetic contact has been shown to enhance outcomes (Grade A)

NUTRITIONAL SCREENING

MONITORING

Screening should be repeated weekly for inpatients.

For outpatients, weight should be recorded at each outpatient visit and weight loss of > 2kg within a 2 week period reported to the dietitian.

IMPACT OF MALNUTRITION

At diagnosis, 50%–75% of patients already have malnutrition.

80% will lose a significant amount of weight during multi-modal treatment.

Malnutrition (10% or greater weight loss in previous 6 months) can lead to a range of problems

Malnutrition associated morbidity

NUTRITIONAL ASSESSMENT

REFEEDING SYNDROME Potentially fatal shifts in fluids and electrolytes that may

occur in malnourished patients receiving feeding resulting in hormonal and metabolic changes causing serious clinical complications.(Mehanna et al )

It can occur irrespective of the feeding route.

The main feature is hypophosphataemia but can feature abnormal sodium and fluid balance;

Changes in glucose, protein, and fat metabolism, thiamine deficiency, hypokalaemia and hypomagnesaemia.

Refeeding Incidence of refeeding syndrome in head and neck

cancer is unknown.

By defining refeeding syndrome as a reduction in serum phosphate to below 0.4mmol/l, retrospective data from a regional cancer centre found 37.5% of patients to be at risk as defined by NICE criteria with an incidence rate of 9.5%

Refeeding Moderate risk patients:

Eaten little or nothing for >5 days

Recommendation : rate of no more than 50% of the energy requirements.

If after careful monitoring of clinical and biochemical status, all remains well this rate can start to be increased.

Management of re-feeding syndrome (Mehanna et al., BMJ 2008)

10kcal

Severe malnourished :

Body mass index ≤ 14 or a negligible intake for >two weeks

NICE guidelines :

1. Refeeding should start at a maximum of 5 kcal/kg/24 hours

2. Cardiac monitoring owing to the risk of cardiac arrhythmias.

3. Circulatory volume should also be replaced but care should be taken not to overload patients.

Refeeding First week: daily electrolyte levels checked

Second week :three times

Assessment of urinary electrolytes can be helpful in assessing losses.

Types of nutrition support1. Oral

2. Enteral

3. Parenteral

Oral nutrition support There are a variety of oral nutritional support products

available.

The choice will depend on

1. patient preference

2. current macro and micro nutrient intake

Enteral nutrition support Clinical considerations

should include:

1. Site of tumour

2. Predicted duration of enteral feeding

3. Patient choice.

Enteral feeding The types of tubes available are

Nasogastric

Nasojejunal

orogastric

tracheo–oesophageal fistulae tubes

gastrostomy

gastro-jejunostomy

jejunostomy

<4 weeks

Enteral nutrition The type and volume of enteral nutrition will depend

upon the patients’ symptoms and current intake and is likely to change throughout and following treatment.

No data to suggest a role for cancer specific enteralformulae and standard polymeric feeds should be used in this population group.

There are a range of nutritionally complete feeds available.

Gastrostomy There are no nationally agreed selection criteria(time

& method)

NICE guidelines on enteral feeding suggest that if enteral feeding is expected to be required for longer than 4 weeks then gastrostomy insertion is recommended.

Gastrostomy Screening and assessment for suitability and method

of gastrostomy insertion by endoscopic, radiological or surgical approach is essential.

Assessment of co-morbidities and contraindications should be undertaken in order to prevent complications of tube insertion prior to oncologicaltreatment

Immune enhanced nutrition Immunonutrition are feeds containing amino acids,

nucleotides and lipids.

may reduce post-operative infective complications=>this premise is yet to be proven.

There is evidence that patients given immunonutritionexperience a reduction in hospital stay.

NUTRITION CONSIDERATIONS DURINGSURGICAL TREATMENT

Preoperative nutrition Inadequate oral intake for more than 14 days is

associated with a higher mortality.

Patients with severe nutritional risk should receive nutrition support for 10–14 days prior to major surgery even if surgery has to be delayed.

Enteral nutrition is indicated even in patients without obvious undernutrition, if it is anticipated that patients will be unable to eat for more than 7 days peri-operatively

Postoperative nutrition Early post operative tube feeding (within 24 hours) is

indicated in patients in whom early oral nutrition cannot be initiated.

Nutrition support, especially enteral nutrition, reduces morbidity.

Nutritional management of chyleleaks Rare complication with an incidence of 1–4% in neck

dissections.

Central lymphatic system has been damaged during surgery.

Fluid : milky appearance

The management

1. conservative: dietary manipulation

2. further surgery.

Chyle leaksThe principal aims of nutritional management:

1. Reduce the flow of chyle whilst maintaining nutritional status

2. Ensuring adequate fluid balance

3. Replacing electrolyte losses.

Chyle leaks No consensus on how to nutritionally manage chyle

leaks.

The nutritional intervention is usually dependant on clinician preference.

Chyle leaks The nutritional management is to use a fat free or high

medium chain triglyceride (MCT) product.

MCT is recommended because it is directly absorbed into the portal system resulting in less chyleproduction.

In clinical practice fat free products are more accessible and practical than MCT feeds.

Chyle leaks If dietary manipulation is unsuccessful parenteral

nutrition may be required.

This should not be used as first line management except in extreme cases eg: very high volume leaks (>1000mls).

Thank you