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




Patient History





Current Research
Medical Interventions
Nutrition Interventions
Social History
Medical History
Nutrition History
Objective Data
Discussion of Treatment and Hospital Course
3
Learning Objectives
1.
2.
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 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
5
http://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
margins2,3


Even with “successful” surgery, margins may
contain pre-cancerous keratinocytes
Local recurrence: about 30%
 SCC



also associated with surgical
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 Immunoenhancing EN
23
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
24
Medical and Nutrition History


PMH: GERD, BPH
10/8/13: Diagnosed at MFA Otolaryngology
clinic


11/17/13: Presented to ED for jaw pain




Squamous cell carcinoma of the right
retromolar trigone
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, peptidebased 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
 Colace
 Tamsulosin
 Gabapentin
 Oxycodone
analgesic
stool softener
BPH treatment
anti-epileptic
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
 Cl
 Mg
 Phos
K
 Glu
 H/H
130 L
95 L
1.5
4.6 H
4.6
138 H
11.1 L/32.2 L
31
Medications (Post-surgery)
 Clindamycin
 Pantoprazole
 Electrolyte



repletion:
Magnesium sulfate
Potassium chloride
Potassium phosphate
antibiotic
anti-GERD
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 proteincalorie 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 needs and
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
1.
2.
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4.
5.
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46
Thank you!
47
Free-Flap Reconstruction:
Video
 Free
Fibula for Mandible Reconstruction
by Prof Rida Franka
 http://www.youtube.com/watch?v=apvi
ekOUMng