Chapter 20: MNT for Pancreatic Cancer Flashcards
Pancreatic tumors arise from ____ & ____ cells.
Exocrine and endocrine
Which is more common? Exocrine or endocrine tumors?
Exocrine. Accounts for 93% of pancreatic cancer cases. Survival rates are poorer.
Most common type of pancreatic cancer is ____.
Adenocarcinoma
Also referred to as ductal cell carcinoma or ductal adenocarcinoma. 95% of exocrine tumors are pancreatic adenocarcinomas.
Risk factors for pancreatic cancer include
Family history
Cigarette smoking
Obesity and abdominal adiposity
Chronic pancreatitis
Diabetes mellitus
Heavy drinking (>3 drinks per day)
Diet high in total fat, saturated fat, red mea, processed meat, or fructose containing foods and beverages.
What lab is likely to be elevated with pancreatic cancer?
Carbohydrate Antigent 19-9 (CA 19-9)
Staging Methods
Resectability staging is based on imaging, CA 19-9 level, patient performance.
Tumors are divided into 3 groups
Resectable (potentially curable)
Borderline resectable
Unresectable (advanced or metastatic)
How is resectable PC treated?
Combination of surgery and systemic treatment. ChemoRT may or may not be included.
Treatment for borderline resectable PC?
Starts with systemic treatment. Subsequent treatment may or may not include surgery, radiation, or both.
Treatment for unresectable PC?
Systemic therapy is used. Largely for palliation.
What is systemic therapy for PC?
Usually a combination of 2 drugs but single agents may be given in cases of poor performance status.
Chemo is often given at the same time of radiation to enhance radiosensitization of the tumor.
Common Chemos
- Capecitabine (Xeloda): mucositis, stomatitis, nausea, vomiting, diarrhea
- Cisplatin (Platinol-AQ): anorexia, taste changes, nausea, vomiting, diarrhea, sodium wasting, magnesium wasting
- Docetaxel (Taxotere): anorexia, mucositis, stomatitis, nausea, vomiting, diarrhea
- Fluorouracil: taste changes, mucositis, stomatitis, nausea, vomiting, diarrhea
- Gemcitabine (Gemzar): anorexia, nausea, vomiting
- Irinotecan (Camptosar), Liposomal irinotecan (Onivyde): anorexia, mucositis, stomatitis, nausea, vomiting, diarrhea
- Oxaliplatin (Eloxatin): taste changes, nausea, vomiting, diarrhea, cold sensitivity
Targeted Therapy
Erlotinib (Tarceva): anorexia, nausea, vomiting, diarrhea
Immunotherapy
Pembrolizumab (Keytruda): anorexia, nausea, vomiting, diarrhea, constipation
First or second line drug combinations for patients with good performance status
FOLFIRINOX: fluorouracil, leucovorin, oxaliplatin, and irinotecan
GA: gemcitabine and albumin-bound paclitaxel, also known as nab-paclitaxel (Abraxane)
First line therapy for patients with poor performance status
GX: gemcitabine and capecitabine (Xeloda)
GEM-E: gemcitabine and erlotinib (Tarceva)
Less Common Drug Combinations
CapeOx or Xelox: capecitabine and oxaliplatin
FOLFIRI: fluorouracil, leucovorin, and irinotecan (or liposomal irinotecan)
FOLFOX: fluorouracil, leucovorin, and oxaliplatin
GemCis: gemcitabine and cisplatin
GTX: gemcitabine, docetaxel, and capecitabine
Role of RT
May be given in neoadjuvant setting to improve chances of clean surgical margins, as adjuvant therapy to help sterilize positive margins, or in those with positive lymph nodes to help reduce the chance of local recurrence.
Surgery is determined by the ____ rather than pathologic type.
location of the cancer
What are the 2 types of pancreaticoduodenectomy (PD)
Whipple (standard PD)
Pylorus-preserving pancreaticoduodenectomy (PPPD)
Nutrition impact symptoms of Whipple
Pancreatic insufficiency
Dumping syndrome
Delayed gastric emptying
Lactose intolerance
Diabetes mellitus
Nutrition impact symptoms of PPPD
Pancreatic insufficiency
Delayed gastric emptying
Lactose intolerance
Diabetes mellitus
Nutrition impact symptoms of total pancreatectomy
Pancreatic insufficiency
Dumping syndrome
Delayed gastric emptying
Lactose intolerance
Diabetes mellitus
Nutrition impact symptoms of distal pancreatectomy
Pancreatic insufficiency
Diabetes mellitus
Weight loss and malnutrition occurs in ____ to ____ % of patients.
50-90%
_____ % of PC patients experience cachexia by time of death.
70-80%
Common symptoms at time of diagnosis
Jaundice
Clay colored stools
Dark urine
Itchy skin
Pain
Weight loss
Anorexia
Malabsorption
Delayed gastric emptying or gastric outlet obstruction
Diabetes mellitus
Ascites
What percentage of patients develop pancreatic exocrine insufficiency (PEI)?
50-94%
Signs and symptoms of PEI
Abdominal bloating
Cramping after meals
Excessive gas (burping, flatulence)
Indigestion
Foul smelling gas or stools
Unexplained weight loss
Stool changes: fatty or oily, frequent, floating, light colored or yellow, loose
*** Note that loose stools are often a hallmark characteristic of PEI BUT may be influenced by narcotic use
Can a Muslim, Jewish, or Vegan patient use PERT?
Yes. Although PERT are porcine based, they are the only clinically proven medication for PEI. Leaders from the Muslim and Jewish religions as well as the Vegan Society have approved their use.
There is an OTC mixture that some people have tried to use in place of PERT but there are no clinical trials showing that this is effective.
Pancreatic Enzymes (PERT) dosages
Maximum: 10,000 lipase units /kg body wt per day OR 2500 lipase units / kg body wt per meal
Are dietary modifications needed if you are using PERT?
No, patients should not need to restrict dietary fat if they are using PERT. If pt does eat lower fat, small meals then they may require less PERT.
A patient is on PERT but has severe steatorrhea. What diet change would you suggest?
Recommend limiting total daily fat intake to 75 grams.
A patient is on continuous TF. How should PERT be administered?
Every 3 hours
What type of enteral formula would you select for a patient with PEI?
Semi-elemental formula high in MCT oil to limit the need of PERT.
How many patients have DM at time of PC diagnosis?
50%
Estimated that 50-75% of those patients were diagnosed with DM within 24 months of PC diagnosis.
Gastric Outlet Obstruction
Small Bowel Obstruction
A late onset effect of PC
May occur due to peritoneal disease in late stages of PC
Symptoms of GOO/SBO
Nausea
Vomiting (with retained, undigested food)
Abdominal distention and pain
A patient presents with an SBO. The MD has decided that surgery is the best treatment option. What surgery will they perform?
Gastrojejunostomy (gastric bypass). The loop of the jejunum is connected to a new opening in the stomach allowing food to bypass the blocked portion of small bowel.
Duodenal stenting
An endoscopic treatment used to hold open the obstructed area of small bowel. Metallic stents are used.
Diet advancement after duodenal stent
Liquids on POD1
Soft diet on POD2
Regular diet on POD3
Your patient with PC has malignant ascites. Do you recommend a low sodium diet?
There is no published evidence that patients need to follow a low sodium diet.
However, in clinical practice, benefit has been seen in limiting sodium intake to 2000 mg day in patients with a high serum ascites albumin gradient (SAAG).
Energy Requirements for PC
25 kcal/kg pre-op
30 kcal/kg post-op
OR REE x 1.2-1.3 stress factor
Dr. X has scheduled a Whipple for John Doe on 7/15. John Doe has severe protein calorie malnutrition. They have lost 20 lb (9%) within the last month. What do you recommend?
For patients at severe nutritional risk, ESPEN recommends nutrition support for 7-14 days pre-op. EN is recommended over PN.
Your surgical team has decided to establish an ERAS protocol for their PC patients. What do you suggest?
Immunonutrition drinks for 5 days prior to surgery.
A/w reduced post-op morbidity, surgical complications, length of stay. Benefits were seen in well nourished and malnourished patients.
Post operative oral diet progression
At MD Anderson:
- Start with clears
- Advance to soft solids
- Solid diet low in fiber, fat, and refined carb
- Goal is Low fiber, low fat at 1-2 weeks post op
- At 4-8 weeks, transition to regular diet.
** patients may benefit from long term restriction of deep fried/fatty foods, full fat dairy products, cream sauces.
MNT for Delayed Gastric Emptying
Low fiber, low fat diet
Drink fluids with meals
Eat 6-8 small meals daily
Achieve good glycemic control in patients with DM
Semisolid and liquids may be better tolerated
What medications can be prescribed with DGE?
Prokinetics (metocloperamide, erythyrmycin)
Treatment for Diarrhea
- Medications (Imodium AD, Lomotil)
- Absorptive fiber 1-4 times daily after meals (psyllium powder or methylcellulose powder)
Postoperative pancreatic fistula is reported in _____ of patients following pancreatectomy.
13-41%
How is a pancreatic fistula diagnosed?
Drain amylase concentration of more than 3x upper limit of normal serum value
Risk factors for pancreatic fistula? List 3
Obesity
Malnutrition
Sarcopenia
MNT for Pancreatic Fistula
x
Chyle Leak
- Occurs in 10% of patients following pancreatic resection and 12.5% of patients s/p PD
- Milky fluids from drain, drain site, or surgical wound
MNT for Chyle Leak
Diet options suggested (no literature proving which is better)
- Fat-free diet or < 0.5 g per serving
- Low fat diet
- Diet supplemented with MCTs
- EN high in MCT
- NPO or clears with PN
EN preferred over PN.
Lipids distributed by IV will not contribute to chyle volume – can be used as part of PN or administered 3 times per week to avoid essential fatty acid deficiency in a patient otherwise maintained on a fat-free diet.
Patients should be maintained on the diet of choice for 7-10 days and be advanced as chyle drainage volume decreases.
Long-term risks for survivors
NAFLD
Bone density loss
Micronutrients to monitor
Vitamin A
Vitamin B12
Vitamin D
Vitamin E
Copper
Iron
Selenium
Zinc
After surgical resection for pancreatic cancer, what will likely need to be supplemented if the pancreatic remnant is attached to the stomach rather than the small intestine?
Pancreatic enzymes
Which chemotherapy used to treat PC can cause clay colored stool?
Gemcitabine (Gemzar)
Following a Whipple or total pancreatectomy, how long should the anti dumping diet be followed?
6 weeks
True or False - Endocrine cells are responsible for release of bicarbonate and digestive enzymes.
False
What nutrition interventions can be added in addition to following guidelines for DGE that will help with ascites in advanced pancreatic cancer?
2g Na restriction
High protein diet (1.5 g/kg/day
Patients using MCT oil should begin with a daily intake of ____ mL and should not consume more than ____ in one day.
15 mL
100 mL
After a duodenal stent or drainage G-tube is placed, patient should be instructed to
Establish a tolerance to liquids before transitioning to a soft, low fiber diet.
Chew foods well
True or false - In patients with severe steatorrhea, MCT oil should be used as a patient’s sole source of fat
FALSE
MCT is an incomplete fat source
What surgeries are NOT associated with dumping syndrome?
PPPD & distal pancreatectomy
Pancreatectomy removes what organs/parts of organs?
Head of pancreas, distal stomach, spleen
You are working with a patient who is 60 kg and starting on PERT. An appropriate dose of lipase units per meal would be _____ and a maximum dose of lipase units per meal would be _____
Start: 10,000-40,000
Max: 150,000 (rec max 2500 mg/kg per meal
** starting doses are usually around 30-40 kg per meal
