Chylothorax Case Study

Patricia Jakubec
5/11/2019
Introduction
• What is chyle?
• Chylothorax
• Pleural effusion
Primary Disease-Endometrial Cancer
• Malignancy of the lining of the uterus
• Most common uterine cancer
• Risks
• Aging, obesity, estrogen, previous infertility, tamoxifen use, and a family
history of uterine cancer, colon or ovarian cancer.
• Unknown etiology
• Hormonal imbalances of estrogen and/or progesterone
• Abnormal uterine bleeding: cardinal symptom
Lab abnormalities, usual medical treatment
• No known lab abnormalities
• Anemia
• CA-125 blood test
• High blood levels suggests metastasis
• Surgery is the most common treatment
• Total hysterectomy
• Radical hyserectomy
• Goal is to remove all cancer
• Lymphadenectomy
• Adjuvant therapy
Usual Prognosis

• Five-year survival rate

• Confined to the uterus > 90 %
• Regional disease 68%
• Distant-stage disease 17%
• Prognosis is dependent on
• Stage at discovery
• Degree of metastasis
• Response to treatment
MNT for Oncology
• Poor nutritional status
• Increased hospital length of stay
• Lower quality of life
• Decreased tolerance to radiation and chemotherapy treatments
• Mortality in adult oncology patients
• Assessment
• Collect data from all assessment domains
• Include malnutrition screening
MNT for Oncology
• Intervention
• Individualized, modified diets, oral nutritional supplements, EN or TPN
• Preventing weight loss, maintaining lean body mass, managing treatment-related
adverse effects and preserving functional status
• Goal
• Improve nutritional status
• Improve patient comfort
• Monitor nutritional status
• Weight gain or loss, fatigue, fat and/or muscle wasting, treatment-related oral
problems and gastrointestinal complications
• Timely reassessments maintain nutritional status and prevent nutritional decline
Current research on endometrial cancer
• Silva et al, compared robotic surgery outcomes to traditional
laparoscopic surgery
• No difference in perioperative morbidity
• de Boer et al, examined benefits of chemotherapy pre- and post-
radiotherapy versus radiotherapy alone
• Did not improve 5-year overall survival
• Signorelli et al, investigated sequential chemoradiotherapy
• Survival rates improved compared with chemotherapy or radiotherapy alone
Social History
• JD
• 66-year-old African American female
• Retired
• Lives alone
• Medicare
• Rationale
• No prior oncology experience
• Learning along with the patient
Present Admit

• Pt presented in the ER
• Shortness of breath
• Primary admission diagnosis
• Post chest x-ray pleural effusion
• Post thoracentesis confirmed as chylothorax
• PMH
• Pulmonary embolism
• Endometrial cancer
• Total abdominal hysterectomy, bilateral salpingo-oophorectomy, removal of
pelvic and periaortic lymph nodes and omentectomy
• Active chemotherapy
Significant Findings
• Physical- tachycardic, shortness of breath
• Laboratory- slightly elevated calcium and total protein
• No pertinent medications
• Other significant data- comparison of chest x-rays
• Surgical interventions
• Thoracentesis -2L of suspected chylous fluid
• Chest tube placed
Assessment
• Physician consult for education: chyle leak diet
• ‘Okay’ appetite flowsheet reflected 50-75 % intake since admission
• Pre-admission diet- low sodium
• Weight history as being stable at approximately 226#
• Biochemical history unremarkable
• Slight elevation in calcium and total protein levels
• NFPE no significant findings Height: 5’ 7” (170.2 cm)
Weight: 225# (102.1 kg)
UBW 226# (102.7 kg)
IBW 135# (61.4 kg)
BMI 35.2
Diagnosis
Increased nutrient needs due to increased demand of nutrients as
evidenced by chronic/catabolic illness.

• Goals of MNT
• Prevention of weight loss
• Preservation of lean body mass
• Management of treatment-related adverse effects
• Protection of functional status
Intervention
• Individualized Nutrition Prescription:
• Calories: 1800-2000 (29-33 kcals/kg IBW) per day
• Protein: 90-100 (1.5-1.6 gm/kg IBW) grams per day
• Fluid: per MD
• Food and Nutrient Delivery:
• Meals and snacks
• Fat modified diet <25 grams per day
• Nutrition Supplement Therapy
• MCT oil 3-4 tbsp per day
• Commercial Beverage: Boost Breeze
• Nutrition Education: Increasing intake and the chyle leak diet
• Coordination of Care: Collaboration with dietary services, RDN’s
Monitoring and Evaluation
• Tolerance was difficult
• Repeated re-instruction and explanation of modifications
• Short term reduce the chylous output to allow healing of the leak
• Long term goals nutritionally stable to continue chemotherapy
• Plan modifications: very low-fat diet < 25 grams per day
• Supplemented with MCT oil
• Compliance expected to be moderate
• Provided contact information for follow-up outpatient nutritional care
Summary

• Prognosis
• Medical- diagnosed at stage 4 fairly poor with a 5-year survival rate of 17% for
distant-stage disease
• Nutritional- will be an ongoing challenge as chemotherapy continues
• Effectiveness of MNT
• Moderately effective –reduced output 6 weeks later
• Full resolution with chest tube removed at ~ 8 weeks
• What could have been done differently?
• Addition of 1-3 tbsp safflower, canola or flax seed oil daily for EFA
References
• Academy of Nutrition and Dietetics. (n.d.). Nutrition Care Manual. Oncology. Retrieved April 20, 2019, from
https://www.nutritioncaremanual.org/
• American Cancer Society. Endometrial Cancer. (n.d.). Retrieved April 4, 2019, from https://www.cancer.org/cancer/endometrial-
cancer.html
• Centers for Disease Control (CDC)- What Are the Risk Factors for Uterine Cancer? (2019). Retrieved April 27, 2019, from
https://www.cdc.gov/cancer/uterine/basic_info/risk_factors.htm
• Cohen CW, Fontaine KR, Arend RC, Soleymani T, Gower BA. Favorable Effects of a Ketogenic Diet on Physical Function, Perceived
Energy, and Food Cravings in Women with Ovarian or Endometrial Cancer: A Randomized, Controlled Trial. Nutrients. 2018 Aug
30;10(9). pii: E1187. doi: 10.3390/nu10091187
• de Boer SM, Powell ME, Mileshkin L, Katsaros D, Bessette P, Haie-Meder C, et al. Adjuvant chemoradiotherapy versus radiotherapy
alone for women with high-risk endometrial cancer (PORTEC-3): final results of an international, open-label, multicentre,
randomised, phase 3 trial. Lancet Oncol. 2018 Mar;19(3):295-309. doi: 10.1016/S1470-2045(18)30079-2
• DeSantis, C., Siegel, R., & Jemal, A. (2014). Cancer Treatment & Survivorship Facts & Figures: 2014-2015. 48. May 4, 2019, from
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/cancer-treatment-and-survivorship-facts-
and-figures/cancer-treatment-and-survivorship-facts-and-figures-2014-2015.pdf
• Haggerty AF, Hagemann A, Barnett M, Thornquist M, Neuhouser ML, Horowitz N, et al. A Randomized, Controlled, Multicenter
Study of Technology-Based Weight Loss Interventions among Endometrial Cancer Survivors. Obesity. 2017 Nov; 25 Suppl 2:S102-
S108. doi: 10.1002/oby.22021
References
• Heffner, J. Etiology, clinical presentation, and diagnosis of chylothorax. (2018). UpToDate. Accessed May 8,
2019. https://www.uptodate.com/contents/etiology-clinical-presentation-and-diagnosis-of-chylothorax
• McCray, S., & Parrish, C. R. (2004). When chyle leaks: nutrition management options. Practical
Gastroenterology, 60-77. https://www.practicalgastro.com/pdf/May04/McCrayArticle.pdf
• Morice, P., Leary, A., Creutzberg, C., Abu-Rustum, N., & Darai, E. (2016). Endometrial cancer. The Lancet,
387(10023), 1094–1108. https://doi.org/10.1016/S0140-6736(15)00130-0
• National Cancer Institute (NCI). PDQ Endometrial Cancer Treatment. (2018). Accessed April 24, 2019.
https://www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq
• Signorelli M, Lissoni AA, De Ponti E, Grassi T, Ponti S, Fruscio R. Adjuvant sequential chemo and radiotherapy
improves the oncological outcome in high risk endometrial cancer. J Gynecol Oncol. 2015 Oct;26(4):284-92.
doi: 10.3802/jgo.2015.26.4.284.
• Silva E Silva A, de Carvalho JPM, Anton C, Fernandes RP, Baracat EC, Carvalho JP. Introduction of robotic
surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative
clinical outcomes and costs. Clinics. 2018 Sep 21;73(suppl 1):e522s. doi: 10.6061/clinics/2017/e522s.
• Sriram, K., Meguid, R. A., & Meguid, M. M. (2016). Nutritional support in adults with chyle leaks. Nutrition,
32(2), 281–286. https://doi.org/10.1016/j.nut.2015.08.002