A Case Study: Astrocytoma

ASTROCYTOMA

Victoria Parry, Dietetic InternJune 9, 2010

Astrocytoma

Astrocytomas normally develop in the cerebrum but can originate in other parts of the brain and spinal cord.

Star-shaped glial cells located in the brain and spinal cord (CNS)

Function: Regulate external chemical environment of neurons; blood flow in brain

Astrocytes

Stages of Astrocytoma

Stage 1: Pilocytic Astrocytoma

Stage 2: Diffuse Astrocytoma

Stage 3: Anaplastic Astrocytoma

Stage 4: Glioblastoma Multiforme (GBM) Gliosarcoma Giant Cell Glioblastoma

(1)

Examples of Astrocytomas

Low-grade Astrocytoma Giant Cell Astrocytoma

(2)

Cause of Astrocytoma

Currently unknown Cell phones Prophylactic Radiation

for Acute Lymphatic Leukemia

Genetics Family history of

astrocytoma Molecular Mutation

(3)

Prevalence

Male predominance 1.18:1 Low-grade 1.87:1 Anaplastic (Grade

III)

Affects all ages 10% less than 20 years 60% 20-45 years 30% 45 years or older

Gender Age

Mortality and MorbidityRace

Affects all races Grade 1: 10 years Grade 2: More than 5 years Grade 3: 2-5 years Grade 4: Less than 1 year

(3)

Symptoms

Altered development or growth (in children)

Double Vision Drowsiness Eyesight Problems Headache Lethargy Mental Status Change Obtuseness Personality Changes Seizures Vomiting

(1,4)

Diagnosis and Treatment

Testing: Neurological Exam

Vision Hearing Balance Coordination

Computed Tomography Scan (CT)

Magnetic Resonance Imaging (MRI)

Angiogram Biopsy

Treatment Options:

Surgery Resection of

tumor Radiation Chemotherapy

Temozolomide

(1, 2, 3, 5)

Case Study Patient Information• Admit Diagnosis: Aspiration Pneumonia,

Dehydration, Sepsis • Sex: Female• Age: 36 Years Old• Weight: 157#• Height: 5’0”• BMI: 31• Ideal Body Weight: 90-110#• Percent Ideal Body Weight: 157%• Adjusted Body Weight: 114#• Home Diet Regimen: G-Tube with Jevity Bolus 5

Cans Daily

Past Medical History

Astrocytoma 1987: Cerebral Astrocytoma

Surgery 1992: Repeat Brain Surgery

Pituitary Insufficiency Post radiation treatment

Seizure Disorder Post brain surgery

Hypothyroidism Pneumonia Gastrostomy Tube Placement

2006

Social History

Resides with mother and other family

Bed bound last 3-4 years

Home Health Care Aide Three times daily

Nonverbal

Relevant Medications

Os-Cal: Calcium supplement. Also used as antacid, phosphate binder, antidiarrheal

Prilosec: Proton Pump Inhibitor. Used to decrease gastric acid secretion and increase gastric pH

Lactinex: Lactobacillus probiotic. Used to aid with GI regulation and antidiarrheal

Zofran: Antiemetic. Used to decrease vomiting

Flagyl: Antibiotic used to treat C. diff. Can cause nausea, diarrhea, anorexia, taste changes

(6)

Laboratory Values

Date Hgb12-18

Hct37-47

MCV82-101

Na+135-155

K+3.5-5.5

Gluc.70-120

BUN8-26

Creat..6-1.3

Ca+8.7-10.2

4/18 16.4 49.2 81.8 141 4.4 86 12 0.9 9.1

4/19 14.2 42.1 80.7 135 3.4 97 10 0.9 8.5

4/20 12.3 35.9 80.9 140 3.8 84 5 0.6 8.2

4/21 N/A N/A N/A 145 2.9 73 1 0.6 8.0

4/22 11.4 33.0 79.5 N/A N/A N/A N/A N/A N/A

4/23 N/A N/A N/A 145 2.9 90 2 0.6 8.0

4/24 12.6 37.0 79.8 141 3.4 102 6 0.6 7.7

4/25 12.3 37.0 81.6 143 3.4 86 8 0.5 7.9

4/26 12.6 37.9 82.3 N/A N/A N/A N/A N/A N/A

Laboratory ValuesDate Alb

3.4-5.0Alk Phos50-136

SGOT7-47

PO42.5-4.9

RBC4.2-5.4

WBC4-10.5

Cl-96-107

4/18 N/A N/A N/A N/A 6.01 16.2 100

4/19 2.4 339 43 3.2 5.21 18.4 102

4/20 N/A N/A N/A N/A 4.44 12.4 107

4/21 N/A N/A N/A N/A N/A N/A 108

4/22 2.2 232 63 N/A 4.16 7.7 N/A

4/23 2.5 257 58 N/A N/A N/A 107

4/24 2.3 189 32 N/A 4.63 16.7 106

4/25 2.2 187 18 N/A 4.53 14.7 109

4/26 N/A N/A N/A N/A 4.60 13.4 N/A

Dietary Trigger

Dietary Consult for Tube Feeding Recommendation

Moderately Depleted Albumin Level of 2.4 and Pre-albumin Level of 11.6

PES Statements

(NC-1.1) Swallowing difficulty related to dysphagia and past medical history as evidenced by patient needing Gastrostomy Tube for main nutrition and hydration support.

(NI-5.1) Increased protein needs related to increased demand for protein as evidenced by moderately depleted albumin level of 2.4 and pre-albumin level of 11.6. (7)

Interventions

Await restart of tube feedings

Recommend necessary adjustments to tube feeding rate and fluids

Monitor tolerance of tube feeding

Energy, Protein, and Fluid Needs*

Estimated Energy Needs: 1266 (BEE) x 1.2 x 1.1= 1,671 kcals

Estimated Protein Needs: 1.2-1.3g/kg= 62-68g

Estimated Fluid Needs: 35mL/kg= 1,820mL

*All needs based on Adjusted Body Weight of 114#

Tube Feeding Recommendations

Jevity 1.5 at 30cc/hr

Provides: 1,080 kcals 46g protein 16g fiber 547cc free water

IV Fluid 100cc/hr

Jevity 1.5 at 50cc/hr Provides:

1,800 kcals 77g protein 26g fiber 912cc free water 100% RDI’s vitamins and

minerals IV Fluid KVO Water Flushes 200cc QID

Initial MD Order RD Recommended Order*

*RD recommendation based on Adjusted Body Weight of 114#

Tests and Procedures

Chest X-Ray

Kidney, Ureters, Bladder X-ray (KUB)

Abdominal Ultrasound

Conversion G-Tube to G-J Tube

Abdominal CT Scan with Contrast

Diet Orders

Tube Feeding via G-Tube Jevity 1.5 at 30cc/hr Held due to projectile vomit

Gatorade via G-Tube 30cc/hr Held for testing

Tube Feeding via G-J Tube Jevity 1.5 at 40cc/hr

Discharge Notes

April 26, 2010

Approximate 15# Weight Gain Positive Fluid Balance

Discharge to home Continue with Home Health Care

Medical follow ups in two-three weeks

Resume Jevity bolus of 5 cans daily

Questions?

Works Cited

1. Astrocytoma. Astrocytoma. 2007. Available at: http://www.astrocytoma.org/. Accessed June 1, 2010.

2. Glioma. Mayo Clinic. April 2010. Available at: http://www.mayoclinic.org/glioma/. Accessed June 1, 2010.

3. Kennedy B, Bruce JN. Astrocytoma. eMedicine Oncology. January 23, 2009. Available at: http://emedicine.medscape.com/article/283453-overview. Accessed June 2, 2010.

4. Brain tumor-primary-adults. Medline Plus Medical Encyclopedia. May 7, 2010. Available at: http://www.nlm.nih.gov/medlineplus/ency/article/007222.htm. Accessed June 5, 2010

5. Adult brain tumor treatment. National Cancer Institute. October 13, 2009. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/adultbrain/HealthProfessional/page7. Accessed June 4, 2010.

6. Pronsky ZM. Food Medication Interactions. 15th Ed. Birchrunville, PA: Food-Medication Interactions; 2008.

7. American Dietetic Association. International Dietetics & Nutrition Terminology Reference Manual. 2nd Ed. Chicago, IL: American Dietetic Association; 2009.