Nursing care for patients with recurrent invasive meningioma undergoing salvage boron neutron capture therapy: a case report

Introduction

Background

According to the 2015–2019 Central Brain Tumor Registry of the United States, the most common brain tumor site is the meninges, representing 40.2% of all brain tumors. The most frequently reported brain histopathology is meningioma (40.0%) (1), which the World Health Organization (WHO) system classifies as benign (Grade I), atypical (Grade II), or anaplastic (Grade III) (2). Unlike slow-progressing benign meningiomas, non-benign meningiomas have invasive characteristics and frequently recur after conventional first-line treatment such as radical surgery and adjuvant photon radiotherapy (3). Aggressive salvage treatment strategies are needed to prevent meningioma recurrence.

Rationale and knowledge gap

Boron neutron capture therapy (BNCT) is a unique cancer treatment strategy. Recent publications highlight its efficacy in targeting these tumors with precision, leveraging the unique mechanism of boron-10-containing drug coupled with low-dose thermal neutrons (low-energy neutron). The ability of BNCT to selectively destroy tumor cells while minimizing damage to surrounding healthy tissue underscores its potential as a valuable treatment modality in neuro-oncology. Following BNCT treatment, patients require specialized nursing management to ensure optimal recovery and ongoing care. By offering comprehensive support, nurses ensure that patients receive the necessary guidance and care to navigate the complexities of BNCT.

Objective

Application of a holistic care model based on Swanson’s caring theory provides a framework for delivering person-centered holistic care to patients undergoing BNCT for meningioma treatment. This theory includes five caring processes: knowing, being with, doing for, enabling, and maintaining belief (4). Special nursing care is needed to guarantee good treatment outcomes and a high quality of care. We have recently reported good tumor response for patients with recurrent meningiomas treated with BNCT (5). This study aims to report the nursing care provided for patients undergoing BNCT for treatment of recurrent invasive meningioma. We present this article in accordance with the CARE reporting checklist (available at https://tro.amegroups.com/article/view/10.21037/tro-23-38/rc).

Case presentation

The BNCT treatment flow is shown in Figure 1. Patients suitable for treatment were required to go through the hospital’s Institutional Review Board committee and the Taiwan Food and Drug Administration (TFDA) for review and approval of the application for compassionate use. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal. Before BNCT, each patient underwent specialized positron emission tomography using 4-borono-2-¹⁸F-fluoro-phenylalanine as a radiotracer (FBPA-PET), and brain tumor activity was detected by positron scanning (6). Patients for whom FBPA-PET indicated a tumor/normal (T/N) tissue ratio >2.5 were eligible for BNCT treatment. During BNCT, a boron-10–containing drug was administered intravenously. Blood samples were drawn after the first and second hour post-injection to monitor the blood concentration of boron, and the dosing rate was adjusted accordingly. After the peak blood concentration of boron was achieved, the patient was positioned in the treatment room. Neutron irradiation was initiated once the medical personnel left the room, and the patient was observed on a monitor. The irradiation treatment time was approximately 20 min (single field). After treatment, the patient was transferred to the observation room, and their vital signs were monitored.

Figure 1 Flow chart of salvage BNCT process. BNCT, boron neutron capture therapy; FBPA-PET, positron emission tomography using 4-borono-2-¹⁸F-fluoro-phenylalanine as a radiotracer; TVGH, Taipei Veterans General Hospital.

Clinical case description

Nurses played an important role in care giving before, during, and after BNCT. This study applied Swanson’s caring theory to assess the patients’ thoughts and needs and to provide individualized nursing care based on specific case problems. Our experiences caring for two special meningioma patients who underwent BNCT as their salvage treatment were as follows.

Case 1

Patient A was a 74-year-old male with a skull-base meningioma that was first identified in 2018, presenting initially with dizziness and unsteady gait. Brain magnetic resonance imaging (MRI) revealed an extensive tumor lesion over the skull base with encasement of the adjacent major arteries. Neurosurgeons recommended against radical surgery because of the high risk of injury to normal tissues. Palliative radiotherapy with 28 Gy in 14 fractions and oral hydroxyurea were administered. However, no significant decrease in tumor size was observed. The patient was then referred to our center for further evaluation to determine his eligibility for salvage BNCT. Before BNCT, FBPA-PET revealed a T/N ratio of 2.89. However, the patient found himself overwhelmed by nervousness regarding the unfamiliar treatment process and was plagued by worries that his symptoms might not improve even after undergoing treatment. These concerns weighed heavily on him as he envisaged the potential impact on his overall quality of life. In an effort to alleviate the patient’s anxiety and fear of the unknown, the nurse requested the physician to provide a comprehensive explanation of patient’s present condition and the BNCT treatment procedures. Additionally, the nurse bolstered the patient’s confidence by sharing the success stories of individuals who experienced positive outcomes following BNCT. His sense of hopelessness gradually decreased after the nursing intervention. The patient underwent BNCT on August 21, 2020. After BNCT, follow-up brain MR revealed partial regression of the meningioma lesion. The patient felt much better a few days after treatment; his dizziness was relieved, and he could walk steadily and gradually.

Case 2

Patient B was a 58-year-old female who suffered from atypical meningioma, first diagnosed in late 2011, presenting initially with intermittent headaches and a feeling of fullness in her head. The first craniotomy was performed in December 2011 (atypical meningioma, WHO grade II). The tumor recurred, and she underwent gamma knife treatment twice (in July 2013 and April 2019), and a second craniotomy was performed in 2021. Unfortunately, the tumor recurred quickly and became very aggressive. She was then referred to our center for further evaluation to determine her eligibility for salvage BNCT. The patient’s concerns involved the fear of losing control over the disease and the looming possibility of death. Through attentive care, the nurse successfully fostered a strong relationship with the patient, gaining a deep understanding of her needs and perspectives. Recognizing the importance of a supportive environment, the nurse actively encouraged family members to accompany the patient, thus establishing a robust family support system. Before BNCT, FBPA-PET revealed a T/N ratio of 2.64. The patient underwent BNCT smoothly in February 2022. Four months after BNCT, a brain MRI revealed near-complete regression of the tumor (Figure 2). The patient experienced relief from headaches, and she gradually recovered the muscle strength in her lower limbs. Her anxiety improved substantially after the treatment.

Figure 2 The patient underwent BNCT in February 2022 (patient B). A near-complete tumor response was observed 4 months later. BNCT, boron neutron capture therapy.

Patient management

Our protocol for nursing care and patient management during BNCT, from pre-therapy preparation to post-therapy care, is described below. Evidence-based nursing care skills required to care for BNCT patients are listed in Figure 3 (7-13).

Figure 3 Evidence-based nursing care for patients undergoing BNCT (7-13). BNCT, boron neutron capture therapy.

Pre-therapy

Nurses assisted in making overnight pretreatment hospitalization arrangements; performed routine blood tests (complete blood count and differential count), liver function tests [aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels], and renal function tests [blood urea nitrogen (BUN) and creatinine, and serum sodium and potassium levels]; and placed an intravenous in-dwelling needle in preparation for injection of the boron-containing drug during BNCT.

During therapy

I. Care during intravenous administration of medication

Peripheral intravenous injection to administer boron-10 (L-BPA)-containing drugs and aseptic drawing of blood samples to measure blood boron concentration are important steps in BNCT. If blood cannot be successfully drawn during therapy, the biological dose response of the tumor cannot be evaluated. The boron-10-containing drug concentrations are converted to tumor concentrations, which reflect the therapeutic dosage of BNCT. To prevent infection during intravenous drug administration, it is important to maintain a sterile injection site and fix the intravenous fluid bottle approximately 75 cm higher than the injection site for continuous flow. The number of drops should be carefully adjusted to avoid rapid cardiac overload. If the patient’s vein is not easily visible or palpable after two to three failed attempts at intravenous catheterization, the immediate treatment time is affected. Additionally, multiple failed attempts can cause pain and anxiety in patients and increase the risk of complications such as injection site infection (14,15). Hence, successful peripheral intravenous catheterization is necessary to reduce patient anxiety and ensure efficient progression of the treatment process.

II. Handling of medical waste and its disposal

Disposable medical equipment is commonly used during medical procedures. Sharp instruments such as injection needle tips, syringes, and infusion catheters are classified as biomedical waste. Empty glass vials containing drugs are commercial waste. Medical personnel should properly handle, sort, and dispose of biomedical waste to prevent needlestick injury, infection due to skin exposure, or inhalation of hazardous materials (16). Therefore, biomedical waste certification and continuous training courses are necessary for all medical personnel.

III. Basic principles of radiation protection

During BNCT, high-penetration particles damage biological macromolecules such as DNA and proteins, resulting in secondary radiation. Therefore, the basic principles of radiation protection apply to BNCT. Neutron-irradiated metal can be activated into radioisotopes that emit radiation and are harmful to the human body. Hence, metal objects should be removed from patients undergoing BNCT. After positioning, the patient was left alone in the irradiation room, radiation dose levels were monitored by medical personnel using dosimeters and they waited for the radiation dose to decrease to a safe level before approaching the patient. Following this protocol reduced the radiation exposure to medical personnel. After BNCT, the patient was encouraged to drink water to facilitate drug metabolism and reduce urine retention. In addition, the working conditions of pregnant radiotherapy personnel should be reviewed according to the Ionizing Radiation Protection Act to ensure the safety of their embryos or fetuses (16).

Post-therapy care

After BNCT administration, nurses assessed the patient’s physical and mental state and provided appropriate nursing interventions to help minimize the impact of treatment side effects on the patient’s quality of life. The common side effects of BNCT include increased intracranial pressure, epilepsy caused by cerebral edema, fatigue, and skin reactions.

I. Increased intracranial pressure

Symptoms of increased intracranial pressure include headache, nausea, projectile vomiting, drowsiness, changes in consciousness, and pupillary dilatation (16). Nurses should regularly assess the patient’s state of consciousness, measure vital signs, check for increased blood pressure and decreased pulse, and administer steroids and intracranial pressure-lowering drugs such as decadron (5 mg/mL) and glycerol (250 mL) as prescribed by physicians. Further, nurses can elevate the head of the bed to 30° to avoid the Trendelenburg position. It is also necessary to maintain tranquility in the ward and reduce the risk of emotional agitation by reducing external stimuli such as noise or bright light. In addition, nurses need to teach patients how to avoid the Valsalva maneuver while straining during defecation or coughing to prevent increased intracranial pressure (17). Bevacizumab was administered to the meningioma patients after BNCT when they were transferred to the ward. Bevacizumab is a target therapy drug that inhibits the growth of cancer cells by blocking the transmission pathway of vascular endothelial growth factor receptors and is also used to treat radiation necrosis (18,19). Here, we used it prophylactically to decrease the possibility of post-BNCT toxicity and brain edema.

II. Fatigue

The causes of fatigue in patients with meningioma include the cancer itself and the treatment process. The “energy conservation and activity management” training proposed by Barsevick aims to reduce energy expenditure and maintain a balance between rest and activity when patients are severely exhausted (20). This training includes (I) setting priorities, (II) delegation, (III) planning, (IV) being active during times of peak energy, (V) pacing, and (VI) resting (20). After BNCT, nurses should educate the patients and their families on measures to reduce fatigue after treatment.

III. Skin care

Discomfort associated with BNCT differs from that of conventional radiotherapy. Before patients with meningioma underwent BNCT, they were instructed to apply self-care for BNCT-induced adverse skin reactions. At the irradiation site, BNCT affects hair follicle cells in the growth phase, which are characterized by rapid cellular division and are easily damaged by ionizing radiation; hence, it results in temporary post-therapy hair loss. The hair regrows in most patients within 2–3 months. Patients should be trained in daily care methods to minimize overstimulation of hair follicles, including gentle hair combing; using a neutral shampoo; and avoiding hair dryers, hair curlers, and excessive hair traction. During the hair-growth recovery period, wigs, headgear, or hats can be used according to the patients’ personal preferences to protect the irradiated area (21).

IV. Other aspects of daily life care

Rehabilitation exercises within the scope of safe activities are allowed for patients with meningiomas to improve their quality of daily life. However, excessively strenuous or stimulating activities should be avoided to prevent harm.

Discussion

BNCT is a novel treatment modality involving the administration of boron-10-containing drugs and irradiation with specialized thermal neutrons. Although this treatment has fewer side effects in normal tissue than in tumors, adverse reactions can occur during and after treatment that result in post-treatment effects. This report highlights the patient-care techniques and principles to be followed before, during, and after BNCT administration. A high-quality care team can assist patients with meningiomas through successful and safe treatment.

Patients with meningioma require specific nursing and personalized care for treatment. Caring is the commitment and responsibility of nurses. Swanson’s caring theory (4) includes the following five processes:

• Knowing. Establish a good nurse-patient relationship through active care and self-introduction to the patient and their families and understand the needs and thoughts of the patient and their families regarding BNCT.
• Being with. Listen to and encourage patients and their families to express their feelings and provide positive support and encouragement before BNCT. Encourage family members to accompany the patient and establish family support systems.
• Doing for. Give the patient a call bell and tell them that nurses can provide immediate assistance when needed after BNCT.
• Enabling. Physicians should explain the current condition and treatment procedures of BNCT to the patient and their families, and nurses should provide special care after BNCT to reduce anxiety and fear of the unknown in the patients and their families.
• Maintaining belief. Share successful cases of previous BNCT to increase patients’ confidence in their treatment.

Attentive nursing care plays an important role in oncological treatment, particularly for patients with meningioma. Building trust among nurses, patients, and their families is key to aiding recovery post-BNCT. Nurses could educate them about the disease and treatment, while offering tailored care addressing both physical and psychological needs, and monitoring their response throughout the process.

Conclusions

BNCT is an effective targeted-particle therapy for intracranial invasive meningiomas, offering distinct advantages over conventional photon radiotherapy, especially in terms of its biological benefits and the response of normal tissues. Given the sensitive nature of brain tissue, specialized nursing care plays a pivotal role in the care of patients with meningioma undergoing BNCT. Hence, the establishment of a specialized nursing care system is essential to ensure optimal treatment outcomes for these patients throughout BNCT.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://tro.amegroups.com/article/view/10.21037/tro-23-38/rc

Peer Review File: Available at https://tro.amegroups.com/article/view/10.21037/tro-23-38/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tro.amegroups.com/article/view/10.21037/tro-23-38/coif). Y.W.C. serves as an unpaid associate Editor-in-Chief of Therapeutic Radiology and Oncology from October 2017 to July 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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