Expanding HDR Brachytherapy Program at a Rural Cancer Center to Include Soft Tissue Sarcoma

Interventions Specific to Soft Tissue Sarcoma

A team comprising nursing staff from radiation oncology, surgical oncology, and the oncology inpatient unit was assembled to plan nursing intervention for patients undergoing interstitial brachytherapy for soft tissue sarcoma. In addition, the wound ostomy nurses were consulted to determine what, if any, dressings might be applied over the wound vacuum during the course of treatment.

Next, a literature review was conducted to identify appropriate nursing interventions for the surgical incision and catheter care. Several published articles on HDR brachytherapy were used as guidelines for handling the specialized catheters and managing skin care at the entry and exit sites. An educational storyboard was created to serve as a visual learning tool for all staff involved in caring for patients on the inpatient unit.

The storyboard included educational materials on brachytherapy, current peer reviewed journal articles depicting the procedure and appropriate postoperative interventions, the American Brachytherapy Society consensus statement for sarcoma brachytherapy, and actual examples of the catheters that would be used. Because the catheter tails would be several inches long immediately after the surgery then cut to size at the time of simulation, both examples were included on the storyboard.

The catheters are the vehicle used to deliver the radiation pellets directly to the surgical bed; therefore, they should not be kinked or bent in a way that might damage patency. Additionally, any moisture introduced into the catheters might cause integrity breakdown. Specific instructions include not to submerge the area in water or wet the catheters during skin care.

One of the biggest challenges faced while implementing the HDR brachytherapy program was dealing with unknowns. For example, whether the margins warranted brachytherapy was at the discretion of the surgeon during surgery. The direction in which to lay the catheters, the plane to place them in in relation to the patient’s anatomy, and whether to use a wound vacuum or close the incision were also at the surgeon’s discretion intraoperatively. The team would not learn whether the case was indeed “a go” and what the site would look like, which ultimately dictate nursing interventions, until the immediate postoperative period.

Another challenge was maintaining catheter integrity for the duration of the treatment course. On postop day 1, the patient was simulated and the catheters cut to rough length. Postop day 2 was spent planning the treatment, which involved dosimetry, physics, and the radiation oncologist. On postop days 3 and 4, the patient underwent treatment twice daily, approximately 6 hours apart. Therefore, nursing staff were required to be diligent about maintaining catheter integrity for approximately 5 days.

Outcomes for the Patient and our Program

Our patient was assessed postoperatively by surgical and radiation oncology. At 3 weeks, the drain was functional and the wound was healing well. At 1 month, there were no wound complications, and the drain was removed. Surveillance scans and additional follow-up were scheduled for 3 months. Feedback from the patient and spouse experience was positive; they reported receiving quality care throughout the process from every member of the team.

After evaluating the program, the team determined that the wound vacuum was absolutely necessary to provide optimal treatment. Without it, the surgical bed would have continuously collected fluid creating changes in the patient’s anatomy that could potentially impact the precision and accuracy of brachytherapy treatment.

Learning opportunities included involving the wound ostomy staff as active participants in planning and implementing the procedure. Future direction includes informing the wound ostomy team during the planning phase about upcoming potential cases and their evaluating the patients at the time of treatment.

Conclusion

Postoperative HDR brachytherapy for soft tissue sarcoma is an acceptable treatment modality that delivers high doses of radiation to the surgical bed and surrounding tissue, provides adequate local control, and reduces acute and late toxicities. It can be administered in the outpatient setting over 2 to 3 days, which reduces overall treatment costs. With the proper equipment, radiation oncology departments can implement a similar program that offers innovative solutions, optimal patient outcomes, and improves patient satisfaction.

In addition to better patient outcomes and the functional benefits of using HDR brachytherapy for soft tissue sarcoma, implementing the service in our hospital has added significant value to the cancer service line and oncology program. This model can serve as a blueprint for other rural hospitals that have a radiation oncology department with the equipment to perform HDR brachytherapy.

Mandy Arnone is a radiation oncology nurse at Kalispell Regional Medical Center in Kalispell, Montana. Leah Scaramuzzo is nursing director, Oncology Clinical Development, Kalispell Regional Healthcare, and a member of the Oncology Nurse Advisor editorial advisory board.

References

1. Holloway CL, DeLaney TF, Alektiar KM, Devlin PM, O’Farrell DA, Demanes DJ. American Brachytherapy Society (ABS) consensus statement for sarcoma brachytherapy. Brachytherapy. 2013;12(3):179-190. doi:10.1016/j.brachy.2012.12.002
2. Beltrami G, Rüdiger HA, Mela MM, et al. Limb salvage surgery in combination with brachytherapy and external beam radiation for high-grade soft tissue sarcomas. Eur J Surg Oncol. 2008;34(7):811-816. doi:10.1016/j.ejso.2007.08.011
3. Itami J, Sumi M, Beppu Y, et al. High-dose rate brachytherapy alone in postoperative soft tissue sarcomas with close or positive margins. Brachytherapy. 2010;9(4):349-353. doi:10.1016/j.brachy.2009.07.012
4. Klein J, Ghasem A, Huntley S, Donaldson N, Keisch M, Conway S. Does an algorithmic approach to using brachytherapy and external beam radiation result in good function, local control rates, and low morbidity in patients with extremity soft tissue sarcoma? Clin Orthop Relat Res. 2018;476(3):634-644. doi:10.1007/s11999.0000000000000079