Brachytherapy (Seed Implantation)
Brachytherapy represents a treatment for prostate cancer by implanting radioactive “seeds” directly into prostatic tissue. Brachytherapy can either be performed as a standalone procedure or in conjunction with external beam radiation therapy.
There was a time near the turn of the century when nearly half of all men treated for prostate cancer were treated with prostate brachytherapy. Since that time, due to the evolution of surgery to robotic prostatectomy, the introduction of more focused external radiation, Cyber Knife radiation and cryotherapy, the popularity of seed implantation for prostate cancer has plummeted. Also leading to this decrease in popularity was the release of ten year data that showed poor long term cure rates in all Gleason scores above six, perhaps worse erectile function after two years as compared to surgery, and significant bowel and bladder symptoms that at times have a worse impact on quality of life than the incontinence seen with surgery. Still, brachytherapy is well applied in certain cases, and is still performed regularly.
Depending on the PSA, and the Gleason score, brachytherapy is either done alone, or in conjunction with external beam radiation therapy as part of a combination radiotherapy protocol.
Brachytherapy, also known, as radioactive seed implantation, is a means of treating prostate cancer whereby seeds composed of radioactive Iodine, Palladium or Iridium are implanted directly into the prostate gland. Depending on the PSA, and the Gleason score, brachytherapy is either done alone, or in conjunction with external beam radiation therapy as part of a combination radiotherapy protocol. In cases where the prostate is very large and must be shrunken, or in cases involving higher-grade tumors, hormonal therapy may be a part of the treatment. Brachytherapy is contraindicated in cases where voiding symptoms are severe, as well as in cases where the tumor has obviously extended outside of the confines of the prostate.
Current controversy exists as to age cut offs for institution of brachytherapy. Despite 15 year data showing comparable disease free survival statistics between brachytherapy and radical prostatectomy for Gleason 6 cancers, some physicians are reluctant to implant men in their 50’s. As the results prove to be more durable, however, the average age of the patient choosing brachytherapy is falling. The upper age limit for this therapy is dictated by the physiologic age of the patient, with some implants being done in healthy men in their 80’s. If you are in your 50’s and desire brachytherapy, discuss this issue with your physician.
It is the practice of our group to offer our patients a consultation with a radiation oncologist in nearly all cases.
It is the practice of our group to offer our patients a consultation with a radiation oncologist in nearly all cases. If brachytherapy is a consideration, the radiation oncologist will receive a summary of the clinical data prior to your visit. If the decision is made to go ahead with brachytherapy, a volume study of the prostate is scheduled through the radiation oncologist. This study is done to determine the size of the prostate as well as to provide parameters for determining the number and location of each of the seeds. Prior to your volume study, it is advised that you give yourself a Fleets™ enema. This procedure is done under local anesthesia, so fasting is not required. You will be able to transport yourself to and from the facility on your own, and to resume normal activity upon leaving the facility. In rare instances, the volume study can be completed utilizing conscious sedation. Occasionally the gland volume will be found to be too large to be practical for implantation. In these cases, the pubic arch may prove to be problematic in allowing for optimal seed distribution. If this is the case, the patient will be offered the option of hormonal downsizing. With an injection of a medication known as a LH-RH agonist (Lupron, or Eligard e.g.) the gland volume will decrease by up to 30% in about 3-4 months allowing for implantation to take place.
Once there is confirmation of a reasonable gland volume, the procedure will be scheduled as a joint effort between your urologist and the radiation oncologist. Since anesthesia is required, we will ask that you receive medical clearance from your primary care physician. This will include laboratory studies, EKG and a chest x-ray if not done recently. You will be instructed to discontinue all medications that impair blood clotting, such as aspirin, anti-inflammatories, plavix, and coumadin, 7 days prior to the procedure. Discuss the timing for restarting these drugs, with your physician. On the evening prior to the procedure, have nothing to eat or drink after midnight. On the morning of the procedure, you should give yourself another enema.
The implant procedure is done as same day (outpatient) surgery. General or regional anesthesia is required. The actual implant will take about 1 hour.
The implant procedure is done as same day (outpatient) surgery. General or regional anesthesia is required. The actual implant will take about 1 hour. Cystoscopy (telescopic examination of the bladder), is done in every case, at the conclusion of the procedure. A decision to leave a catheter draining the bladder is made at that time. If a catheter is placed, the patient is taught how to remove it on the first postoperative day.
A postoperative appointment is scheduled with your urologist for 2 weeks after the procedure. You will see the radiation oncologist 1 month after the procedure, at which time a post implant CT scan will be done to assess the adequacy of the implant. In some instances, the CT scan is completed on the day of the implant. The first PSA will not be done until 4 months following the implant. Follow up after that will be alternated between the urologist, and the radiation oncologist.
The most common post implant symptoms encountered by our patients include urinary urgency, frequency, rectal irritation and frequent bowel movements, as well as burning on urination. There are usually some black and blue marks from the puncture sites. The discoloration may often include the scrotum, and rarely the penis. A rare individual will have problems with urinary retention. Urinary or rectal bleeding is rare. Alpha-blockers, which are given to help improve the urinary flow, are generally started days to weeks prior to the procedure. You may benefit from doubling the dose of the alpha-blocker for 2-3 days following the procedure. Discuss this with your physician. Upon discharge from the operative facility, each of our patients is given a prescription for pain medicine, anti-inflammatories, and antibiotics.
Once you are home, an ice pack to the perineum may help with some of the discomfort, along with the prescribed analgesics. You may shower the day following the procedure, and resume normal activity as long as you are comfortable. Sexual activity should be avoided for 1 month. You may safely be in the same room with small children, or pregnant women, but should avoid contact such as having the child sit in your lap. Again, 1 month is reasonable.
Approximately 10 half-lives are required for the radioisotope to lose its entire radioactivity. The half-life for iodine is 60 days, while for palladium it is 16. If you are planning air travel during this period of time, please tell us so that we may provide you with documentation should you trigger low-level radiation detectors at the airports!
Please feel free to contact us for an appointment to discuss the particulars of your case. Our physicians have extensive experience with brachytherapy, as well as all other prostate cancer treatments, and are able to compare and contrast these complicated procedures.