Radioactive seed implants are a form of radiation therapy for prostate cancer. Brachytherapy, or internal radiation therapy, are also terms used to describe this procedure. There are two types of prostate brachytherapy: permanent and temporary.
Compared to external radiation, which requires eight to nine weeks of daily treatments, convenience is a major advantage of brachytherapy.
Permanent (Low Dose Rate) Brachytherapy: LDR
A doctor or clinician implants radioactive (iodine-125 or palladium-103) seeds into the prostate gland using an ultrasound for guidance. The number of seeds and where they are placed is determined by a computer-generated treatment plan tailored for each patient. Anywhere from 40 to 100 seeds are commonly implanted.
The implants remain in place permanently, and become biologically inert (no longer useful) after a period of months. This technique allows a high dose of radiation to be delivered to the prostate with limited damage to surrounding tissues.
Temporary (High Dose Rate) Brachytherapy: HDR
With this technique, hollow needles are placed into the prostate gland and filled with radioactive material (iridium-192) for 5-15 minutes. After the treatment both the iridium and the needles are removed. This is repeated two to three times over the next several days.
Who Is Eligible For This Procedure?
Seed implants are relatively low-energy sources, and subsequently have limited tissue penetration. Therefore, the best candidates for these procedures are patients who have a cancer that is contained within the prostate and is not very aggressive. The usual criteria for treatment include a PSA level of less than 10, a Gleason score (which measures the aggressiveness of the tumor) less than or equal to six, and minimal or no abnormality on the digital rectal exam.
What Happens Before The Procedure?
A transrectal ultrasound is done to provide the radiation oncologist with specific details about your case. Newer techniques using a CAT scan or MRI may be used to guide the proper placement of the implants. This information is used to custom-design the treatment plan for you. Another option is for the ultrasound and treatment plan to be done at the same time as the radioactive seeds are implanted.
What Happens During The Procedure?
The entire procedure takes approximately 90 minutes. Most patients go home the same day.
A radiation oncologist and urologist perform the procedure. Both physicians are actively involved in all aspects of the implantation, from the planning to the post-operative care. During the procedure, the urologist provides ultrasound guidance and the radiation oncologist places the radioactive seeds.
The procedure is performed as follows:
- After general or spinal anesthesia, the legs are elevated and padded very carefully.
- The ultrasound probe is inserted into the rectum and is used to take pictures of the prostate. The probe remains in place throughout the procedure.
- The radioactive seeds are loaded into the designated number of needles.
- In a specific order, each needle is inserted through the skin in the perineum (the area between the base of the scrotum and the anus) and into the prostate using continuous ultrasound guidance. Once accurate needle placement is confirmed, the seeds in that needle are released. This process is continued until all of the radioactive seeds have been implanted. No surgical incision or cutting is necessary. For HDR, once the needle placements are confirmed, they are filled with a radioactive material. After a period of minutes both the needles and the radioactive material are removed.
- The urologist inserts a tube with a camera called a cystoscope through the penis and into the bladder. If he or she detects any loose radioactive seeds within the urethra or bladder, they are removed.
- If some blood is in the urine, the urologist may place a catheter into the bladder for a short period of time to ensure proper drainage. All patients are instructed how to drain urine from the bladder, if necessary.
What Are The Results?
Results from this treatment approach show that in patients with similar types of prostate cancer, brachytherapy alone or in combination with external beam radiation therapy appears as effective as a radical prostatectomy and regular external radiation therapy.
What Are The Side Effects?
Urinary symptoms are the most common. These include frequent urination and a need to get to the bathroom quickly. Some men have a burning with urination and, in a few cases, an inability to empty the bladder completely.
These symptoms can usually be managed with medicine, and they improve over time. Temporary self-catheterization may be necessary to help drain the bladder.
Urinary incontinence from brachytherapy is rare. The risk may be somewhat increased in patients who have undergone a previous surgical procedure to remove a part of the prostate called a TURP (transurethral resection of the prostate). A doctor can minimize this risk by doing a careful prostate ultrasound before the procedure to determine how much prostate tissue is still present to implant the seeds.
The impotence rate at five years after the procedure is about 25% using brachytherapy alone. If hormone therapy is added, the impotence rate rises depending on the duration of the hormonal treatment.