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How Are Seeds Implanted For Prostate Cancer

Clinical & Imaging Findings

Prostate brachytherapy: what to expect

Prostate brachytherapy is considered a minor procedure with a high success rate and minimal complications. Short-term complications arise in several hours to several weeks and most commonly include urinary urgency, frequency, retention and incontinence. Long-term complications such as erectile dysfunction, rectal toxicity and urethral stricture, often require over a year to ensue . Seed migration is considered a relatively common complication however, it is underreported because most cases of seed migration are clinically silent. They rarely cause symptoms at the ectopic site and do not appreciably affect the post-implant dosimetry or efficacy of the procedure . The most common site of migration is the lung it is thought that seeds follow the venous circulation, passing from the periprostatic venous plexus through the inferior vena cava into the pulmonary arterioles. However, seeds can reach the arterial circulation and end up in virtually any anatomical location if a patent foramen ovale, pulmonary arteriovenous shunt, or other right-to-left shunt is present .

Migrated seeds can be identified with plain radiography or computed tomography they present as small linear hyperdensities simulating the intraprostatic seeds. Identification can be difficult given their small size in our case, multiplanar and 3-D reconstructions greatly aided localization and diagnostic certainty.

What Is Prostate Seed Brachytherapy

It is estimated that 1 in 9 men will develop prostate cancer during their lifetime. If prostate cancer is detected early, there are several methods of treatment currently available which provide a good chance of a cure. Choosing the treatment option that is best for you should involve obtaining enough information to allow you to understand what each treatment involves.

You should make an informed decision in close consultation and discussion with your doctor.

This procedure involves the insertion of radioactive seeds directly into the prostate gland where they remain. The seeds emit low level radiation for approximately 1 year after implantation. Each seed is 4.5mm in length and 0.8mm wide and resembles a grain of rice, grey in colour.

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How Is The Radioactive Seed Inserted

Using a mammogram as guidance, a radiologist places one seed, so tiny it can be safely injected with a needle, inside the tumour. It emits a very small amount of radiation that is picked up in the operating room with a small, handheld Geiger counter. After the piece of breast tissue with the radioactive seed is removed, the seed is separated from the tissue and appropriately disposed of, with every seed being accounted for.

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How Long Does It Take To Recover From Radiation Treatment

Theres no doubt radiation therapy can make the difference between life and death for cancer patients, but unfortunately it often comes at a cost.

Radiation therapy is associated with harsh side effects, many of which dont emerge until months or years after treatment. Acute side effects occur and disappear within 14 days of treatment, but long-term effects like bone degeneration, skin ulcers, and bladder irritation take much longer to manifest.

The complications of radiation therapy are frustrating, painful, and often embarrassing, but using ongoing therapy, such as hyperbaric oxygen therapy , can accelerate your radiation therapy recovery in a natural way and stop your symptoms from defining your quality of life.

What Happens Before The Procedure

Migration of a strand of four seeds in low

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.

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Coping With Side Effects Of Radiation For Prostate Cancer

The side effects you experience from radiation and other prostate cancer treatments can be upsetting and challenging to live with.

Erectile dysfunction and urinary problems may be worse in people who have these issues prior to treatment. Your age and underlying conditions such as high blood pressure and diabetes may also be factors.

Urinary dysfunction often lessens or resolves on its own, over time. It can also be treated successfully with oral medication. In some instances, surgical solutions may produce long-term, satisfactory results.

Radiation therapy can damage nerves located near the prostate gland that help you have an erection. Challenges with getting and keeping an erection hard enough for penetration is common after radiation therapy.

If no nerve damage occurred, your doctor may prescribe medications, such as Cialis , that can help you have and keep an erection. Other treatments, such as penile injections, vacuum pumps, and penile implants can also help.

Side Effects Of Brachytherapy

Brachytherapy causes the same types of side effects that external beam radiation therapy does, such as erectile dysfunction.

In some instances, side effects to the bowels may be less severe than those caused by EBRT. Side effects that impact the bladder, however, may be more severe.

High-dose brachytherapy may cause temporary pain and swelling. It may also cause your urine to look red or brown for a short period of time.

Brachytherapy presents with some risks that external beam radiation therapy does not. If you have permanent brachytherapy, you may emit radiation to others for several weeks or months. Your doctor may advise you to stay away from pregnant people and small children during this time.

Occasionally, the seeds may migrate away from their original placement. For this reason, you may also be instructed to wear condoms during sexual activity, to protect your partner.

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Who Can Have Permanent Seed Brachytherapy

On its own

Permanent seed brachytherapy on its own may be suitable for men with CPG 1 localised prostate cancer. This is because the radiation from the radioactive seeds doesnt travel very far, so will only treat cancer that is still inside the prostate.

It may also be suitable for some men whose cancer have a CPG 2 or CPG 3 of spreading.

With other treatments

If you have CPG 4 or CPG 5 localised prostate cancer, you may have brachytherapy together with external beam radiotherapy and hormone therapy. This is sometimes called a brachytherapy boost. Having these other treatments at the same time as permanent seed brachytherapy can help make the treatment more effective. But it can also increase the risk of side effects.

Some men with intermediate risk localised prostate cancer or locally advanced prostate cancer may be offered a brachytherapy boost.

When is permanent seed brachytherapy not suitable?

Permanent seed brachytherapy wont be suitable if your cancer has spread to other parts of your body .

It may not be suitable if you have a very large prostate. If you do have a large prostate you may be able to have hormone therapy before treatment to shrink your prostate.

Not all hospitals offer permanent seed brachytherapy. If your hospital doesnt do it, your doctor may refer you to one that does.

Continued Refinements For Improved Accuracy

Prostate Seed Implant – Brachytherapy By Chicago Prostate Center Video

Memorial Sloan Kettering doctors and physicists have helped to develop a refined approach, known as intraoperative computer-based conformal optimization. Here, the treatment team including radiation oncologists, medical physicists, and radiation therapists visualize the prostate using CT scans to assess optimal seed placement while in the operating room.

Pioneered at Memorial Sloan Kettering in 1998, the use of sophisticated computer programs in the operating room to help target where and how many seeds to place within the prostate gland allows the optimal radiation dose to be delivered to the prostate, sparing as much normal tissues as possible from radiation exposure. Planning is done in the operating room during the actual procedure instead of weeks before the procedure, as had been previously done.

Using on-site computers and ultrasound images, our medical physicists employ a sophisticated computer program developed at Memorial Sloan Kettering that can examine within minutes millions of configurations of seed-coordinate placement possibilities, says Marco Zaider, PhD, Head of Brachytherapy Physics at Memorial Sloan Kettering. The program selects the placement plan that will deliver the most effective dose to the prostate while keeping the dose delivered to the rectum and urethra as low as possible.

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Advantages And Disadvantages Of Brachytherapy

Advantages

  • Treatment time is short: 1-2 days.
  • You can return to your normal routine quite quickly.
  • Compared to external radiotherapy, brachytherapy may have fewer immediate side-effects and cause less damage to surrounding tissues like the back passage, urethra and bladder.

Disadvantages

  • It can cause urinary, erection and bowel problems.
  • You may have some temporary discomfort after the procedure.
  • You will need to have a general anaesthetic.
  • You may not be able to have prostate surgery in the future, due to the effects of the radiotherapy.

Incidence Of Seed Migration

We found that 0.36% of implanted seeds migrated to the chest in 20% of our patient population, similar to previous reports . It has been reported that the incidence of seed migration to the chest can be as high as 55% per patient population and 0.98% per number of implanted seeds . The variability of the incidence of seed migration to the chest among the reported results is considered to be attributed to different types of seeds , different designs of seed placement , different timings of follow-up radiographs, and different protocols of follow-up chest radiographs .

Table 2 Literature Survey of Seed Migration

In contrast, the incidence of seed migration to the abdomen and pelvis has been reported rarely . A possible reason is that the American Brachytherapy Society does not specifically recommend follow-up abdominal and pelvic radiographs after seed implantation . Therefore, in most institutions, follow-up abdominal and pelvic radiographs would not be undertaken routinely. However, we found that seed migration to the abdomen and pelvis occurred in 2.2% and 5.6%, respectively, of our patient population. Although the incidence of seed migration to the abdomen and pelvis is lower than that of seed migration to the chest, we would consider it advisable to undertake follow-up abdominal and pelvic radiographs after seed implantation.

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How Long Has This Procedure Been Around

Using internal radioactive sources to treat cancer is not a new concept it emerged over 100 years ago. However, radioactive seed localization specifically is a relatively new technique the first procedure in the Ottawa Hospital Radioactive Seed Localization Program was on April 21, 2015. Our hospital was the third centre in Canada to have this program, and we are a leader in the procedure, with other healthcare centres looking to us for guidance.

Prostate Seed Implantation At Princeton Radiation Oncology Treats Prostate Cancer Effectively

Calypso/Fiducial Seed Placement

Prostate seed implantation is a minimally invasive procedure for treating prostate cancer in which radioactive seeds are placed in the prostate gland to target cancer cells while maximizing the preservation of healthy tissue. This outpatient procedure requires general anesthesia and takes only a few hours. Most patients return to normal activities within two to three days.

At Princeton Radiation Oncology, our doctors are experts in treating prostate cancer patients using prostate seed implantation, having pioneered its use more than two decades ago.

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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 . 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.

Rectal bleeding occurs in less than 1% of patients. Diarrhea is rare.

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.

Bowel problems can sometimes happen and include rectal pain, burning pain and diarrhea.

Stereotactic Body Radiation Therapy

This technique uses advanced image guided techniques to deliver large doses of radiation to a precise area, such as the prostate. Because there are large doses of radiation in each dose, the entire course of treatment is given over just a few days.

SBRT is often known by the names of the machines that deliver the radiation, such as Gamma Knife, X-Knife, CyberKnife, and Clinac.

The main advantage of SBRT over IMRT is that the treatment takes less time . The side effects, though, are not better. In fact, some research has shown that some side effects might actually be worse with SBRT than with IMRT.

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Who Is A Candidate For Prostate Seed Implantation At Princeton Radiation Oncology

Prostate seed implantation is not for everyone. Treatment decisions are based on important prognostic factors:

An ideal candidate should have a PSA level less than 10 and a Gleason grade 6 or less, with non-palpable disease. The size of the prostate is also an important factor. As a general rule, patients with prostate glands greater than 60cc are at increased risk for pelvic arch obstruction and poor dose distribution. Several months of androgen deprivation can be used to shrink large prostates to allow an optimal seed implant.

Patients whove previously had a vigorous transrectal resection of the prostate for benign prostatic hypertrophy may not be ideal candidates for this implant procedure. Higher rates of urinary complications have been reported for this subset of patients.

Prostate Cancer: Radioactive Seed Implants

Prostate Brachytherapy for the Teal Stage of Prostate Cancer | Prostate Cancer Staging Guide

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 five to eight weeks of daily treatments, convenience is a major advantage of brachytherapy.

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What Other Details About The Radioactive Seed Implant Procedure Are Important

Close, prolonged contact with young children should be limited to 20 minutes per hour for the first two months after the procedure. Its safe to sleep in the same bed if your partner/spouse is NOT pregnant. If your partner/spouse is pregnant, separate sleeping arrangements will be necessary for two months. If you have other questions, please call your radiation oncologist or urologist.

Last reviewed by a Cleveland Clinic medical professional on 11/30/2020.

References

Long Term Side Effects Of Brachytherapy For Prostate Cancer

Brachytherapy for prostate cancer can cause some long term side effects such as passing urine more often and difficulty getting an erection.

Everyone is different and the side effects vary from person to person. You may not have all of the effects mentioned. Tell your doctor or nurse if you have any of these problems. They can help you to find ways of controlling the effects.

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Influence Of Seed Migration On Postimplant Dosimetry

Cancer Center at Gaithersburg » Prostate Cancer

The postimplant prostate D90 was not significantly different between patients with and without seed migration. Moreover, in 15 patients who had multiple migrated seeds, the postimplant prostate D90 was relatively acceptable, and no supplemental seed implantation was required. These results indicate that seed migration did not have a significant effect on postimplant prostate dosimetry in the present study. Possible reasons are as follows. First, in most patients with seed migration, only one or two seeds had migrated, which would have less effect on the dosimetry of the prostate. Tapen et al. have suggested that the loss of a few seeds may not have a significant effect on dose homogeneity or total dose to the prostate . Second, seed migration would have much less effect on the dosimetry of the prostate than other mechanisms of seed loss, such as seed misplacement to the seminal vesicle or perineum and being voided in the urine postoperatively. Merrick et al. have reported that seed migration to the chest accounted for only 10% of total seed loss from the prostate region, highlighting the importance of other mechanisms of loss .

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After The Implant Surgery

Most patients are discharged three to four hours after the implant procedure. Occasionally, a patient may need to be observed in the hospital until the next day. Your urologist will determine when you will be discharged from the hospital.

You will be given specific instructions about your implant. Keep these instructions so you can share them with your family members or with any doctors you see after your implant. The instructions will answer any questions you may have about radiation exposure to your family and friends after the implant. They are the same precautions that the radiation oncologist discussed with you.

There is little discomfort after the implant. Some patients do experience mild soreness when they sit. This soreness may last for one or two days after the implant. Sometimes, a patient will notice small spots of blood on his underwear after the procedure. This comes from the spot where the needles were inserted and should stop within 24 hours. Applying mild pressure with a clean cloth will stop the spotting. You may notice a small amount of blood in your urine. This is normal and should stop within one to two days after the implant. If the blood in your urine lasts more then two days, or if you see clots, call your urologist.

You should avoid heavy lifting or hard, physical activity for the first two days that you are home. After that time, you may return to your normal activity level.

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