Brachytherapy
Prostate
Brachytherapy or Radioactive Seed Implants consist of a radioactive
source inside a with titanium shell. One seed is about the size of a
grain of rice. There are three radioactive sources is use - Iodine
(I-125), Palladium (Pd-103) and Cesium 131 (Ce-131). The
radioisotopes emit very low energy radiation, which is primarily
absorbed in the prostate rather than the normal tissue outside of
the gland.
The average number
of seeds implanted is about 80. However fewer or many more may be
used, depending on the clinical situation. The prostate size, type
of seed used and whether external beam radiation is added determine
the number to be implanted. The seeds remain permanently in place.
However, they gradually lose their radioactivity over a period of
time - Iodine seeds over a period of about 12 months, Palladium
seeds in about three months and Cesium in 6 weeks.
Brachytherapy is
performed as an outpatient procedure. After anesthesia is
administered, needles are inserted through the skin above the anus.
The physicians will use an ultrasound probe to guide the needle and
seed placement. In addition, a computer program will further direct
the correct placement of the seeds so the prostate receives the
proper dose of radiation. This new computer based system has been
shown to deliver higher radiation doses than most of the systems
currently available. A recent study by Mount Sinai Physicians report
some of the highest cure rates using I-125 seeds utilizing this same
approach (see Kao article).
The following
information will help you prepare for the procedure and after
discharge.
The Process:
-
This procedure is
done by the Radiation Oncologist and your Urologist
-
Using the rectal
ultrasound to verify placement, needles penetrate the perineal
skin between the scrotum and the rectum
-
The seeds are
then injected with caution; this takes about 3 hours
-
The procedure is
done in the operating room of the hospital; you will have general
anesthesia and an IV will be started
-
A foley catheter
will be inserted after you are asleep and may be left in for a day
or two
-
You will wake up
in the recovery room and when you are fully awake, the catheter
may be removed if ok with the urologist
-
You will be
discharged with instructions and prescriptions from the urologist
-
You will
experience swelling and soreness between the legs for a day or two
-
2 to 4 weeks
after implant, you will see the radiation oncologist for a
follow-up; at that time, you will be scheduled for a post-implant
CT scan which is the final step in the process, this is done for
final physics calculations to determine the exact dose of
radiation the prostate received
Patient Preparation:
-
Stop any blood
thinners one week before surgery; this includes aspirin, coumadin,
plavix, persantine, ibuprofen, motrin, advil, aleve, indocin or alka
seltzer
-
Follow a clear liquid diet the day before
surgery; NO SOLID FOODS
-
Foods
allowed include: carbonated beverages, coffee, tea, Kool-Aid,
Gatorade, water, plain gelatin, clear ice popsicles, apply,
cranberry and white grape juice and clear broth or bullion
-
Foods
to avoid include: all solid foods and any liquid that you cannot
see through
-
Sample
breakfast: apple juice, tea or coffee and broth
-
Sample
lunch: bullion, ginger-ale, jello and coffee or tea
-
Sample
dinner: broth, white grape juice, jello and tea or coffee
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At 4:00pm, the day before surgery:
-
Add 1 1/2 oz. Fleets Phospho Soda
to 4 oz. water and drink
-
Follow with (1) 8 oz. glass of
clear liquid
-
Drink at least 3 more glasses of
clear liquids within the next hour
-
Repeat above again at 7:00pm
-
Nothing to eat or drink after midnight and NO
smoking
-
On the day of surgery, take a Fleets enema one
hour before leaving home
-
Take a list of your current medications with
you to the surgery center
Discharge
Instructions:
-
Diet:
resume your regular diet regimen
-
Activity: avoid heavy lifting or strenuous physical activity for
the first 2 days, after that, you may return to your normal activity
level
-
Prescriptions: your urologist will give you prescriptions for
antibiotics, pain and medicine to improve urination after the
implant
Possible side
effects:
There are
very few side-effects from the implant procedure. There may be some
slight bleeding and swelling beneath the scrotum. Bruising or
tenderness between the legs can be seen from the needle placement.
Applying and ice bag will provide some comfort.
You may
experience burning on urination, frequency of urination, mild
discomfort or feeling unable to pass urine. These are common side
effects and subside in 1 to 4 months. If you are unable to urinate
at home, contact your urologist or go the emergency room. They will
place a temporary catheter in the bladder until the swelling goes
down.
You
may notice blood in the urine for 24 hours after the procedure. If
this persists or you pass clots, please contact your urologist.
Radiation safety
rules to follow:
Radiation safety is of concern. The seeds are low-energy and lose
activity within 2 months. The radiation is contained within the
prostate gland. You are not radioactive. Items you touch or use are
not radioactive. Your urine and stool are not radioactive.
Pregnant women and small children should avoid close physical
contact for the first 2 months after the implant. They can be in the
same room, but of a distance of 3ft. Small children should not sit
on your lap. You may pick them up and hug them but then put them
down.
Sexual intercourse using a condom may be resumed 2 weeks after
implant. Ejaculate may be discolored dark brown, this is normal. Use
a condom for at least 2 weeks after implant.
In
the unlikely event that you find a seed, do not pick it up with your
hands. Use a spoon or tweezers to pick it up and flush it down the
toilet.
Follow-up:
You
urologist will inform you when to see him after implant. It is
usually within a few days. Should you have any side effects, call
the urologist.
Your
radiation oncologist will see you in 1 month. You will be given
information at that time to schedule a post-implant CT scan. This is
done to enable the physician to determine the exact position of each
seed in teh prostate and for the final physics to be completed.
Follow-up with the urologist and radiation oncologist will be done
on a regular basis.
Patients taking
hormonal therapy:
Lupron or similar
-
You will receive a depot injection that
lasts for 3 months. Ask your urologist when to return for your
next shot. Most patients receive at least 1-2 such injections.
If you are receiving both seed implantation and external beam
radiation, you may need 3 or more Lupron injections.
-
You may
experience “hot flashes” while on this medication. These are
similar to the flashes experienced by women in menopause. These
will go away after the medication is stopped. This can some times
take up to 6 months after the last injection. In some cases, if
the hot flashes are very bad, your urologist can treat you with
Megace to control them. Megace must be stopped within 3 months of
the last injection or testosterone levels will not return.
-
If you have pain
or swelling at the injection site, put ice on for the first 48
hours, followed by heat till it no longer bothers you.
-
Most men become
impotent after receiving Lupron. It usually takes about a month
for this to occur. Sexual function should return about the time
the hot flashes stop. The likelihood that sexual function will
return is about 50%. A few men will also experience a decrease in
the volume or loss of the ejaculate.
Casodex or Eulexin
-
You will also be
taking 1 pill of Casodex or 6 capsules a day of Eulexin (2 caps
every 8 hours). This medication also helps to eliminate the
cancer cells. You should continue to take the Casodex or Eulexin
for 3 months after your last Lupron injection.
-
Some patients
experience diarrhea while on Eulexin. If this happens, stop the
Eulexin and wait till the diarrhea stops. Restart the Eulexin,
but at only one capsule a day. Slowly increase by one capsule per
day until the full dose is reached. If the diarrhea recurs call
your urologist.
-
Eulexin has also been known to affect the
liver. You should have your liver functions checked every 2-3
months after starting Eulexin.
To
download a printer-friendly version of the above guidelines,
click here.
Clinical
articles about Brachytherapy available for download:
12-Year Outcomes
Following Prostate Brachytherapy
Relapse Free Survival
in Clinical Stage T1 - T3 Prostate Cancer
Customized Dose
Prescription for Permanent Prostate Brachytherapy
Ultra-High Dose IMRT
for Localized Prostate Cancer
Intermediate
Brachytherapy Results
Long-Term
Brachytherapy Rates
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