Perirectal seeds as a risk factor for prostate brachytherapy-related rectal bleeding

To correlate rectal wall doses and perirectal seed numbers with late rectal bleeding after prostate brachytherapy.

We studied 148 patients randomized to implantation with I-125 vs. Pd-103 at the VA Puget Sound HCS from 1998 through 2001 and for whom postimplant dosimetry was available. Implants were performed by standard techniques, using a modified peripheral loading pattern. A postimplant computed tomography (CT) scan (3 mm slice thickness) was obtained 1-4 h after implantation. Rectal doses were expressed as the R100, R200, and R300, defined as the rectal volume (cc) that received more than 100%, 200%, or 300% of the prescription dose, respectively. The rectum was considered to be a solid structure defined by the outer wall, without attempting to differentiate the inner wall or contents. In addition to conventional dose parameters, each patient's postimplant CT scan was reviewed for the number of seeds within 0, 0.1-2, and 2.1-4 mm of the outer rectal wall. The proximal edge of the seed was used for distance determinations from the outer rectal wall. Patients who reported Grade 1 or higher Radiation Therapy Oncology Group morbidity were contacted by telephone to obtain more details regarding their rectal bleeding. Those who reported persistent bleeding lasting for more than 1 month were categorized as Grade 2.

Patients had a wide range of rectal wall doses, with R100 values ranging from 0.0 to 10.4 cc (median, 0.95 cc). Similarly, the number of perirectal seeds within 0.0 to 2.0 mm of the rectum varied widely, ranging from 0 to 12 seeds (median: 1 seed). Seven patients (7 of 144 = 5%) developed persistent rectal bleeding, one of whom required a colostomy. Both rectal radiation doses and the number of perirectal seeds were higher in patients with persistent rectal bleeding. The number of perirectal seeds < or =2.0 mm of the rectal wall was higher in patients with rectal bleeding (p = 0.037), but the number of seeds 2-4 mm from the wall were not related (p = 0.72). In multivariate regression analysis including prostatic D90 (the dose that covers 90% of the postimplant prostate), preimplant transrectal ultrasound volume, R300, and the number of seeds < or =2 mm from the rectal wall as independent variables, only the R300 was statistically significantly associated with the likelihood of persistent rectal bleeding (p = 0.025).

A limited number of errant perirectal sources in itself does not appear to place patients at increased risk of rectal bleeding, providing that the overall rectal wall doses are within acceptable values.