Embolized prostatic brachytherapy seeds mimicking acute chest pain syndromes.

A 59-year-old male with a history of nonobstructive coronary artery disease, diabetes mellitus, hypertension, and prostate cancer presented to the hospital with 1-day history of pleuritic chest pain. Initial workup for acute coronary event was unremarkable. Chest X-ray revealed multiple small radial densities which were linear and hyperdense, consistent with embolization of metallic seeds to the pulmonary circulation. The patient was noted to have had radioactive metallic seeds implanted for prostate cancer 6 months ago. Diagnosis of pulmonary embolization of prostatic seeds is challenging as they frequently present with chest pain mimicking acute coronary syndromes.

A 59-year-old male with a medical history of nonobstructive coronary artery disease, diabetes mellitus, hypertension, and prostate cancer presented to the hospital with 1-day history of pleuritic chest pain. Initial workup for acute coronary syndrome including cardiac enzymes, Electrocardiogram (EKG) was unremarkable and an exercise stress echocardiography failed to reveal any wall motion abnormalities suggestive of coronary artery disease. Erythrocyte sedimentation rate and C-reactive protein levels were not elevated, and echocardiogram did not reveal any pericardial effusion suggestive of pericarditis. Chest X-ray revealed multiple small radial densities which were linear and hyperdense consistent with embolization of the metallic seeds to the pulmonary circulation [Figure 1]. The patient had radioactive metallic seeds implanted for prostate cancer 6 months earlier. A computed tomography scan of the chest was done which confirmed the location of the seeds in the peripheral pulmonary circulation [Figure 2].

Figure 1

X-ray revealing multiple small radial densities which were linear and hyperdense consistent with embolization of the metallic seeds to the pulmonary circulation

Figure 2

Computed tomography scan of the chest showing the location of the seeds in the peripheral pulmonary circulation

Patients with localized prostatic cancer can be treated with brachytherapy. It consists of image-guided placement of radioactive seeds in the prostate and periprostatic soft tissues. One of the noted complications of this procedure is migration of seed implantation to vital organs such as heart and lungs.[1] The seeds may detach from their insertion sites and migrate through the prominent periprostatic venous plexus and inferior vena cava.[23] Less than 1% of all implanted brachytherapy seeds migrate to distal organs. Factors such as planning volume, the number of seeds, and type of seeds (stranded vs. free) determine the incidence and rate of seed embolization. Higher planning volume requires higher number of seeds required for implantation, therefore increasing more chances of migration. Stranded seeds have significantly lower incidence of migration, particularly to the lung. Seeds implanted in the extracapsular area also show lower incidence of migration because the Vicryl sutures or spacers, to which the seeds are attached, are dissolved and absorbed. Pulmonary embolization of seeds is usually asymptomatic, but acute pulmonary symptoms such as pain or cough are rarely reported. Diagnosis of patients with pulmonary embolization of prostatic seeds is often challenging as they may present with chest pain mimicking acute coronary syndromes. Radiological imaging in combination with the medical history of patients is usually sufficient to identify most cases with certainty. Although there were no reported short-term sequelae, potentially feared complications are pneumonitis and carcinogenesis. Therefore long-term follow-up with chest radiographs and pulmonary function studies may be indicated. With the increasingrole of brachytherapy in early stage of prostate cancer, a clinician should be aware of these potential complications.

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