Presentation
Penetrating pelvic trauma. Incidental foreign bodies on chest CT.
Patient Data
The portable chest is unremarkable except for the linear brachytherapy seeds identified within the right mid zone, left infra hilar and overlying the left heart border adjacent to the overlying ECG lead.
A bullet embedded in the right ischiorectal soft-tissues (subsequently localized by CT).
Left flank entrance wound and fractures of the left iliac blade and acetabulum.
Numerous brachytherapy seeds in situ, a previous L4/L5 posterior interbody fusion with 2 Harrington rods, 4 transpedicular screws and a decompression laminectomy.
No sclerotic or lytic bone lesions are identified.
There is bibasal cicatricial atelectasis likely due to a combination of granulomatous disease (with calcific granulomata), post anesthetic and gravity-dependent atelectasis.
Necrotizing pneumonia and radiation fibrosis especially within the left lower lobe cannot be definitively excluded.
The brachytherapy seeds are identified within the right upper lobe and left lower lobe due to their extreme beam and streak artefacts.
The third brachytherapy seed is identified within the left anterior descending coronary artery rather than within the left ventricular parenchyma or wall.
(Limited images have been uploaded).
The reformats demonstrate the brachytherapy seeds within the right upper lobe (RUL), left lower lobe (LLL) and the left anterior descending coronary artery (LAD).
Case Discussion
Prostatic brachytherapy seed migration via the periprostatic veins is an uncommon complication of prostatic brachytherapy. The most common site of migration is the lung 1, 2. There are multiple published case reports of seed migration to the heart, coronary arteries, liver, bladder, renal arteries and testicular veins 1, 2.
This is an example of seed migration to the lung and left anterior descending coronary artery.
There is no radiation fibrosis or mass lesion relating to the right upper lobe seed. There is no preceding history of any cardiac event, chest pain or dysrhythmia in view of the left anterior descending coronary artery seed.
Case assistance: Dr IA Nagdee and Dr VKS Bhagwandas