The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Preoperative high dose rate brachytherapy for rectal cancers, in August 2015.


Endorectal HDR brachytherapy for rectal cancer is usually carried out under sedation. Before treatment the tumour size and stage are determined using imaging techniques, and a 3-dimensional CT-based treatment planning system may be used to guide source positioning and appropriate dosing. Radio-opaque clips may be placed to mark the margins of the tumour, using proctoscopy or sigmoidoscopy.

A rigid or flexible endorectal applicator is used to deliver radiation to the tumour within the rectum. A balloon may be placed over the applicator to displace the uninvolved rectal mucosa away from the radioactive source to reduce toxicity. When the balloon is inflated, it immobilises the applicator and also helps to facilitate close contact with the tumour. Catheters within the applicator are subsequently loaded with the radioactive source (this is sometimes called ‘afterloading’), according to the treatment plan.

A few weeks after completion of brachytherapy, residual tumour is removed surgically. 

Coding recommendations

The OPCS-4 codes for Pre-operative high dose rate brachytherapy for rectal cancer are:

X65.2 Delivery of a fraction of intracavitary radiotherapy

Note: Use a subsidiary code to identify introduction of radioactive material (Y35, Y36)

Y35.4 Introduction of radioactive substance into organ for brachytherapy NOC

Y89.1 High dose rate brachytherapy treatment

Z29.1 Rectum

In addition the ICD-10 code C20.X Malignant neoplasm of rectum would be recorded.

C20.X Malignant neoplasm of rectum


Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)