The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on, low energy contact X-ray brachytherapy (the Papillon technique) for early stage rectal cancer in September 2015.


Low-energy contact X-ray brachytherapy (CXB; the Papillion technique) aims to improve local control or cure rectal cancer. The procedure involves inserting an X-ray tube through the anus and placing it in close contact with the tumour, to kill cancer cells and reduce the size of the tumour.

Low-energy CXB for rectal cancer is usually delivered in a day-care setting. The patient is given an enema before treatment, to clear the bowel. With the patient in a knee-to-chest, prone jack-knife or supine position, local anaesthesia and glyceryl trinitrate are applied to the anal sphincter to numb the area and relax the sphincter muscles. A sigmoidoscope is inserted to check the size and position of the tumour. A rigid endorectal treatment applicator is then inserted and placed in contact with the tumour. A contact X-ray tube is introduced into the applicator and treatment commences. The tube emits low-energy X-rays that only penetrate a few millimetres. This minimises damage to deeper tissues that are not involved in the cancer. If the tumour does not respond to low-energy CXB, or recurs after treatment, surgery may be performed.

Coding recommendations


X65.2 Delivery of a fraction of intracavitary radiotherapy

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

Z29.1 Rectum


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

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)