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Dosimetric and clinical comparison of two cohorts of Iridium-192 (Ir-192) and Cobalt-60 (Co-60) high-dose-rate brachytherapy (DR-BT) boost for localized prostate cancer. Patients with localized prostate cancer receiving either Ir-192 or Co-60 high-dose-rate brachytherapy (HDR-BT) boost in combination with external beam radiotherapy (EBRT) in the period of 2002–2019 were evaluated for dosimetric differences, side effects, biochemical relapse-free survival (bRFS), metastasis-free survival (MFS), and overall survival (OS). EBRT, delivered in 46 Gy (D Mean ) in conventional fractionation, was followed by two fractions HDR-BT boost with 9 Gy (D 90% ) 2 and 4 weeks after EBRT. Genitourinary (GU)/gastrointestinal (GI) toxicity were evaluated utilizing the Common Toxicity Criteria for Adverse Events version 5.0 and biochemical failure was defined according to the Phoenix definition. A total of 338 patients with a median follow-up of 101.8 (IQR 65.7–143.0) months were evaluated. At 10 years the estimated bRFS, MFS, and OS in our patient sample were 81.1%/71.2% ( p =.073), 87.0%/85.7% ( p =.862), and 70.1%/69.7% ( p =.998) for Ir-192/Co-60, respectively. Cumulative 5-year late grade ≥2 GU toxicity was 20% for Ir-192 and 18.3% for Co-60 ( p =.771). Cumulative 5-year late grade ≥2 GI toxicity was 5.8% for Ir-192 and 4.6% for Co-60 ( p =.610). Grade 3 late GU side effects were pronounced in the Ir-192 cohort with 8.1%  versus  1.4% in the Co-60 cohort ( p =.01), which was associated with significantly lower dose to the organs at risk in the Co-60 cohort. PTV D 90%  was 9.3 ± 0.8 Gy  versus  9.0 ± 1.1 Gy ( p =.027) for Ir-192  versus  Co-60. PTV V 100%  and PTV V 150%  were not significantly different between both cohorts. Co-60 brachytherapy sources are an effective alternative to Ir-192 in combined prostate HDR-BT boost + EBRT.

Comparing Iridium-192 with Cobalt-60 sources in high-dose-rate brachytherapy boost for localized prostate cancer