The following information was received by facsimile:
A misadministration involving the implantation of radioactive seeds into the prostate (permanent brachytherapy) was reported to [the New York State Department of Health] office on May 28, 2010. The patient, a 58 year old male diagnosed with prostate cancer, Gleason score of 6, PSA of 3.8, was implanted on May 26, 2010. The prescribed dose was 145 Gy, to be delivered using Iodine-125 seeds, with an activity of approximately 0.36 mCi/seed. The patient was implanted with 112 seeds. A significant number of seeds (22) were placed outside the prostate gland, inferior to the gland (5.4 cm) and in the perineum. According to the medical physicist's calculations, the implanted area of the prostate received a D90 of 140 Gy.
The initial indication is that the misplacement is a result of misidentification of the prostate by the radiation oncologist who performed the procedure. Ultrasound and C-arm fluoroscopy systems were used to aid with positioning the seeds. It appears that the patient's colon was not properly prepared, which caused poor ultrasound imaging. In addition, a Foley catheter was not inserted into the bladder, which made bladder localization difficult. A post implant confirmatory fluoroscopic image was obtained and the radiation oncologist observed that the sources were outside of the prostate area. On May 28, 2010, a post implant CT scan was performed which confirmed the seed locations and allowed for a calculation of the DVH [Dose-Volume Histogram] to the perineum of 10.0 Gy. The medical record has been requested and will be sent out for an expert review.
New York Event Report ID No: NYDOH-10-01
A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.