The following information was obtained from the Commonwealth of
Kentucky via fax:
KY RHB [Radiation Health Branch] was notified via e-mail by the Medical Physicist of the facility of two past medical events. The medical events involved two patients treated for prostate cancer with I-125 and Pd-103 seeds for which the Medical Physicist had developed the treatment plans. The Radiation Oncologist and the Urologist, who performed the procedures determined the dose delivered to the target organ based on D90 was less than 80% using the Variseed Treatment Planning software. The Radiation Oncologist who contoured the prostate and determined the post implant D90 doses, was not aware that a D90 less than 80% of the prescribed dose was a medical event that required reporting to the Radiation Health Branch. The patient treated on 6/3/11 was treated with 101 Bard STM1251, I-125 seeds (0.37 mCi/seed) monotherapy and received a D90 of 76.7%. The intended dose to the prostate was 145Gy and the administered dose was 111.2Gy. The second patient was treated on 4/12/12 with 73 seeds of Theraseed Model 200, Pd-103 (1.1 mCi/seed) as a part of a boost therapy to IMRT [Intensity Modulated Radiation Therapy]. This patient received a post implant D90 of 68.3%. The intended dose to the prostate was 90Gy and the administered dose was 61Gy. The Medical Physicist discovered these two medical events after performing an audit of the facility's permanent implant prostate brachytherapy program since its inception for a total of 71 patients. The State will continue to keep NRC informed of the status of our investigation.
KY Event Report ID No: KY120013
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.