ENS 49197

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v t e ENS Event
16:30 Jul 16, 2013
Title	Agreement State Report - Permanent Prostate Brachytherapy Underdose
Event Description	The following information was obtained from the Commonwealth of Kentucky via facsimile: RHB [Kentucky Radiation Health Branch] was notified by telephone on 7/16/13 at approximately 1445 [EDT] by the licensee's authorized medical physicist of a medical event involving a permanent prostate brachytherapy implant. A CT scan performed at 30 days post-implant revealed that 16 of the 60 I-125 seeds (lsoAid IAI-125A) representing 26% of the implanted activity had migrated from the planning treatment volume to a region cephalad to the prostate. Post implant dosimetry revealed the dose to 90% of the prostate to be 113 Gy rather than the prescribed dose of 144 Gy (78% of prescribed). This represents a V100 of 54% with the current prostate delineation on CT. The licensee is now undertaking a complete investigation as to why these seeds migrated from their initial implantation site. The referring physician is scheduled to perform a cystoscopy 7/25 to check for seeds that may have migrated into the bladder based on CT visualization. The prescribing physician will be scheduling an MRI for final target and adjacent organ delineation. Final dose to the tissues at risk will then be calculated. The referring physician was notified 7/17/13 at 1045 EDT. The patient was notified 7/17/13 at 1130 EDT. 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.

ENS 49197 +/-
Where
Hardin Memorial Hospital Elizabethtown, Kentucky (NRC Region 1)
License number:	202-148-26
Organization:	Kentucky Dept Of Radiation Control
Reporting

Agreement State
Time - Person (Reporting Time:+20.85 h0.869 days <br />0.124 weeks <br />0.0286 months <br />)
Opened:	Curt Pendergrass 13:21 Jul 17, 2013
NRC Officer:	Dong Park
Last Updated:	Jul 17, 2013
49197 - NRC Website
v • d • e

v t e Emergency Notification System
Hardin Memorial Hospital with Agreement State
WEEKMONTHYEAR2018-09-07T04:00:00 [Table view]
[ENS list for Hardin Memorial Hospital]

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