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. |
| 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 | |
Hardin Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 535852018-09-07T04:00:0007 September 2018 04:00:00
[Table view]Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 526112017-02-16T05:00:00016 February 2017 05:00:00 Agreement State Agreement State Report - Administered Dose Lower than Prescribed Dose ENS 509342015-03-25T17:00:00025 March 2015 17:00:00 Agreement State Agreement State Report - Medical Event During Prostate Brachytherapy ENS 491972013-07-16T16:30:00016 July 2013 16:30:00 Agreement State Agreement State Report - Permanent Prostate Brachytherapy Underdose ENS 480862012-06-04T05:00:0004 June 2012 05:00:00 Agreement State Kentucky Agreement State Report - Medical Event Involving Prostate Seed Implants ENS 454852009-08-28T06:00:00028 August 2009 06:00:00 Agreement State Agreement State Report - Brachytherapy Patient Received More than Prescribed Dose 2018-09-07T04:00:00 | |