The following information was received by the State of
Ohio via facsimile:
A patient had a prostate volume study done on 7/24/15 at Mount Carmel St. Ann's (MCSA). The mass that was observed on the ultrasound is in the location of a typical prostate and takes the shape of a typical prostate. Implant (I-125) procedure was performed on 8/21/15. During the implant, ultrasound guidance was used when placing the seeds and the images that were seen matched what was taken at the time of the volume study on 7/24/15.
A CT [Computerized Axial Tomography] scan was taken on 9/23/15 for post implant study to verify the seed placement and target coverage. The post implant study was performed on 10/1/15 and revealed that the prostate that is visible by CT is not adequately covered by the seeds, and that the seeds may be in the rectum. The images were reviewed further and there is a mass located between the rectum and the prostate. This is what is believed to have been visualized on the ultrasound, and what was treated in the OR [Operating Room].
The licensee is still investigating to determine whether this tissue is part of the prostate, possibly rectum, or something else altogether. The patient has been scheduled for an MRI [Magnetic Resonance Imaging] to better visualize the tissues in this area. What is known at this time is that a large part of the prostate was not treated, the coverage to the intended target organ is below 80%, and this is being treated as a medical event. The licensee will submit a complete report when the analyses are finalized.
ODH [Ohio Department of Health] intends to send an investigator to the licensee for follow-up. This NMED record will be updated as more information becomes available.
Ohio Incident: OH150010
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.