The following event was received from Auxilio Mutuo Radiation Therapy Center via phone:
A patient who had undergone three gynecological intracavitary brachytherapy procedures was noticed to have a skin reaction. The skin reaction was noticed on the third of the three treatments occurring on 1/24/2018. At this point, it was unclear if the skin reaction was related to the treatments. On 2/6/2018, the attending physician saw the patient and declared that the skin reaction was caused by the radiation treatments, because it had progressed to moist desquamation.
The prescribed dose was 400 cGy per fraction for 3 fractions for a total of 1,200 cGy to a depth of 5 cm.
This event is under further investigation.
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.
- * * UPDATE ON 02/23/2018 AT 1245 EST FROM LUIS RIVERA TO STEVEN VITTO * * *
The following is an excerpt from the licensees submittal received via email:
Following review of the aforementioned information, it was now clear that the reaction was radiation related, and the incident report was carried out on that same day as per protocol.
The dose estimate for skin directly in contact with the surface of the 'internal catheter' is between 51.54 Gy and 85.55 Gy.
Notified R1DO (Burritt),
NMSS (Bollock), and
NMSS Events Notification via email.