ENS 46543
ENS Event | |
|---|---|
06:00 Nov 23, 2010 | |
| Title | Agreement State Report Involving a Medical Event |
| Event Description | The following report was received from the State of Illinois via email:
On January 13 [2011], the licensee's Radiation Safety Officer contacted the Agency [Illinois Emergency Management] to report an apparent medical event that had been discovered during routine post surgery follow up. A patient had undergone treatment for prostate cancer utilizing permanent brachytherapy I-125 seed placement. A total of 102 seeds were inserted into the region in order to deliver a prescribed dose of 14,500 Rad. Manual insertion of the 0.4 milliCi I-125 seeds was done by ultrasound guided placement of the needle template. A C-arm x-ray scan was done post implant of the 0.4mm x 1mm seeds. Visualization of the seed placement was problematic in the post operation scan. Initial estimates were that the seeds may have been inferior to the ideal placement, but still acceptable. However, engorgement of the surrounding tissue and prostate due to the surgical procedure made visualization difficult and performance of additional dosimetry was deemed inappropriate and of little value. The patient was kept appraised of the situation beginning just prior to discharge and advised of the need for continued follow up. As the patient healed, additional scans were scheduled at the 4 week post treatment mark. Those scans suggested the seed placement to be 4-5 cm inferior of the treatment plan. Although the inferior placement of the seeds resulted in avoiding doses to the rectum and bladder as intended in the original treatment plan, as wells as the urethra, the dose to the prostate was suboptimal. Regions receiving elevated dose were the soft tissue at the base of the penis and the penile bulb. Dosimetry values for dose to the prostate provided by the licensee at this time are rough estimates, but are less than 80% of the intended dose. Currently, the patient is asymptomatic. No prediction of long term effects has been made at this time. Physicians are considering the application of external x-ray beam to provide a more effective treatment to the tumor site. This matter remains under investigation by the licensee and the Illinois Emergency Management Agency. The licensee is obliged to file a written report [to the Illinois Emergency Management Agency] in compliance with the rules within 15 days. Given: Therapeutic Procedure: BRACHY, MANUAL IMPLANT Organ: ND Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 4400 rad 44 Gy Intended: Therapeutic Procedure: BRACHY, MANUAL IMPLANT Organ: PROSTATE Radiopharmaceutical: Radionuclide: I-125, Activity: 42.7 mCi 1579.9 MBq, Dose: 14500 rad 145 Gy % Dose Exceeds Prescribed: 0 % Dose is Less Than Prescribed: 70 Effect on Patient: UNKNOWN The patient was informed of the underdose. IL Report No.: IL11-004 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 | |
|---|---|
| Rush University Medical Center Chicago, Illinois (NRC Region 3) | |
| License number: | Il-01766-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+1257.82 h52.409 days <br />7.487 weeks <br />1.723 months <br />) | |
| Opened: | Daren Perrero 15:49 Jan 14, 2011 |
| NRC Officer: | Steve Sandin |
| Last Updated: | Jan 14, 2011 |
| 46543 - NRC Website | |
Rush University Medical Center with Agreement State | |
WEEKMONTHYEARENS 573852024-10-14T05:00:00014 October 2024 05:00:00
[Table view]Agreement State Medical Underdose ENS 569422024-01-31T06:00:00031 January 2024 06:00:00 Agreement State Medical Underdose ENS 567662023-09-28T05:00:00028 September 2023 05:00:00 Agreement State Underdose to Patient ENS 535602018-08-23T05:00:00023 August 2018 05:00:00 Agreement State Illinois Agreement State Report - Medical Event ENS 465432010-11-23T06:00:00023 November 2010 06:00:00 Agreement State Agreement State Report Involving a Medical Event 2024-10-14T05:00:00 | |