ENS 46842
ENS Event | |
|---|---|
05:00 Sep 27, 2006 | |
| Title | Agreement State Report - Delivered Dose Different than Prescribed Dose |
| Event Description | The following information was received by e-mail:
The Director of Oncology Services at Decatur Memorial Hospital contacted the Agency [state] to give a preliminary notification of a medical event that happened in September 2006. Following the receipt of additional training by their oncologists regarding medical event criteria, they began to conduct a retrospective review of past prostate cancer treatments that have been performed at their facility since 2002. A particular case was readily notable when the comparison of dose intended vs. dose received was made. Using 81 I-125 seeds, the prescribed dose to the target (D100) was 132.5 Gray, the delivered dose was 32.5 Gray which is only 24.5 percent of the intended dose. However the review showed all seeds intended to be implanted were successfully placed under guided ultrasound and post operative x-ray imaging showed all seeds to be within the target volume. Subsequent follow-ups with the patient over the past 5 years have shown a significant reduction in PSA levels, no evidence of recurrent cancer and no adverse side effects to the bladder, rectum, urethra or other associated dysfunction for the now 87 year old patient. At the time of implant, there were no notes in the surgical file to suggest a change in shape or size of the prostate which would suggest pre-treatment planning performed was invalid. Routine CT imaging conducted at 30 days post treatment as part of the follow-up process showed the prostate had expected swelling present. When dosimetry calculations were performed using the increase in volume, the total delivered dose value for the intended treatment site fell, resulting in the criteria for a medical event being met. The attending oncologist does not intend to notify the patient of this recent discovery. The doctor believes that such a notification would be against his medical judgment and would do unnecessary harm to the patient in this instance considering the success of the treatment. The responsible oncologists and the rest of the treatment team were interviewed by the [Illinois Emergency Management] Agency yesterday afternoon regarding additional details of this event and planned actions. The team indicated that [they] would continue review of the 240 cases but didn't believe that any changes to its current program were warranted at this time based on this one observation. Anecdotally, none of the physicians could remember any of their patients having adverse or unexpected effects during subsequent follow-ups. Nor had any [patients] required additional or supplemental treatment of any kind (i.e. hormonal, surgery, external beam, additional seeds) for recurrent cancer. [The team] couldn't rule out that a similar medical event requiring reporting wouldn't be discovered as they continued their review. Illinois Event: IL11053 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 | |
|---|---|
| Decatur Memorial Hospital Decatur, Illinois (NRC Region 3) | |
| License number: | Il-01410-01 |
| Organization: | Illinois Emergency Mgmt. Agency |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+40500.18 h1,687.508 days <br />241.072 weeks <br />55.477 months <br />) | |
| Opened: | Daren Perrero 17:11 May 11, 2011 |
| NRC Officer: | Vince Klco |
| Last Updated: | May 11, 2011 |
| 46842 - NRC Website | |
Decatur Memorial Hospital with Agreement State | |
WEEKMONTHYEARENS 559612022-06-20T05:00:00020 June 2022 05:00:00
[Table view]Agreement State Occupational Overexposure ENS 468422006-09-27T05:00:00027 September 2006 05:00:00 Agreement State Agreement State Report - Delivered Dose Different than Prescribed Dose 2022-06-20T05:00:00 | |