NY Times article on RT accidents

[alphacentauri]

thought you all might find this interesting if you haven't seen it yet....

http://www.nytimes.com/2010/01/24/health/24radiation.html?hp

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[Eta Carinae]

Yeah, read that this morning in the papers too.

My questions are:
1. Is this a failure on the part of the dosimetrists or the actual Rad-Onc Docs or the techs operating the IMRT devices?
2. I know this has got to be extremely rare, but has anyone had experiences even remotely similar to this? Instances where 2x or 3x dosages are administered?
3. Does anyone have plans of going up to St. Vinnie's for training or is the program going to undergo disciplinary action (if not outright dis-accreditation)?

I don't see a story like this dissuading patients from opting for radiation therapy, though. Especially with very targeted therapies like Brachytherapy.

 

[loveoforganic]

It's my understanding that it's actually a medical physicist's job to look at the proposed treatment plan to verify that the computer output translates correctly to machine output, while the radonc verifies that desired treatment guidelines (e.g. radiation level limits to surrounding tissue) are met by the dosimetrist's plan. Is this not the case?

 

[Palex80]

Call me stupid, but I don't get it...

How does not closing leafs result into such serious complications, if the error only happened 3 times and the patient did not receive any further treatment?

 

[deleted4401]

IMRT plan
~7-9 fields
A few hundred MU per field
= badness
S

 

[qwert]

Yep that New York H&N case is famous and we studied it in our department.
Lesson: don't try to change IMRT plans on the fly and never force dosimetry to speed up the process.

I have a question though: what is the attendings' liability in a case of Q&A failure?

 

[medgator]

Call me stupid, but I don't get it...

How does not closing leafs result into such serious complications, if the error only happened 3 times and the patient did not receive any further treatment?

Each of those fields is getting way more MUs than would be needed to deliver the therapeutic dose to the patient. The reason it works is because the MLC leaves are shaping/modulating the field during that MU output, so what the patient is supposed to end up getting is much lower.

In this case, the open field included some nearby critical structures (namely, brainstem) that should have been blocked if the plan was delivered correctly.

 

[Palex80]

Each of those fields is getting way more MUs than would be needed to deliver the therapeutic dose to the patient. The reason it works is because the MLC leaves are shaping/modulating the field during that MU output, so what the patient is supposed to end up getting is much lower.

Oh, now I get it!

The MLC leafs never moved at all!
They irradiated that poor patient with open leafs!

Mother of God...

Sorry for my stupidness, typical Monday-morning problem...

In this case, the open field included some nearby critical structures (namely, brainstem) that should have been blocked if the plan was delivered correctly.

But still, if the brainstem was left out, the patient would surely have serious damage done to his mucosa and jaw, getting something like >15 Gy/d on the mucosa, right?

 

[Gfunk6]

Here is ASTRO's official response:

http://cs.astro.org/blogs/astronews...er-to-the-new-york-times-january-25-2010.aspx

 

[medgator]

Here is ASTRO's official response:

http://cs.astro.org/blogs/astronews...er-to-the-new-york-times-january-25-2010.aspx

Tim Williams wrote a great response. Between this and "The Contract" speech at ASTRO, I've really liked what he's had to say.

 

[radioh3ad]

Throw it down, big man. Throw it DOWN!

 

[JumpingFrenchmn]

F/u article:

http://www.nytimes.com/2010/02/05/health/05radiation-.html?ref=health

"Still, The Times reported that the Radiological Physics Center had found that nearly 30 percent of hospitals seeking admission into National Cancer Institute trials had failed to accurately irradiate an object, called a phantom, that mimicked the human head and neck.

A study group of the American Association of Physicists in Medicine called that failure rate “a sobering statistic.” Medical physicists play a vital role in ensuring that radiation equipment is properly calibrated and that patients receive only what has been prescribed, no more, no less."

Anyone happen to know what this is referring to?

 

[Werg]

In one of the NYT articles they quoted the 30% failure rate of a test administered by the Radialogical Physics Center associated with MDACC. Basically it's an IMRT QA test that is required of clinics wanting to enter NCI trials using IMRT.

I think that the 30% failure actually refered to one specific part of the test and may not have refered to the actual qualification for NCI trials.