Severe radiotherapy accident involving 23 patients
Period: May 2004 – May 2005
Facility involved: Beam therapy center, Centre hospitalier Jean Monnet (Epinal, France).
See the final report (Feb. 2007) of the French Nuclear Safety Authority (ASN).
The ASN was informed on July 6, 2006 that 23 patients treated by external beam therapy for prostate cancer between May 2004 and May 2005 received an exposure at a dose exceeding (by 7% to 34%) the radiation dose initially prescribed. Currently, 16 patients have already developed acute complications (rectal inflammation/burns), and at least one patient died as a result of the overexposure. This repetitive accident was caused by a lack of training of the operators on the use of the CADPLAN treatment planning software (TPS) and by design aspects – the software was not translated into French, and some acronyms used were unclear – that couldn’t prevent a subsequent wrong setting of the accelerator. The TPS simulation was performed with static wedges, but the accelerator was set with dynamic wedges.
The ASN notified this event to the French health products agency (AFSSAPS). The manufacturer VARIAN has been contacted by the AFSSAPS to implement corrective actions at two other beam therapy centers still using CADPLAN in France. The ASN also asked its technical support organization IRSN to assess the radiological consequences precisely and to propose recommendations for undertaking curative therapeutical actions.