Oral and Poster Presentation – Clinical Abstracts Archive

UK & Ireland Prostate Brachytherapy Conference 2017

Abstract number 5

610 Patients, What Went Wrong? What Did We Learn?

Woulfe P*; Sullivan FJ**; Dooley C*; Cronin J*
*The Galway Clinic; **The Galway Clinic & The Prostate Cancer Institute

AIMS/INTRODUCTION: Transperineal interstitial implantation of radioactive I125 seeds is a technique which utilises three-dimensional image-based treatment planning and real-time visualization of needle insertion and seed deposition. Seed placement and dosimetry are verifi ed using a CT scan between 0 to 30 days post implant, ideally within 24 hours of implantation with a catheter in place. Having a catheter in place allows for much more accurate contouring of the urethra and thus more accurate dose calculations are possible. The aim of this presentation is to provide an overview of the past nine years’ clinical experience within our programme and to describe the various incidents and problems we encountered.

MATERIALS/METHODS: Approx 610 patients have received LDR Brachytherapy and over that period of time we have recorded three incidents and three near misses which affected the workfl ow. We will describe these events and how we overcame the issues to provide a quality implant to the patient. The objective is to share our experience with other centres so we can all learn and create an awareness of these possible risks.

RESULTS: March 2011 – Atmospheric Pressure incorrect units in calculation. April 2012 – 3 seeds missing in Catridge May 2014 – Calibrated seed differences Dec 2015 – Contaminated Seed (Comprimised) March 2016 – Missing Seed July 2016 – Varian Treatment Planning System Crashes.

CONCLUSION: Some of these events may not be preventable but the attitude should always be how will we adapt and cope with the issue so our patient can receive a quality implant.