The October BrachyBlast is Now Posted!

A Message From the President

The Denver Prostate Workshop on November 1 ^st and 2 ^nd will be the largest to date with 103 attendees, 14 teams and 15 vendors. After this workshop, ABS will have trained over 200 participants and 100 teams since December of 2017. In a sense, we are over two-thirds of the way there for reaching our “prostate brachytherapy goal” of the 300 in 10 mission . Analysis is underway to determine the number of teams who have implemented brachytherapy programs. Industry support for our brachytherapy schools and workshops has been phenomenal for which ABS is extremely grateful. To date, our industry partners have provided approximately $500,000 that includes scholarships, and in kind support for items such as phantoms, seeds, equipment (computers, ultrasound probes) sales force, technicians, shipping, personnel, food and lodgings costs.

Registration is now open for the Big Sky Brachytherapy Summit February 14-17 with details provided on our website. Please consider attending as registration is limited. As detailed in previous communications, this will be a phenomenal meeting for maintaining a vibrant brachytherapy practice and to help teams reinvigorate their practice. Also, this will be a tremendous opportunity to network with brachytherapists, other specialties and industry.

A special thank you to Drs. Peter Orio and Mitch Kamrava for taking the time and effort to represent ABS at the 2019 Chinese Interventional Brachyseed Society (CIBS) Annual Meeting in Nanjing, China. Partnering with our international colleagues will be essential for increasing brachytherapy access for everyone. Finally, registration is now open for the World Congress of Brachytherapy from April 2-4, 2020 in Vienna, Austria.

Thank you,

Daniel G. Petereit, MD, FASTRO

President

@AmericanBrachy

Chairman's Corner

Peter F. Orio, III, DO, MS

Welcome to the Chairman’s Corner of the American Brachytherapy Society’s BrachyBlast .

In September, Dr. Mitch Kamrava and I had the honor of representing the American Brachytherapy Society at the 2019 Chinese Interventional Brachyseed Society (CIBS) Annual Meeting in Nanjing, China.

During our time in Nanjing, I observed numerous presentations and engaged in several thoughtful discussions which showed that Chinese brachytherapists are utilizing Low Dose Rate brachytherapy techniques for a wide variety of malignancies including thoracic, pancreatic, prostate and brain malignancies as well as bone metastases. In China, High Dose Rate brachytherapy is not widely available, however, Chinese brachytherapists are using ingenuity and innovation to utilize the brachytherapy resources that are available to them in order to treat as many patients as they can with this highly conformal and effective treatment.

Seeing all the innovations and successes of the CIBS during our time in Nanjing has reinvigorated my passion for the ABS to work collaboratively with our sister societies across the globe. Together, with our international colleagues, we can push brachytherapy forward into the future, develop new techniques and refine our specialty even further in the years to come. As we look to the future, I am excited to attend the World Congress of Brachytherapy from April 2-4, 2020 in Vienna, Austria. As we collaboratively plan this meeting over the coming months and many of us attend in April 2020, we must remember to continue to develop strong ties with our sister societies across the globe.

Thank you,

Peter F. Orio III, DO, MS

Chairman of the Board

@ AmericanBrachy

@ peter_orio

ABS Medical Event Project

Medical Event case 0007

Panagiota Galanakou, Graduate Student, Florida Atlantic University

Sarah Wisnoskie, PSMMP

Zoubir Ouhib MS FACR FABS FAAPM

Lynn Cancer Institute/Florida Atlantic University

Hello Brachyblast readers! We would like to once again thank those who provided feedback on case 0006. Such feedback is valuable and hopefully leads to prevention of reoccurrence. In this month’s BrachyBlast we present case 0007 which was reported to NRC in 2000. While 2000 is a long time ago, errors do not use a calendar and could happen again several years later. Please continue to share your thoughts as we work together to encourage safe brachytherapy/radiotherapy practices! As a reminder the purpose is to focus on the process and see how one can prevent similar errors from occurring.

Case 0007: Misadministration involving Iodine-125 eye plaque brachytherapy implants

Summary: The licensee notified NRC that he/she identified two potential misadministration involving two patients that were treated with I-125 temporary brachytherapy eye implants. Both patients were prescribed a dose of 7000 cGy and their treatments started on September 15, 2000. On September 20, 2000, the eye plaques were removed at the conclusion of the treatment. The licensee reported that due to a calculation error, both patients received higher than the planned dose of 7000 cGy. The error resulted in an administered dose of 11,470 cGy to one patient and 10,866 cGy to the other patient.

Details: The error was made in converting the Air-Kerma strength of the I-125 sources to millicuries. The licensee’s treatment planning system is in Air-Kerma units, whereas the vendor requires the order to be placed in millicuries. The licensee stated that to convert I-125 source strength from Air-Kerma to millicuries, Air-Kerma value is divided by a conversion factor of 1.27. However, the dosimetrist erroneously multiplied the conversion factor to obtain the source strength and that resulted in the two misadministration. The error was identified on September 22, when the physicist recognized that the dosimetrist was ordering seeds for an upcoming case with an activity that was higher than expected.

Results: The conversion error was recognized, and all I-125 cases were reviewed. The review process identified the two misadministration and three recordable events. Specifically, the inspector noted that the licensee identified three recordable events involving the eye plaque treatments that were performed in April 2000. The recordable events occurred when the patients were planned to be treated for five days (120 hours), however, the implants were removed after four days of treatment. The error that Monday-Friday treatment would be a four-day treatment (implants started during the day on Monday, April 24, 2000 and explanted during the day on Friday, April 28, 2000) instead of the required 5-days (120 hours) treatment was not identified by the authorized physician or the support staff (physicist and dosimetrist) until September. A QMP audit in September 2000, identified the error and the consequent under-dosing of the patients by 12-15% of the prescribed dose.

What preventive action(s) could stop reoccurrence of a similar event? Consider both corrective (immediate and long term) and preventive actions.

Please send your suggestions before November 15, 2019 to: [email protected] including the title of the event (or case #), your name, your institution (optional), and your profession (Med. Phys., Rad. Onc., etc.). We intend to acknowledge all individuals who provided feedback. Please include in your response whether you approve of this recognition. You could also be anonymous if that is your choice. Please feel free to contact us if you have any inquires or questions regarding the case 0007.

NURSES WANTED

ABS Members-

We are pleased to announce that brachytherapy nursing/patient care content and resources are being created and will be available to ABS members soon on the ABS Website and at future ABS meetings. This information is intended for MDs looking for materials for their teams, brachytherapy nurses and others involved in direct patient care to become more knowledgeable and confident in their abilities to care for brachytherapy patients. Stay tuned for more information on this exciting new development!

Click here to sign up

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Registration for the Big Sky BrachySummit that will be held over Presidents’ Weekend — February 14-16, 2020. We strongly encourage you to consider this destination meeting based upon the location, largest ski resort in the United States with diverse terrain to accommodate skiers at every level, a highly educational and interactive program, and a most relaxing atmosphere. This will be in 3-day conference with educational sessions in the morning, skiing all afternoon, and a few more sessions in the early evenings.