Fact Sheet on Failed Prostate Implant Procedures at the Veterans Affairs Hospital in Philadelphia
Brachytherapy is a common surgical procedure used to treat prostate cancer by implanting radioactive iodine-125 seeds into the prostate. Procedures performed at the VA hospital in Philadelphia, between 2002 and 2008, routinely resulted in treatments that failed to place the radioactive seeds as prescribed. This failure resulted in 97 medical errors out of 116 prostate cancer treatments performed.
The misuse of the radioactive seeds resulted in medical errors to our nations veterans. These medical errors at the VA hospital in Philadelphia were also not reported to the NRC as required by regulation.
How the Procedure Works
Step 1 Treatment Planning An ultrasound probe is inserted into the rectum to get an exact measurement of the size of the prostate. A computer pre-treatment image is prepared for the doctor to aide in determining the number of radioactive seeds needed to treat the patient. |
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Step 2 Procedure The computer pre-treatment image is also used to determine where to position the needles loaded with radioactive iodine-125 seeds. During the actual surgical procedure, a template is also used to aide in inserting the needles in the locations prescribed. |
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Step 3 Post-procedure Seed Location Verification A computer x-ray is taken after the surgical procedure is completed to show the location of the seeds in the body. This will help determine if the seed position matches the positioning prescribed by the doctor. |
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Step 4 Post-procedure Dose Verification This image shows the prostate in relation to the other organs and shows the location of the seeds. The doctor determines if the number and location of the seeds matches what was prescribed. The doctor will then decide if the implant was successful. |
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What Went Wrong at the VA Hospital in Philadelphia
These computer images are examples of the medical errors NRC inspectors identified at the VA hospital in Philadelphia.
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| Figure 1 Nearly all of the radioactive seeds have been placed outside of the prostrate. This means that the radiation dose delivered to treat the patient’s prostrate cancer was only a small fraction of the prescribed dose for effectively treating the cancer. | Figure 2 Many of the radioactive seeds intended for the prostrate were implanted near the patience’s rectum. This caused an unnecessary exposure of radiation to the rectum. |
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Figure 3 Many of the radioactive seeds are outside of treatment areas. As a result, the prostrate was not treated but tissue outside of the prostrate was exposed to unintended radiation. |
March 2010
