Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques

Thomadsen, Bruce R.; Lin, Shi; Laemmrich, Patrick; Waller, Tonia; Cheng, Arif; Caldwell, Barrett S.; Rankin, Rebecca; Stitt, Judith A.

doi:10.1016/s0360-3016(03)01622-5

Cited by 74 publications

(46 citation statements)

References 8 publications

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“…Nevertheless, HDR BT is a meticulous technique and procedural variations caused by factors such as patient motion, needle movements, anatomical changes occurring between imaging and treatments, as well as potential human inaccuracies or errors, may lead to a significant degradation of the plan (Thomadsen et al, 2003). Therefore, to ensure the delivered dose agrees within acceptable limits to that planned, rigorous quality assurance (QA) procedures should be implemented for independent treatment verification.…”

Section: Trus-probe Integratedmentioning

confidence: 99%

TRUS-probe integrated MOSkin detectors for rectal wall in vivo dosimetry in HDR brachytherapy: In phantom feasibility study

Tenconi

Carrara

Borroni

et al. 2014

Radiation Measurements

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The increasing complexity and high amount of dose per fraction delivered in prostate high dose rate (HDR) brachytherapy treatments call for the implementation of accurate and effective methods for the systematic and independent quality control of the overall treatment procedure. In this study, MOSkin detectors were placed on a trans-rectal ultrasound (TRUS) probe with the aim of performing both imaging and real time rectal wall in vivo dosimetry with the use of just one single instrument. After an adequate calibration of the detectors, which was carried out in a solid water phantom, the use of MOSkins integrated to the TRUS probe was studied in a gel phantom with a typical (simplified) prostate implant. Measured and calculated doses from the treatment planning system were compared, with a resulting very low average discrepancy of -0.6 ± 2.6%. The results are very promising and of particular clinical importance, however, further in vivo investigation is planned to validate the proposed method. Disciplines Engineering | Science and Technology Studies Publication DetailsTenconi, C., Carrara, M., Borroni, M., Cerrotta, A., Cutajar, D., Petasecca, M., Lerch, M., Bucci, J., Gambarini, G., Pignoli, E. & Rosenfeld, A. (2014). TRUS-probe integrated MOSkin detectors for rectal wall in vivo dosimetry in HDR brachytherapy: in phantom feasibility study. Radiation Measurements, 71 379-383. ABSTRACTThe increasing complexity and high amount of dose per fraction delivered in prostate high dose rate (HDR) brachytherapy treatments call for the implementation of accurate and effective methods for the systematic and independent quality control of the overall treatment procedure. In this study, MOSkin detectors were placed on a trans-rectal ultrasound (TRUS) probe with the aim of performing both imaging and real time rectal wall in vivo dosimetry with the use of just one single instrument.After an adequate calibration of the detectors, which was carried out in a solid water phantom, the use of MOSkins integrated to the TRUS probe was studied in a gel phantom with a typical (simplified) prostate implant. Measured and calculated doses from the treatment planning system were compared, with a resulting very low average discrepancy of 0.6 ± 2.6%. The results are very promising and of particular clinical importance, however, further in vivo investigation is planned to validate the proposed method.

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Section: Trus-probe Integratedmentioning

confidence: 99%

TRUS-probe integrated MOSkin detectors for rectal wall in vivo dosimetry in HDR brachytherapy: In phantom feasibility study

Tenconi

Carrara

Borroni

et al. 2014

Radiation Measurements

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“…Some researchers have reported that failure modes in HDR brachytherapy tend to occur because of human error during treatment planning and delivery rather than because of malfunctions of the treatment machine 10, 11, 24. Failures frequently result because of lack of training or experience.…”

Section: Discussionmentioning

confidence: 99%

“…Several radiation misdeliveries caused by incorrect applicator information have been reported, all attributable to a lack of understanding of the applicator structure 4, 5, 6, 7, 8, 9, 10, 11, 12, 13. To prevent accidents, independent pretreatment verification is important.…”

Section: Introductionmentioning

confidence: 99%

High‐dose rate intracavitary brachytherapy pretreatment dwell position verification using a transparent applicator

Otani

Sumida

Nose

et al. 2018

J Applied Clin Med Phys

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PurposeThe major errors in HDR brachytherapy are related to treatment distance, almost all of which are caused by incorrect applicator information. The aim of this study is to propose a quick pretreatment verification method to evaluate channel length and dwell position with a transparent applicator, which, in addition, is suitable as an education tool to assist in the understanding of the applicator structure.MethodsA transparent applicator model was fabricated using a three‐dimensional printer and transparent resin. Its aim is to be a replica of a real gynecological applicator. The pretreatment verification is performed by observing the planned dwell positions of a check cable inside a transparent applicator. A digital camera acquired images and the dwell positions of the radioactive source and check cable were evaluated by comparing them with respect to the theoretical dwell positions marked by the proper x‐ray marker. The potential effectiveness of verification using a transparent applicator was also evaluated using brachytherapy events reported in the literature.ResultsThe transparent applicator closely resembles the real applicator in shape and had an error of less than 0.2 mm. The average dwell position displacement between the radioactive source and check cable was 0.4 mm. The analysis of brachytherapy events showed that channel‐length, dwell‐position, and step‐size errors made up 50% of all events, but affected 64% of all patients.ConclusionsThe transparent applicator model enables a noninvasive, repeatable verification of the channel length and dwell positions to be performed before treatment. This verification has the potential to help prevent common errors in treatment delivery. In addition, the transparent applicator model can be used as a teaching tool to help clinicians understand the operation of the applicator, lowering the risk of events.

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“…Numerous other risks can be identified in the radiotherapy process chain, but they are beyond the scope of this report. For a more exhaustive risk assessment we refer to the report of TG100 (work in progress, (122)) and several other publications (124)(125)(126).…”

Section: Scopementioning

confidence: 99%

“…The process chain can be visualized by a so-called process tree (125). This process tree is a schematic diagram of all the processes involved in the treatment of a patient.…”

Section: Hfmea / Safermentioning

confidence: 99%

NCS Report 22: Code of practice for the quality assurance and control for intensity modulated radiotherapy

Wal¹,

Wiersma²,

Ausma³

et al. 2013

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Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques

Cited by 74 publications

References 8 publications

TRUS-probe integrated MOSkin detectors for rectal wall in vivo dosimetry in HDR brachytherapy: In phantom feasibility study

TRUS-probe integrated MOSkin detectors for rectal wall in vivo dosimetry in HDR brachytherapy: In phantom feasibility study

High‐dose rate intracavitary brachytherapy pretreatment dwell position verification using a transparent applicator

NCS Report 22: Code of practice for the quality assurance and control for intensity modulated radiotherapy

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