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Poland Radiotherapy Accident
Dear colleagues,
I received a message asking me if I have information on the Poland
Radiotherapy Accident. As this subject could be of interest of Members of
this list I am sending also the information to Radsafe the data that I have
about.
I know the IAEA sent a team to Poland; however I have not the IAEA
conclusions. I’ll write to IAEA to obtain more details.
This is the resume of the Poland Radiotherapy Accident
Jose Julio Rozental
Madrid, until 02-10-2002
--------------------
Poland Radiotherapy Accident
J.M. Cosset*, P.Gourmelon**, F.Mettler***
* Institut Curie, Paris, France
** Institut de Radioprotection et de Sureté Nucléaire (IRSN) -
Fontenay aux Roses, France
*** Chairman, ICRP Committee 3
On February 27, 2001, in Bralystock (Poland), an unexpected power failure
suddenly stopped a linear accelerator working with 8 MeV electron node. When
the power returned, the treatments were resumed for five patients irradiated
for breast cancer (One was treated on her breast, while the four others were
irradiated in the chest well, after a mastectomy).
No recalibration was performed before resuming the treatments. Very
unusually, two patients complained from a strange feeling of burning at the
end of their session, so that the physicist immediately checked the
dose-rate: it was than found to be 10 to 20 times higher than expected. The
five patients developed areas of radionecrosis in the treated areas
in the following months, with the patients treated first showing lesions
less severe than the last ones, suggesting a progressive deterioration of
the accelerator function during the treatment of the five patients. At
present, one patient is dying from liver metastases. Two patients show an
impressive fibrotic retraction of the treated area, together with
superficial radionecrotic lesions. Two patients (the last treated ones)
present with a complete destruction of their chest wall, down to the
pericardium. One of these two patients is presently hospitalised at the
Paris Institut Curie, in France, for a complex two-step surgery, involving
first a transfer of an omentum flap, to be secondly covered by a free-skin
graft Surgery is also planed for the other patients.
This unusual accident emphasizes the need for a complete and systematic
recalibration of a linear accelerator when ithas stopped unexpectedly,
whatever the reasons.
Of note, the ICRP just released its publication N°86, on "Prevention of
Accidental exposures to patients undergoing Radiation therapy".
Reference ALARA Newsletter
Issue 11 - August 2002
----------------------------------------------------------------------
Institute for Nuclear Protection and Safety
http://www.irsn.org/va/01A/1_020524.htm
May, 24 2002
A Polish patient, a radiation accident victim,
is rushed to the Curie Institute
On 23 May 2002, a young Polish woman seriously affected by a medical
radiation accident, was transferred to the Curie Institute. Dr Wieczorek,
head of the Radiotherapy and Oncology Department of the Kielce Cancer Centre
in Poland, was at her side.
The accident, which had occurred in the Radiotherapy Department of the
Bialystok Regional Oncology Centre on 27 February 2001, had been reported to
the IAEA. A preliminary international medical appraisal mission involving
Professor J.M. Cosset of the Curie Institute had already been sent out (28
November - 6 December 2001).
Five breast cancer patients had been accidentally exposed to a dose well in
excess of the planned dose, as the result of a fault on a linear accelerator
used to treat them.
As the patients' health was deteriorating, the Polish authorities sought
assistance from the IAEA on 8 May 2002, stating that they would like some of
the victims to be treated in France.
The IAEA assigned Professor J.M. Cosset (Curie Institute) and Dr Gourmelon
(IRSN), to carry out a mission on 17 and 18 May 2002. They hurried to Warsaw
to evaluate the clinical state of the patients and put forward a therapy
strategy.
The experts concurred that surgical treatment was required forthwith for one
of the patients who was in a critical condition and proposed to transfer her
rapidly to a specialised centre that had experience in treating radiation
accidents. Three of the other patients will also require specific surgical
treatment, but their cases are less urgent.
We remind readers that France has been asked to take in radiation victims
several times over the past few years, because of the quality of treatments
developed in French hospitals and because of the technical support given by
the IRSN. Following the accidental irradiation of Georgian border guards
and villagers, the Curie Institute and the Percy Military Hospital treated
five victims in 1997 and 2001.
In contrast to accidents due to industrial radioactive sources, the
occurrence of medically induced radiological accidents is extremely rare
across the world. Only three serious accidents have been reported in the
past ten years Zaragoza, Spain in 1990; Costa Rica in 1996 and Panama in
2000.
_________________________________________________________________
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