[Epinal radiotherapy accident: passed, present, future]
Fiche publication
Date publication
novembre 2007
Auteurs
Membres identifiés du Cancéropôle Est :
Pr PEIFFERT Didier
Tous les auteurs :
Peiffert D, Simon JM, Eschwege F
Lien Pubmed
Résumé
The accident of radiation oncology at the Public General Hospital in Epinal, Vosges, is the highest in France. It is classified level 6 on a 10 degrees scale of the ASN/SFRO (Autorite de surete nucleaire/Societe francaise de radiotherapie oncologique). It is linked to errors in the process of treatment, and a mistake in the use of dynamic wedges, with an overdosage of 20%. The clinical consequences are severe, for the patients treated for a prostate cancer and exposed to this overdosage, between May 2005 and August 2006. Sequelae were classified grade 2 to 5 on the CTCAE 3.0 scale. A second cohort of 397 was identified, which received an overdose of 10% linked to the daily use of portal imaging, which explained a higher risk of gr 2-3 rectitis. The treatments were interrupted in this hospital for several months, to organize a new management of the department, based on quality and safety. The preventive actions to avoid such an accident necessitate to evaluate standard and innovative treatments, to develop an internal and external quality control program.
Référence
Cancer Radiother. 2007 Nov;11(6-7):309-12