Incidents That Happened Through the Development of Radiology

Technology has helped the growth of radiology but there have been many incidents when dealing with radiation. It all started with the “Tickling the Tail of the Dragon” where two scientists were exposed to lethal doses of radiation while performing experiments. More severe safety procedures were applied until the second fatal radiation accident occurred. Even though more safety procedures were regulated, incidents still occurred. Ionizing radiation happens when the atomic nucleus of an unstable atom decays and starts releasing ionizing particles.

  It causes damage to cells which can increase the risk of cancer later in life due to the amount of energy it creates but the health effects of ionizing radiation depend on the dose received.  Radiation can lead to burns, problems with the blood, gastrointestinal system, cardiovascular and central nervous system, cancer, and sometimes death.

A tragic event occurred in the United Kingdom, between January 5th, 2006 and January 31st, 2016, where unintended overexposures were given to a Lisa Norris. She was receiving radiotherapy treatment for pineoblastoma at Beatson Oncology Centre in Glasgow.

Pineoblastoma is a tumor that arises in the pineal gland and is typically present with a buildup of fluid pressure within the brain. It is a rare but vicious tumor of the central nervous system. Surgical removal for this type of tumor is the most difficult operation, so the treatment of choice is chemotherapy followed by radiation therapy. Treatment uses a radiation beam that is produced by a linear electron accelerator which is directed at the tumor site. Of course, the goal is to provide the highest possible radiation to the cancer while limiting the dose to the non-tumor cells.

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This is accomplished though daily radiation which requires a series of small doses, called fractions.  Shaping the beam of radiation and irradiating from different angles, maximizes the radiation towards the target.

Complex treatments rely on computer treatment planning systems designed for this purpose. The treatment planning system used at Beatson Oncolgy Centre (BOC) is called Eclipse, which is a major component of a comprehensive computer system called Varis. Eclipse provides a Treatment Plan Report that includes treatment delivery parameters. BOC upgraded their system in May of 2005 from Varis to Varis 7.  For some of the most complex plans like the whole CNS, which was Lisa’s situation, the use of paper forms was retained at the BOC. The change allowed the treatment delivery parameters in Eclipse Treatment Plan Report to be transferred electronically to another software within Varis system.  Upgrading the system introduced a new feature that, if selected by the treatment planner, changed the nature of the data in the Eclipse Treatment Plan Report relative to that in similar reports prior to the upgrade.

Since the feature was selected, it caused a critical error. The person who transcribed the data to paper form, the treatment planner, was unaware of the difference and therefore failed to accommodate the changed data. Overexposure happened because the amount entered on the planning form, for one of the treatment delivery parameters, was significantly higher than the number that should’ve been used. This equipment has a monitor that confirms that the treatment stops when the prescribed dose of radiation has been received. The error was not identified in the checking process for the treatment plan so the planning form with the error was given to the radiographer who managed treatment delivery. Since the same setting was used for each treatment, it caused each of the first 19 daily treatments to be too high and the cumulative radiation dose received by the patient in these 19 series was 58% higher than the total that was prescribed.

The consultant clinical oncologist prescribed a dose of radiation of 35 Grays to a treatment volume to include the whole CNS. A total of 20 equal fractions of 1.75 Grays were also delivered and to be followed by 19.8 Grays targeted on the tumor itself in 11 equal fractions of 1.8 Grays. The treatment planner omitted the normalization procedure and error entered and output figure of 91 monitor units (MU) per 100 centiGrays instead of the correct figure of 54 centiGrays.  Because of the overdose, the second phase of the treatment for Lisa was discontinued on the instruction of the clinical oncologist. The error was discovered because the same treatment planner made the same error with the same kind of treatment but for a different patient. The treatment planning colleague became aware of the mistake and an investigation was initiated which later demonstrated the error for Lisa.

The investigation also confirmed that no other patient at the BOC had been affected. It was also discovered that the errors were not associated with faults in the Varis 7 computer system.  After these types of treatments, survivors have long term neurological deficits that may include poor school performance, memory deficits, and neuroendocrine dysfunction including short stature. Long term survival is exceptional. Patients with dispersed cancer uniformity die within 5 years of diagnosis and 50% of them may be dead within two years  Lisa’s prognosis was poor because her autopsy reported residual cancer.  It is possible that the overdose could’ve prolonged her survival by destroying more tumor than the intended dose would have.

On the other hand, she suffered burns on the back of her neck and head which made it difficult for her to lie on her back to sleep. Once blood vessels are damaged, it becomes difficult for oxygen to be transported around the body.  This causes healing to slow down in the affected area. Lisa had been complaining of blurred vision and had lost more than two stone weight.  On October 18th of 2006, Lisa Norris passed away but further examination following her death found that she died from her tumor and not from the overdose. Her parents have never accepted this, believing the radiation overdose killed their daughter.

Several months after, the Beatson was found to have given a series of other patient’s radiation overdoses.  Some suggestions to reduce such incidents ate to have the principal radiotherapy physicist to organize programs of test and checks.  These test would inform the physicist if the equipment is working properly and providing the correct information. When new equipment is being considered into the Radiotherapy Department, appropriate training would provide assurance against error.  This allows suitable use of the new technology being presented. New equipment or system updates shouldn’t be allowed in the department without manuals explaining the different types of operations that can be performed and the scientific understanding of the operation.