ESTRO Brachytherapy for Prostate Cancer 2018

The most severe case …

• Occurred in 1992 ; • The source ( HDR Iridium) became detached from the drive mechanism during an anorectal cancer treatment • Conflicting signals; the area monitor actually detected the radiation, while the equipment indicated « source shielded » • Unfortunately, previous radiation monitor malfunctions encouraged misinterpretation and induced the staff not to trust it …