ESTRO Brachytherapy for Prostate Cancer 2018

• Therefore the wrong indication of the equipment was accepted … • And the patient, clothes and room were not checked with another radiation monitor • The patient kept the HDR source 4 days , for a total dose of about 16,000 Gy ! ( 18 Gy prescribed …..) • … and was disposed in a waste container, without identification of the source …