Safety Alert for C-Series High Energy Linear Accelerator

Safety alert

2014-06-24

2014-06-24

Hong Kong

DH

https://www.mdco.gov.hk/english/safety/recalls/recalls_20140624a.html

Medical device safety alert: varian medical systems c-series high energy linear accelerator medical device manufacturer, varian medical systems, has issued a medical device safety alert concerning its c-series high energy linear accelerator, [affected models: novalis tx, trilogy, trilogy tx, clinac ix, clinac cx, clinac 2100 c/d, clinac 2300 c/d, clinac dx, clinac 21 ex, clinac 23 ex 6 mv configurations only]. the manufacturer has seen a trend in reports of unexpected decrease in beam output in c-series high energy linear accelerators for 6mv photon treatment mode. this failure mode in the target only affects the 6 mv photon treatment modes (6srs, 6fff, and 6x). no other energies are affected. the manufacturer has determined the cause of the unexpected variations in beam output to be degradation of the 6mv target. specifically, the effects of modern, highly modulated treatment modes can create high levels and frequency of stress cycles in the targets particularly if the beam spot size is small. this can lead to the target’s deterioration and failure at an accelerated rate resulting in a rapid change in the beam output and symmetry. specifically:- the photon generation, or bremsstrahlung yield, decreases as fewer electrons are converted to photons in the target, and; due to a resulting escape of primary electrons the output of photons, as measured by the ion chamber, might appear to be constant, but the actual photon output is decreasing according to the local supplier, the affected products were distributed in hong kong. if you are in possession of the affected products, please contact your supplier for necessary actions. posted on 24 jun 2014.