| Type of Product |
Medical Device |
| TGA Recall Reference |
RC-2014-RN-01355-1 |
| Product Name/Description |
Monaco (radiation therapy planning system)
Release 3.30 and above
ARTG Number: 215960 |
| Recall Action Level |
Hospital |
| Recall Action Classification |
Class II |
| Recall Action Commencement Date |
24/12/2014 |
| Responsible Entity |
|
| Reason/Issue |
When a CT phantom is scanned and the images are transferred to Monaco, it is possible to sample the densities using the Image Statistics tool in Monaco. In the case where CT slice thickness is not the same as CT slice spacing the Image Statistics tool will report an incorrect HU. If the user bases their CT to ED file on this incorrect density information, dose calculation errors will result. The magnitude of the dose calculation error will be dependent on the magnitude of the HU error.
This problem can only occur for sites who satisfy ALL of the below criteria:
1. Running Monaco Release 3.30 and higher;
2. Using a CT Slice Spacing not equal to the CT Slice Thickness; and
3. Using the Image Statistics Tool to quantify CT phantom densities which are then used to populate the CT to ED file. |
| Recall Action |
Recall for Product Correction |
| Recall Action Instructions |
As an immediate workaround:- The problem can be avoided by using a CT Slice Spacing equal to the CT Slice Thickness; and
A software fix will be provided to rectify the defect as soon as possible. This action has been closed-out on 14/07/2016. |
| Contact Information |
02 8907 1800 - Elekta Pty Ltd |