Proteus235- Proton Therapy System: to produce and deliver… recallZ-1205-2022 · Ion Beam Applications S.A. · initiated Apr 20, 2022

Why it was recalled

First layer of Uniform Scanning treatment fields is sometimes irradiated with incorrect Scanning Magnet setpoints resulting in the field size may be smaller than expected and the irradiated area may receive more dose than prescribed

FDA root cause category: Under Investigation by firm

What the company is doing

***UPDATE 12/22/22*** Ion Beam Application S.A. (IBA S.A.) issued an Amended Urgent Medical Device Correction to customers starting December 22, 2022 (supersedes previous letter Sept 15, 2022). Letter provides quantitative data about the impact on the dose distribution, and the description of the solution (software upgrade) as well as the time schedule for its deployment. Cyclic check thresholds verification and software upgrade Additionally, IBA will provide each impacted customer with a report including: - The list of the Uniform Scanning fields with the first layer entirely delivered with the tuning setpoints and a significant difference (above 0.3V) between the prescribed setpoints and the tuning setpoints, - The modelled maximum and average dose errors for these fields IBA will upgrade the PTS version to ensure that: - the irradiation of a layer cannot be started if the Scanning Magnet setpoints for the layer are not properly sent to the Scanning Magnet Power Supply, and - no setpoints request can be lost (even if previous requests are not yet executed or completed). The report including the identified impacted Uniform Scanning fields with the modelled maximum and average dose errors for these fields will be provided to each impacted customer by February 28, 2023. On the sites where IBA has not yet finalized the verification and the possible adaptation of the field size and dose rate cyclic check thresholds, this action will be completed by January 15, 2023. The PTS version upgrade will be deployed on your site by March 31, 2023. Contact: HEAD OF POST MARKET VIGILANCE Sonia PINEL [email protected] +32 10 497 516 ___________________________________________________________________________ **UPDATED 9/15/22*** The cause of these events has been identified as a software race condition between the different tasks that handle the Scanning Magnet Electronic Unit (SMEU). IBA CAPA PNC-543 has been opened. The root cause analysis is in progress. This recall re

Recall details

Recall number

Z-1205-2022

Status

Open, Classified

Initiated by the company

Apr 20, 2022

Posted by the FDA

May 27, 2022

Recalling firm

Ion Beam Applications S.A.

Quantity

4 units

Product code

LHN

FDA submissions

K163500

Distribution

Worldwide distribution - US Nationwide distribution in the states of IL, VA, WA and the country of Germany.

Product description

Proteus235- Proton Therapy System: to produce and deliver a proton beam for the treatment of patients with localized tumors and other conditions susceptible to treatment by radiation

Devices named in this recall

1 device in the FDA device registry whose identifier appears in the recall's code information.

• IBA Proton Therapy System – Proteus 235 Proteus PLUS/Proteus ONE

  Ion Beam Applications SA · System, Radiation Therapy, Charged-Particle, Medical
  8 recalls1 report