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Proteus 235 Proton Therapy System for cancer treatment.

FDA device recall Z-0020-2015 · posted 2014-10-29 · Terminated

Recall details

Recalling firm
Ion Beam Applications S.A.
Reason for recall
While the Proteus 235 is in the pencil beam scanning (PBS) treatment mode, on rare occasions, Low Level Radio Frequency (LLRF) pulsed dee voltage (i.e., voltage applied between two electrodes in the cyclotron to accelerate protons) may generate a hot spot on a pencil beam position within a tumor, generating a dose that might exceed the prescribed dose on a single voxel.
Action taken
A User Notice was sent to direct accounts in/about March/April 2014 to notify them of the issue and provide instructions to avoid the identified potential risk to patients.
Root cause
Device Design
Status
Terminated
Product code
IYE
Quantity affected
8
Distribution
Worldwide Distribution-USA (nationwide) including the states of PA, NJ, IL, WA, and TN, and the countries of Germany, Italy, and Czech Republic.
Date initiated
2014-03-27
Date posted
2014-10-29
Date terminated
2014-12-10
Location
Louvain La Neuve, Belgium

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Related 510(k) clearances

RecordFirmDate
IBA PROTON THERAPY SYSTEM- PROTEUS 235 (K082416)Ion Beam Applications S.A.2008-12-12