Recall StatusOpen, Classified
Date Initiated2020-03-04
Product Quantity1389 licenses
Reason for Recall
Due to physical limitations of the treatment machine, the maximum field opening for Siemens Virtual Wedge fields recommended by the LINAC vendor will be more restricted in the wedged direction than the maximum field opening without a wedge. Delivering a larger field opening with a virtual wedge will not result in a wedged field shape over the entire field. Instead, a high dose plateau region will be the result at the toe side of the field beyond the recommended field size.
Firm Action
Field Safety Notice, Medical Device Correction #56089 was emailed to customers on 3/4/20.
ACTIONS TO BE TAKEN BY THE USER
" Do not use Siemens Virtual Wedge fields outside the Siemens recommended specification. If a
field outside the recommended specification with a virtual wedge is sent to the LINAC, the treatment
machine console (console software versions 8 and higher) will display a warning message, for
example Initial gap > 1 cm! Proceed (y/n)?, or The distance between the static jaw and the
moving jaw is greater than 1 cm. Do you want to continue? (y/n). If this happens, select n
to prevent the treatment machine from delivering the field.
" In RayPhysics, use the wedge Field size limits parameters (Figure 3) to restrict the maximum
allowed field size for a wedged field, see Setting wedge field size limits in RayPhysics on page6
below for details.
" Verify through measurement at the LINAC that a wedged shape is delivered for the maximum field
opening allowed by the Field size limits parameters for each wedge angle for Siemens Virtual
Wedge before clinical use.
Please educate planning staff and all users about this workaround.
Inspect your product and identify all installed units with the above software version number(s), then confirm
that you have read and understood this notice by replying to the notification email.
This notice needs to be passed on to all those who need to be aware within your organization. Please
maintain awareness of this notice as long as any version of RayStation/RayPlan affected by this issue is
in use to ensure effectiveness of the workaround.
Thank you for your cooperation, and we apologize for any inconvenience.
For regulatory information, please contact
[email protected]
Root Cause
Under Investigation by firm
Distribution Pattern
US Nationwide distribution in the states of AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, LA, MA, MD, ME, MI, MO, MS, MT, NC, NE, NJ, NY, OH, OK, OR, PA, RI, TN, TX, UT, VA, VT, WA, and WI.
Related FDA 510(k) Records
Devices referenced by this recall via K-numbers.
Official Source
View FDA Recall →Source: FDA Enforcement Report / Recall database. Always confirm against the official FDA record.