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U.S. Department of Health and Human Services

Class 2 Device Recall Radiation Therapy Treatment Planning System

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  Class 2 Device Recall Radiation Therapy Treatment Planning System see related information
Date Initiated by Firm March 11, 2019
Create Date April 21, 2019
Recall Status1 Terminated 3 on May 12, 2021
Recall Number Z-1205-2019
Recall Event ID 82601
510(K)Number K142108  K170750  
Product Classification System, planning, radiation therapy treatment - Product Code MUJ
Product RT Elements
Software revisions of the RT Elements applications have a specific software version number. Specifically the following RT Elements applications/versions are affected:
- Cranial SRS 1.0.0 and 1.5.0
- Spine SRS 1.0.0 and 1.5.0
- Multiple Brain Mets SRS 1.5.0
- RT QA 1.0.0 and 1.5.0

Product Usage:
The RT Elements are applications for radiation treatment planning for use in stereotactic, conformal, computer planned, Linac based radiation treatment of cranial, head and neck and extracranial lesions.
Code Information Software revisions of affected RT Elements applications: - Cranial SRS 1.0.0 and 1.5.0 - Spine SRS 1.0.0 and 1.5.0 - Multiple Brain Mets SRS 1.5.0 - RT QA 1.0.0 and 1.5.0  Unique Identifier (UDI): GTIN for affected product(s): Cranial SRS 1.0 -7 04056481000554 Cranial SRS 1.5 -704056481140403 Spine SRS 1.0 - 04056481000547 Spine SRS 1.5 - 04056481140380 Multiple Brain Mets SRS 1.5 7 04056481006853 RT QA 1.0 -7 04056481007119 RT QA 1.5 -7 04056481140397  Model/catalogue numbers: 21702A ELEMENTS MULTIPLE BRAIN METS SRS SUB. 21702-04C ELEMENTS MULTIPLE BRAIN METS SRS INST 21702-0 6 ELEMENTS MULTIPLE BRAIN METS SRS LICENSE 21702-12A ELEMENTS MULTIPLE BRAIN METS SRS SUB. 21702-36A ELEMENTS MULTIPLE BRAIN METS SRS SUB. 21702-60A ELEMENTS MULTIPLE BRAIN METS SRS SUB. 21712A ELEMENTS MULTIPLE BRAIN METS SRS 21722A ELEMENTS MULTIPLE BRAIN METS SRS SUB FOC 21722-12A ELEMENTS MULTIPLE BRAIN METS SRS SUB FOC 21741A UPD TO ELEMENTS BRAIN MET PLAN 21742 ELEMENTS CRANIAL SRS 21742A ELEMENTS CRANIAL SRS 21743 ELEMENTS CRANIAL SRS SUBSCRIPTION 21743A ELEMENTS CRANIAL SRS SUBSCRIPTION 21743-01 ELEMENTS CRANIAL SRS LICENSE ELEMENTS CRANIAL SRS LICENSE 1.5 ELEMENTS CRANIAL SRS INSTALLER 21743-02A ELEMENTS CRANIAL SRS INSTALLER 1.5 21743-12 ELEMENTS CRANIAL SRS SUBSCRIPTION 21743-36 ELEMENTS CRANIAL SRS SUBSCRIPTION 21743-60 ELEMENTS CRANIAL SRS SUBSCRIPTION 21744 ELEMENTS CRANIAL SRS SUBSCRIPTION FOC 21744A ELEMENTS CRANIAL SRS SUBSCRIPTION FOC 21744-12 ELEMENTS CRANIAL SRS SUBSCRIPTION FOC 21744-36 ELEMENTS CRANIAL SRS SUBSCRIPTION FOC 21744-60 ELEMENTS CRANIAL SRS SUBSCRIPTION FOC 21745 ELEMENTS CRANIAL SRS (UPD) 21745A ELEMENTS CRANIAL SRS (UPD) 21747 ELEMENTS SPINE SRS 21747A ELEMENTS SPINE SRS 21748 ELEMENTS SPINE SRS SUBSCRIPTION 21748A ELEMENTS SPINE SRS SUBSCRIPTION 21748-01 ELEMENTS SPINE SRS LICENSE ELEMENTS SPINE SRS LICENSE 1.5 ELEMENTS SPINE SRS INSTALLER 21748-02A ELEMENTS SPINE SRS INSTALLER 1.5 21748-12 ELEMENTS SPINE SRS SUBSCRIPTION 21748-36 ELEMENTS SPINE SRS SUBSCRIPTION 21748-60 ELEMENTS SPINE SRS SUBSCRIPTION 21749 ELEMENTS SPINE SRS SUBSCRIPTION FOC 21749A ELEMENTS SPINE SRS SUBSCRIPTION FOC 21749-12 ELEMENTS SPINE SRS SUBSCRIPTION FOC 21749-36 ELEMENTS SPINE SRS SUBSCRIPTION FOC 21749-60 ELEMENTS SPINE SRS SUBSCRIPTION FOC 21750 ELEMENTS SPINE SRS (UPD) 21750A ELEMENTS SPINE SRS (UPD) 21762 RT QA 1.0 21762A RT QA 1.5 21762-01 RT QA LICENSE RT QA LICENSE 1.5 RT QA INSTALLER 21762-02A RT QA INSTALLER 1.5  
Recalling Firm/
Manufacturer		 Brainlab AG
Olof-palme-str. 9
Munich Germany
Manufacturer Reason
for Recall		 There is a potential for an incorrect dose distribution calculation by Brainlab RT Elements software (for affected versions) under specific circumstances when using the Pencil Beam algorithm on the GPU (graphics card), as is the default system setting.
FDA Determined
Cause 2		 Device Design
Action On March 11, 2019, Brainlab sent FIELD SAFETY NOTICE/PRODUCT NOTIFICATION emails to their consignees advising them of the problem. Brainlab will disable the Pencil Beam GPU calculation in the settings of the affected RT Elements Radiation Treatment Planning Software, and thus correct the described issue permanently for all affected customers.
Quantity in Commerce US - 164 units; Outside the US - 333
Distribution Worldwide Distribution - US Nationwide in the states of AL, AR, AZ, CA, CO, CT, FL, GA, IA, ID, IN, KY, LA, MA, MD, MS, NC, NJ, NY, OH, OR, PA, SC, TN, TX, UT, VA, & WV. Algeria, Argentina, Australia, Austria, Belgium, Brazil, Canada, China, Colombia, El Salvador, Finland, France, Germany, Hong Kong, Iran, Ireland, Israel, Italy, Japan, Jordan, Lebanon, Martinique, Mexico, Monaco, Morocco, Netherlands, Poland, Portugal, Russian Fed., South Africa, South Korea, Spain, Switzerland, Taiwan, Tunisia, United Arab Emirates, and United Kingdom.
Total Product Life Cycle TPLC Device Report
1 A record in this database is created when a firm initiates a correction or removal action. The record is updated if the FDA identifies a violation and classifies the action as a recall, and it is updated for a final time when the recall is terminated. Learn more about medical device recalls.
2 Per FDA policy, recall cause determinations are subject to modification up to the point of termination of the recall.
3 For details about termination of a recall see Code of Federal Regulations (CFR) Title 21 §7.55.
510(K) Database 510(K)s with Product Code = MUJ and Original Applicant = BRAINLAB AG
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