A
New York State Department of Health licensee reported on 8/10/04 that prostate seed implant needles were found to be contaminated during a post implant radiological survey in the operating room. Two post implant urine samples from the patient were saved and were found to be contaminated as well. Radiograph of the prostate post implant indicated all seeds were implanted. Hospital staff believed that the contamination was attributable to the implant procedure as the patient had not received a diagnostic nuclear medicine procedure and there was no evidence of any other source for the contamination. The radiation oncologist contacted the patient and was able to administer KI [Potassium Iodide] later in the day, and he will evaluate the need for ongoing treatment with KI.
New York State Department of Health staff went to the hospital on 8/11/04 to investigate this incident. Confirmatory measurements were made and the plastic needle packing tray, needles, lead pouch and urine samples were found to be contaminated. A third urine sample was obtained from the patient on 8/11/04, which also is contaminated. The radiation oncologist who performed the procedure stated that there were no problems with the needles or the implant procedure. The needles were examined and no bends, crimps or damage were observed. The hospital, has notified the pharmacy that had provided the preloaded sterile needles. NRC Region 1 staff were contacted by phone and were given the name of the pharmacy.
The Radiation Safety Officer took the initial urine sample to another New York State Department of Health licensee on 8/11/04 for nuclide identification and rough quantification using a HPGe detector. The isotope in the urine was identified as I-125 and the activity was estimated to be 34 nanocuries per cc (volume of urine sample collected was 200 cc). The patient's urine samples will be sent to DOH Wadsworth Laboratories for analysis. Future samples are expected to be collected and analyzed.
The brachytherapy seeds were manufactured by Mills Biopharmarmaceuticals, Inc., sold by Mentor MBI (Oklahoma City, OK) and loaded into needles by the pharmacy. Brachytherapy seed specifics are:
Model: 125SL
Lot Number: 042814
Batch Number: IB040142N
Seed activity on 8/10/04: 0.405 millicuries