The Radiation Safety Office for the licensee reported an event where a patient received less than the prescribed dose during a treatment for liver cancer using
Yttrium - 90 microspheres. Specifically, the patient was prescribed 9.8 millicuries to the liver using
Yttrium - 90 SirTex Sirspheres using a intrahepatic catheter. The patient only received 6.5 millicuries due to problems in the administration of the dose.
After administering about half of the treatment dose, the physician started to encounter injection resistance which is not uncommon with this treatment due to vasculature loading. The physician stopped the treatment and was trying to view the microsphere placement in the liver using fluoroscopy when he noted some unusual "clumping" of the microspheres between the delivery vial and a 3-way stop cock that connects to the catheter. Because of the clumping and the resistance, the physician elected to discontinue the administration of the remainder of the dose.
The licensee has contacted SirTex and plans to send the delivery device with the clumped microspheres to SirTex when the Yttrium - 90 has decayed away (in a couple weeks) for further evaluation of the product.
The licensee has also contacted the Region 3 NRC inspector (Piskura) about this event.
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
- UPDATE FROM SCHULTZ TO KNOKE AT 14:29 ON 01/11/07 ***
The
RSO called to indicate this event was reviewed by Region 3 and was determined to not meet the criteria for a reportable event, therefore the event is being retracted. Notified R3DO (Kozak) &
NMSS (Janet Schlueter).