The state provided in the following information via e-mail:
On 10/10/08, licensee's RSO notified DRH [Division of Radiological Health] of a Yttrium-90 SIR-Spheres medical event. The reportable event involved the administration of 54 mCi of SIR-Spheres for one patient with approximately 27 mCi instilled into both the right and left hepatic arteries. After instilling approximately 27 mCi of Yttrium-90 SIR Spheres based on radiation readings into the right hepatic artery, a smaller catheter for the left hepatic artery was used due to anatomy and to get to the segment feeding the tumor. While attempting to instill the Yttrium-90 SIR Spheres into the left hepatic artery over-pressurization caused the three (3) way valve in the containment box to give way and resulted in the release of a therapeutic dose of Yttrium-90 SIR Spheres into the delivery system containment box as per design. Due to the release of the second part of the dose into the containment box only approximately 50% of the dose was able to be administered. The procedure was terminated and the delivery box was bagged and held for decay-in-storage. Personnel in the room were monitored for contamination and the room was surveyed and released. The patient was released with no harmful effects foreseeable by the Radiation Oncologist. The patient and referring physician were notified of additional future treatment.
Licensee suggested the incident may have been caused by the size of the catheter, a kink in the catheter, or a smaller syringe being used by the interventional radiologist putting increased pressure on the 3 way valve. As a result of the medical event the licensee's treatment team will review the delivery system setup before pressure is applied to ensure the flow of the SIR-Spheres will not be impeded within the catheter.
License No.: MS-MBL-01
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.