A patient was being treated for prostate cancer. After a treatment of (15)
I-125 seeds, the magazine used to inject the seeds into the patient was surveyed and the survey indicated that the magazine was contaminated. Initially, the staff believed that a seed may have been stuck inside the magazine. However, upon disassembly the staff determined that the magazine was empty. The prostate cancer therapy treatment continued without incident. The patient was x-rayed, and all seeds were accounted for. A survey of the room, instruments, and packaging material revealed no loose surface contamination. The contamination is confined to the inside of the magazine. The staff believes there are two potential scenarios to explain the contamination inside the magazine: (1) the seeds had external contamination when placed inside the magazine, or (2) during the autoclave a weak
weld failed and the seed began to leak. If a seed is leaking
iodine into the patient, then if left untreated, the patient could potentially receive a dose of 50
Rem to the thyroid gland. A physician has prescribed a treatment to block uptake to the thyroid, and the blood and urine samples thus far are inconclusive in determining if
iodine is leaking into the patient.
I-125 seed activity is .302 millicuries per seed. The patient is aware of the issue. Thyroid scans and urine assays will continue for the next four weeks to determine if radioactive
iodine is present in sufficient quantities to indicate a leaking seed.
- * * RETRACTION PROVIDED BY DEAN TAYLOR TO JASON KOZAL 0N 03/26/09 AT 1125 * * *
The licensee's theory is that the seed in question had a bad weld that was not realized until the seed was exposed to the heat sterilization process. This is due to the fact that there was no contamination present prior to the sterilization process.
The licensee completed multiple thyroid scans and blood work on the patient with negative results. Additionally, the licensee performed multiple urine assays with negative results. The patient will continue with potassium iodine treatment for the next 2 years to minimize thyroid uptake. Based on this information the licensee is retracting this event.
Notified the R3DO (Peterson) and
FSME (McIntosh).