At approx. 1415 hrs. [3/19/09] the physicist was performing a post operative dosimetry analysis of the
Iodine-125 prostate seed
brachytherapy implant for [the patient] when it was discovered that none of the implanted seeds made it to their intended destination, and were, in fact, implanted outside the target organ. The seeds retained their planned pattern grouping, with the superior end of the seed cloud being about 2 cm from the apex of the prostate gland. A dosimetric analysis of the
CT image revealed all 93 seeds accounted for, and a calculated dose to 90% of the target organ (prescription line) being 2.24 Gy. The prescribed dose in the Written Directive was 145 Gy.
As the seeds appear distal to the target organ, the dose appears to be maximally confined to soft tissue including muscle and subcutaneous fat. A complete analysis was requested of the Radiation Oncologist who was immediately informed. A preliminary dose report was printed for review.
Actions Taken: The attending Radiation Oncologist was immediately notified. It was also noted by the physicist/RSO that this event was reportable as a Medical Event under 10CFR35. [The] License Administrator, was notified at approximately 3:00 PM as was the Nuclear Medicine Manager. The preliminary dosimetry report was printed at 1632 hrs and the NRC Operations Center was notified at 1701 hrs by telephone. A follow-up notice will be emailed to the Ops Center within 1 hr.
The involved individuals were notified of the NRC contact and a request was made for an investigation. Marlton Risk Management will also be informed.
Incident Number: 2009-03-19
A Medical Event may indicate potential problems in a medical facilities use of radioactive materials. It does not necessarily result in harm to the patient.