The following information was obtained from the Commonwealth of
Massachusetts via email:
Report of medical event. A dose that differs from the prescribed dose by more than 50 rem to an organ, the liver, and the total dose delivered differs from the prescribed dose by 20% or more.
The licensee reported to the Agency [Massachusetts Radiation Control Program] on 2/21/2014 that on 2/19/2014 licensee administered yttrium-90 SIR-Spheres to patient's left lobe of liver and that treatment was palliative in nature; that 7.2 millicuries of yttrium-90 was prescribed; and that 5.06 millicuries was administered resulting in an underdose of 29.7 percent.
The licensee reported that the dose administered differs from the dose prescribed by more than 50 rem to the liver and that licensee will determine what the likely dose difference actually was.
The licensee reported that during the procedure it was apparent that spheres were collecting on the tubing between the stop cock and the source vial and that when procedure was concluded, assays were performed of treatment apparatus and source vial and licensee determined that only 5.06 millicuries of the 7.2 millicuries prescribed was administered.
The licensee reported that the manufacturer, Sirtex, will be onsite on February 24th to begin a joint investigation.
The licensee reported that the referring physician has been notified and it is unknown at time of report whether referring physician has elected to notify patient.
The licensee reported that they do not anticipate any adverse effects on the patient's treatment outcome.
The licensee will submit a written report within 15 days in accordance with the requirements of 105 CMR 120.594(A)(4).
Root cause and corrective action are not known at this time and the Massachusetts Radiation Control Program continues to investigate.
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.