ENS 50673

v t e ENS Event
05:00 Dec 10, 2014
Title	Maryland Agreement State Report - Misadministration of I-125 Seeds During Prostate Therapy
Event Description	The following information was obtained from the State of Maryland via email: Post implant CT determined that all seeds missed the prostate and were deposited in an unintended area of soft tissue at the base of the patient's penis. A medical determination has been made to not remove the seeds due to the difficulty of removal. The patient will be followed over the next two weeks to determine whether damage to the urethra has occurred. The licensee states that the patient has been informed. Preliminary root cause evaluation is that the Medical Center's ultrasound unit used to guide insertion is 12 years old and has a poor (grainy) display. No defect with the Mick applicator has been determined. The Maryland Radiation Program will conduct an on-site investigation of this incident. The patient was administered 53 seeds at a nominal 0.36 mCi I-125 per seed manufactured by Best Industries. Intended dose to the prostate was 108 Gy. 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.

ENS 50673 +/-
Where
University Of Maryland Helen Dent Cancer Center Olney, Maryland (NRC Region 1)
License number:	MD-31-310-01
Organization:	Maryland Dept Of The Environment
Reporting

Agreement State
Time - Person (Reporting Time:+57.67 h2.403 days <br />0.343 weeks <br />0.079 months <br />)
Opened:	Ray Manley 14:40 Dec 12, 2014
NRC Officer:	Howie Crouch
Last Updated:	Dec 12, 2014
50673 - NRC Website
v • d • e

v t e Emergency Notification System
University Of Maryland Helen Dent Cancer Center with Agreement State
WEEKMONTHYEAR2014-12-10T05:00:00 [Table view]
[ENS list for University Of Maryland Helen Dent Cancer Center]

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