The following was received from the
California Department of Public Health via email:
On June 16, 2021, the Radiologic Health Branch was notified of a reportable medical event that occurred on June 15, 2021 during a patients' liver metastases treatment with Y-90 Sirtex SIRSpheres. The AU's treatment plan called for treating the left lobe of the liver with 0.29-0.83 GBq of Y-90 SIRSpheres. The reason for the range was that if the liver became saturated, the treatment would be stopped at that point. During the treatment, periodic flushing cycles with contrast and flouroscopy were performed. At a mid-way point, the team discovered contrast material in the right liver lobe, indicating the microcather had moved from the left artery to the right artery. Upon discovery, the procedure was stopped, the microcatherter was removed and a new one was placed and the they began to infuse the left liver lobe again with the remaining Y-90 SIRSpheres without incident. Post treatment, a bremsstrahlung image of the two liver lobes indicated that both lobes had received Y-90 activity. The Radiation Oncologist estimated that the left lobe received less than the intended Y-90 activity. The right lobe received between 33%-67% of the Y-90 activity.
The actual dose to either lobe has not been calculated, but based on dosimetry information in the package insert, the dose to the right lobe was > 0.5 Gy ( 50 rem). Treatment of the liver's right lobe was not intended during this procedure. On June 1, 2021, the patient had been treated with Y-90 SIRSpheres of the patient's right liver lobe. The patient was informed of the issue and there are no negative consequences expected for the patient.
California Item Number: 061621
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.