The following is a summary of information provided by the
North Carolina Department of Health and Human Services Radioactive Materials Branch (
RMB) via email:
The licensee reported to RMB that around 1500 EDT on 05/29/25, a routine Pluvicto infusion (the second of six planned) presented challenges with gravity delivery of the dose. Staff experienced difficulty initiating forward flow from the saline line into the vial. Attempts to correct the condition were unsuccessful and the procedure was discontinued.
The patient was prescribed to receive 200 mCi of Lu-177 to the prostate but it was calculated the patient only received 117.1 mCi. Post-treatment surveys of the patient were completed; the highest survey reading at one meter was 1.01 mr/hr. Contamination surveys were completed directly after infusion and minimal contamination was found around vial. The tubing, peripheral intravenous (PIV) extensions, and vial were all secured and assayed by radiation safety specialist. Staff moved all waste to disposal and all subsequent area survey readings were at background. The infusion room was cleared for general use. The unused dose was stored for disposal. Staff dosimetry has been sent for processing, but no elevated readings are expected.
The patient was immediately notified of the event and was released. The licensee does not expect the patient's treatment plan to alter due to this event. The medical director also reached out to the patient and referring physician later that day to discuss the event.
After discussions with the radiation safety officer and review of available staff reports, [RMB determined that] the licensee did follow the manufacturer's procedure.
RMB's investigation is ongoing.
NC Event Number: NC250007
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.