Information Notice 1986-84, Rupture of a Nominal 40-Millicurie Iodine-125 Brachytherapy Seed Causing Significant Spread of Radioactive Contamination

Rupture of a Nominal 40-Millicurie Iodine-125 Brachytherapy Seed Causing Significant Spread of Radioactive Contamination

ML031250253
Person / Time
Site:	Beaver Valley, Millstone, Hatch, Monticello, Calvert Cliffs, Dresden, Davis Besse, Peach Bottom, Browns Ferry, Salem, Oconee, Nine Mile Point, Palisades, Palo Verde, Perry, Indian Point, Fermi, Kewaunee, Catawba, Harris, Wolf Creek, Saint Lucie, Point Beach, Oyster Creek, Watts Bar, Hope Creek, Grand Gulf, Cooper, Sequoyah, Byron, Pilgrim, Arkansas Nuclear, Three Mile Island, Braidwood, Susquehanna, Summer, Prairie Island, Columbia, Seabrook, Brunswick, Surry, Limerick, North Anna, Turkey Point, River Bend, Vermont Yankee, Crystal River, Haddam Neck, Ginna, Diablo Canyon, Callaway, Vogtle, Waterford, Duane Arnold, Farley, Robinson, Clinton, South Texas, San Onofre, Cook, Comanche Peak, Yankee Rowe, Maine Yankee, Quad Cities, Humboldt Bay, La Crosse, Big Rock Point, Rancho Seco, Zion, Midland, Bellefonte, Fort Calhoun, FitzPatrick, McGuire, LaSalle, 05000000, Zimmer, Fort Saint Vrain, Shoreham, Satsop, Trojan, Atlantic Nuclear Power Plant, Skagit, Marble Hill
Issue date:	09/30/1986
From:	Partlow J NRC/IE
To:
References
IN-86-084, NUDOCS 8609250062
Download: ML031250253 (3)

1I

191 HAL SSINS No.:

IN 86-84

6835 UNITED STATES

NUCLEAR REGULATORY COMMISSION

OFFICE OF INSPECTION AND ENFORCEMENT

WASHINGTON, D.C. 20555 September 30, 1986

4 F INFORMATION NOTICE NO.' 86-84: RUPTURE OF A NOMINAL 40-MILLICURIE IODINE-125 BRACHYTHERAPY SEED CAUSING SIGNIFICANT SPREAD

OF RADIOACTIVE CONTAMINATION

Addressees

All NRC medical institution licensees.

Purpose

of iodine-125 contamination

This notice is to alert licensees of a spread the seed encapsulation during removal

resulting from the inadvertent cutting of The seed was one of eight

of the seed from Heyer-Schulte coaxial catheters.

a brain tumor. It is expected that.

seeds used for brachytherapy treatment of applicability to their facilities and

licensees will review this information for

consider actions, if appropriate, to preclude similar problems from occurring

contained in this information notice

at their facilities. However, suggestions no specific action or written

do not constitute NRC requirements; therefore, response is required.

Description of Circumstances

are intended to be reusable

The seeds, which are manufactured by 3M Company,seeds (40 millicuries per seed).

because of the initial high activity of thethem for several patients because of

Users of the seeds are motivated to reuse seeds are removed from the old

the relatively high cost of the seeds. The implant into other patients. It was

catheters and loaded into new catheters for that one of the seeds ruptured.

during removal of the seeds from the catheter by cutting the catheter to free the

The rupture was believed to have been caused

blade or scissors. The licensee did

seeds with a sharp object, such as a razor seeds, including the ruptured seed, not know that a seed had been ruptured. The into a patient. As a result, the

were reloaded into new catheters and implanted microcuries and a radiation dose

557 patient sustained a thyroid burden of about

to the thyroid of about 2087 rads.

that one or more seeds had

Licensee personnel were not immediately aware in a source/transport bucket

ruptured until they found iodine-125 contamination

room (BSSR) on the day after the

stored in the brachytherapy source storage of the seeds into the new catheters.

implant into a patient following reloading

IN 86-84 September .30, 1986 The seeds were removed from the old catheters and loaded into new catheters

in the BSSR an area not ventilated by a fume hood. Consequently, approximately

received

60 hospital personnel, including those involved in cleanup operations, thyroid uptakes of iodine-125 from 0.04 to 209 nanocuries. A proper radiation

survey meter was used, but the high background radiation in the BSSR masked

the positive indication of contamination.

Discussion:

The isolated incident described is the only incident of its kind known by the

NRC involving high-activity iodine-125 seeds. However, there have been several

other similar incidents involving the use of low-activity seeds containing

0.1 to 1 millicuries used as permanent implants. Both types of seeds are

manufactured by 3M Company.

The risk of iodine-125 seed rupture is relatively high when the seeds are used

for several patients. The incident was caused because:

the seeds are susceptible to damage from sharp tools such as razor blades

or scissors

the discolored or stained condition of the catheters after use in therapy

makes viewing of the seeds difficult

personnel

The consequences of the seed rupture (involving patient exposures, other

iodine-125 uptakes, and facility contamination) can be mitigated by performing

(1) adequate radiation surveys of the work area, using a radiation detection

instrument capable of detecting the low-energy photons (average of 28 keV),

(2) the proper handling of tools used to remove the seeds from the catheters, and (3) leak tests of the seeds. Also, contamination of the facilities probably

can be prevented if the seed removal operation is performed in a fume hood.

Personnel uptakes of the radioactive materials and facility contamination also

might be mitigated by using radiation safety procedures designed to detect seed

leakage promptly.

No specific action or written response is required by this notice. If you have

any questions regarding this information notice, please contact the Regional

Administrator of the appropriate NRC regional office or this office.

James G. Part ow, Director

Division of Inspection Programs

Office of Inspection and Enforcement

Technical Contacts: J. Metzger, IE

(301) 492-4947 H. Karagiannis, IE

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j, Attachment 1 IN 86-84 September 30, 1986 LIST OF RECENTLY ISSUED

IE INFORMATION NOTICES

Information . Date of

Notice No. Subject Issue Issued to

86-83 Underground Pathways Into 9/19/86 All power reactor

Protected Areas, Vital Areas, facilities holding

Material Access Areas, And an OL or CP; fuel

Controlled Access Areas fabrication and

processing facilities

86-82 Failures Of Scram Discharge 9/16/86 All power reactor

Volume Vent And Drain Valves facilities holding

an OL or CP

_ 86-81 Broken Inner-External Closure 9/15/86 All power reactor

Springs On Atwood & Morrill facilities holding

Main Steam Isolation Valves an OL or CP

86-80 Unit Startup With Degraded 9/12/86 All power reactor

High Pressure Safety Injection facilities holding

System an OL or CP

\, -86-79 Degradation Or Loss Of 9/2/86 All power reactor

Charging Systems At PWR facilities holding

Nuclear Power Plants Using an OL or CP

Swing-Pump Designs

86-78 Scram Solenoid Pilot Valve 9/2/86 All BWR facilities

(SSPV) Rebuild Kit Problems holding an OL or CP

86-77 Computer Program Error Report 8/28/86 All power reactor

Handling facilities holding

an OL or CP and

nuclear fuel man- ufacturing facilities

86-76 Problems Noted In Control 8/28/86 All power reactor

Room Emergency Ventilation facilities holding

Systems an OL or CP

86-75 Incorrect Maintenance 8/21/86 All power reactor

Procedure On Traversing facilities holding

Incore Probe Lines an OL or CP

I- , _ . , I

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