ML19340D040
| ML19340D040 | |
| Person / Time | |
|---|---|
| Issue date: | 10/10/1980 |
| From: | Engelken R NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V) |
| To: | VETERANS ADMIN. JERRY L. PETTIS MEMORIAL HOSP., LOMA |
| References | |
| NUDOCS 8012180580 | |
| Download: ML19340D040 (1) | |
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'o UNITED STATES i f g ~,,g NUCLEAR REGULATORY COMMISSION g;
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October 10, 1980 r
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. Gentlemen:
The enclosed IE Information flotice flo. 80-35 is forwarded to you for information.
If there are any ouestions related to your understanding of this notice, please contact this office.
Sincerely,
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Enclosures:
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IE Information ilotice ilo. 80-33 91 2.
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8006190046 IEIll 80-35 UflITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTI0ft AND ENFORCEMENT WASHINC..., D.C.
20555 October 10, 1980 IE Information Notice No. 80-35:
LEAKING AND DISLODGED,10 DINE-125 IMPLANT SEEDS 1
Description of Circumstances:
During surveys performed following the implant of iodine-125 seeds for inter-stitial treatment of cancer of the prostate, iodine-125 was detected in the patient's urine and thyroid. As a result of the iodine leakage, the patient's thyroid received an estimated eighty (80) rem dose.
The cause of the leakage of iodine-125 was determined to be physical damage to one of the seeds prior to implantation. The hospital staff had inserted the seeds into nylon tubing prior to steam sterilization in an autoclave. The nylon tubings were supplied with a permanent interstitial implant instrument, Model#6501,manufacturedbyMickRadio-NucigarInsgruments, Incorporated.
After autoclaving for six (6) minutes at 275 F (135 C) and 30 psi, the iodine-125 seeds could not be pushed out of the nylon tubing. Forceps and scissors had to be used to free the seeds and place them into the implant instrument.
It was determined that, during this process, one of the iodine-seeds had been superficially cut.
The surveys performed after the surgery indicated that some iodine-125 seeds had been dislodged.
Some seeds were found on the floor, the operating table, and in suction liquids collected during surgery.
In addition, an iodine-125 seed was found in the patient's urine specimen collected on the sixth day following implant surgery.
1 Notice to Licensee:
Your staff responsibla far preparation and implantation of sealed sources of byproduct material shu. I be made aware of the contents of this Information Notice.
They should review handling procedures for the sealed sources, including methods of sterilization, to eliminate those procedures which could physically damage the sealed sources.
Necessary procedures should be established to assure that, following implantation, proper surveys are performed for detecting leaking or dislodged sources.
4 No written response to this Information Notice is required.
If you need addition-al information regarding this subject, contact the Director of the appropriate NRC Regional Office.
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" 80-35 iOctober 10, 1980 RECEllTLY ISSUED IE IflFORfiATIO!1 f!0TICES Information Date of flotice flo.
Subject Issue Issued to 80-34 Boron Dilution of Reactor 9/26/80 All Pressurized Coolant During Steam Water Reactor Generator Decontamination Facilities holding power reactor OLs 80-33 Determination of Teletherapy 9/15/80 All teletherapy Tiner Accuracy (G3) licensees 80-32 Clarification of certain 8/12/80 All flRC and agreement requirements for Exclu-state licensees sive-use shipments of radioactive materials 80-31 f4aloperation of Gould-8/27/80 All light water reactor Brown Boveri Type 480 facilities holding OLs volt type K-600S and or cps K-D0tt 600S circuit breakers 80-30 Potential for unaccept-8/19/80 All boiling water reactor able interaction between facilities holding power the control rod drive scram reactor OLs or cps.
function and non-essential control air at certain GE BWR facilities 80-23 Broken studs on Terry 8/7/80 All light water reactor turbine steam inlet facilities holding flange power reactor OLs or cps
- Supplement to flotification of 7/29/80 All holders of reactor 80-06 significant events at and near-term OL operating power reactor applicants facilities 80-28 Prompt reporting of 6/13/80 All applicants for and required information holders of nuclear power to flRC reactor cps I
80-27 Degradation of reactor 6/11/80.
All pressurized water coolant pump studs reactor facilities holding power reactor OLs or cps l
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- Operating Licenses or Construction Permits i