Text

Informs That IE Info Notice 80-35, Leaking & Dislodged I-125 Implant Seeds, Sent to Listed Licensees on 801010
	ML20037C613
Person / Time
Issue date:	10/14/1980
From:	Pappas H; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III)
To:	Wright G; ILLINOIS, STATE OF
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ML19345F354	List: ML19345F353; ML20037C613;
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	NUDOCS 8102170334
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' GLEN ELLYN, ILUNOIS 60137 Oct14 Illeo State of Illinois Department of Public Health ATTN:

Mr. Gary N. Wright, Chief

. Division of' Nuclear Safety-i 535 West Jefferson Street Springfield, IL 62761 Gentlemen:

l The attached IE Information Notice No. 80-35, titled " Leaking and Dislodged Iodine-125 Implant Seeds," was sent to all medical licensees f

l on the attached address listing on October 10, 1980.

Sincerely,

- ee ap s, th'le l

Administrative Branch Attachments:

1.

IE Information Notice l

No. 80-35 9

Address Listing cc w/ encl:

Mr. D. W. Kane, Sargent & Lundy Central Files Reproduction Unit NRC 20b AEOD Resident Inspectors, RIII Local PDR NSIC TIC 810'217033It

SSINS No.:

6870 Accession No.

8006190046 IEIN 80-35

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UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C.

20555 October 10, 1980 IE Information Notice No. 80-35:

LEAKING AND DISLODGED 10 DINE-125 IMPLANT SEEDS 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, manufactured by Mick Radio-Nuclear Instruments, 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.

Notice to Licensee:

Your staff responsible for preparation and implantation of sealed sources of byproduct material should 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 w eveys are performed for detecting leaking or dislodged sources.

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.

IN 80-35 October 10, 1980 g

RECENTLY ISSUED IE INFORMATION NOTICES Informatinn Date of Notice No.

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 Timer Accuracy (G3) licensees 80-32 Clarification of certain 8/12/80 All NRC and agreement requirements for Exclu-state licensees sive-use shipments of radioactive materials 80-31 Maloperation of Gould-8/27/80 All light water reactor Brown Boveri Type 480 facilities nolding OLs volt type K-6005 and or cps K-DON 6005 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 facilities 80-29 Broken studs on Terry 8/7/80 All light water reactor turbine steam inlet facilities holding flange power reactor OLs or cps

Supplement to Notification 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 NRC reactor cps 80-27 Degradation of reactor 6/11/80 All pressurized water coolant pump studs reactor facilities holding power reactor OLs or cps

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