During an on-site NRC Inspection on 10/26/10, two (2) medical events were identified both involving a delivered dose less than the prescribed dose following implant of Palladium-103 seed for prostate therapy. Specific details as follows:
First Medical Event
Preplanning date: 08/26/09
Post planning date: 09/03/09
D-90 (dose received by 90% of the prostate volume): 72%
Underdose: 28%
Prescribed: Palladium-103, 156U consisting of 65 seeds, 2.4U/seed
Second Medical Event
Preplanning date: 12/08/09
Post planning date: 12/29/09
D-90 (dose received by 90% of the prostate volume): 64%
Underdose: 36%
Prescribed: Palladium-103, 173U consisting of 74 seeds, 2.4U/seed
Both underdoses are attributed to prostate swelling. The physician reviewing the results concluded that there was no adverse impact on either patient. The licensee will continue reviewing medical records to identify any additional occurrences of this nature.
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.
- * * RETRACTION FROM MIREL PALAMARU TO VINCE KLCO ON 1/25/11 AT 1829 EST * * *
Based on a post evaluation by the licensee's Radiation Safety Officer and physicians, all delivered dose came within 20% of overall prescribed dose. Thus, this is not considered a medical event.
Notified the R3DO (Stone), and
FSME (McIntosh).