D
Patient 1
IT WAS INITIALLY REPORTED THAT AN IODINE SEED RUPTURED DURING A BRACHYTHERAPY SEED IMPLANT PROCEDURE. FOLLOW-UP WITH THE NUCLEAR MEDICINE TECHNICIAN REVEALED THAT THE APPLICATOR JAMMED DURING THE IMPLANT AND THE RADIATION ONCOLOGIST FORCEFULLY REMOVED THE CARTRIDGE FROM THE APPLICATOR. AFTER REMOVING THE CARTRIDGE, A SEED WAS FOUND STILL IN THE APPLICATOR AND THE DOCTOR FORCIBLY REMOVED IT. THE REMOVAL PROCESS COMPROMISED THE SEED AND RESULTED IN THE APPLICATOR BECOMING CONTAMINATED. FOLLOWING THE IMPLANT, REMOVABLE CONTAMINATION WAS FOUND ON THE APPLICATOR AND THE GENERAL WORK AREA. ALSO, FOLLOWING A CYSTOSCOPY, THE PATIENT'S BLADDER WAS FLUSHED AND METALLIC PIECES WERE FOUND IN THE FLUSHED URINE. THE URINE WAS SURVEYED AND FOUND TO BE RADIOACTIVE. SEVERAL DAYS LATER, A BIOASSAY WAS PERFORMED ON THE PATIENT AND THERE WAS A SMALL UPTAKE IN THE PATIENT'S THYROID LESS THAN 1 CGY (REM). THIS DOSE FALLS SHORT OF A MEDICAL EVENT AS OUTLINED IN 10CFR PART 35.3045 (A) (1). THE PATIENT WAS PRESCRIBED POTASSIUM IODINE AS A THYROID BLOCKER AND WILL REMAIN ON THIS FOR TEN DAYS. THE DOCTOR COULD FIND NO IODINE -125 REMAINING IN PATIENT'S URINE INDICATING CONTAMINATION CAME FROM THE RECOVERED COMPROMISED SEED AND NOT FROM AN IMPLANTED SEED.