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SSINS No.: 6870 Accession No. 8006190046 IEIN 80-35 UNITED STATES NUCLEAR REGULATORY COMMISSION OFFICE OF INSPECTION AND ENFORCEMENT WASHINGTON, D.C. 20555 October 10, 1980 Information Notice No. 80-35: LEAKING AND DISLODGED IODINE-125 IMPLANT SEEDS Description of Circumstances: During surveys performed following the implant of iodine-125 seeds for interstitial 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 surveys are performed for detecting leaking or dislodged sources. No written response to this Information Notice is required. If you need additional information regarding this subject, contact the Director of the appropriate NRC Regional Office.
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