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Event Notification Report for July 15, 2020

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
7/14/2020 - 7/15/2020

** EVENT NUMBERS **

Agreement State	Event Number: 54763
Rep Org: FLORIDA BUREAU OF RADIATION CONTROL Licensee: Cleveland Clinic Florida - Weston Region: 1 City: Weston State: FL County: License #: 3871-1 Agreement: Y Docket: NRC Notified By: David Pieski HQ OPS Officer: Brian P. Smith	Notification Date: 07/06/2020 Notification Time: 11:40 [ET] Event Date: 07/01/2020 Event Time: 00:00 [EDT] Last Update Date: 07/06/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): ANTHONY DIMITRIADIS (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via email:

"A 98 microCurie I-125 breast cancer localization seed (titanium encapsulated) was inadvertently cut in half during its extraction from a patient. All portions of seed presumably removed and lavage performed. A pancake probe was used at tissue surface prior to tissue closure and measured 200 microR/hr. Tissue entry point was closed and re-surveyed at some later time with a measurement of 10 microR/hr. Post recovery, patient was apprised of the event and initiated a 10-day KI treatment plan. [The Radiation Safety Regional Health Director] is in consultation with the dose calibrator manufacturer and seed manufacturer (Team Best) in order to better calculate activity of recovered seed portions and subsequently compare to initial, inserted activity. The difference will yield activity remaining in the patient."

Florida Incident Number: FL20-073

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.

Agreement State	Event Number: 54764
Rep Org: IOWA DEPARTMENT OF PUBLIC HEALTH Licensee: University of Iowa Region: 3 City: Iowa City State: IA County: License #: 0037-1-52-AAB Agreement: Y Docket: NRC Notified By: Randal Dahlin HQ OPS Officer: Jeffrey Whited	Notification Date: 07/06/2020 Notification Time: 13:26 [ET] Event Date: 07/02/2020 Event Time: 00:00 [CDT] Last Update Date: 07/06/2020
Emergency Class: Non Emergency 10 CFR Section: Agreement State	Person (Organization): KARLA STOEDTER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MEDICAL EVENT

The following was received via email:

"On 6/30/20 microspheres were injected in the patient [intended target of Hepatic Segments 4 through 8] at the vessel branch point with the intention of targeting both the right hepatic artery (RHA) and the middle hepatic artery (MHA). However, post-therapy imaging demonstrates that radiotracer was preferentially deposited along the MHA distribution. This is attributed to unforeseeable clumping of microspheres at the origin of the RHA, such that a majority of the microspheres were preferentially injected into MHA. As such, microspheres were predominantly deposited in the extrahepatic lymph node as well as an unexpected pancreaticoduodenal lymph node. Deposition in this second node can be attributed to additional unintended reflux into a third branching vessel upstream from the RHA and MHA, and further supports the assertion flow into the RHA was hindered by the clumping of microsphere particles. Ultimately, SPECT-CT image analysis suggests no more than approximately 40 percent of the therapy dose was deposited within the liver (as detailed below).

"It is estimated the following activity distribution from post-treatment imaging: At most, approximately 40 percent of the administered activity appears to be within the liver, with the other 60 percent being in extrahepatic tissue (e.g. lymph nodes). This breakdown should be considered approximate, as these images are not scatter corrected.

"From pre-treatment macro aggregated albumin (MAA) imaging, it appears that 84 percent of the administered activity was expected to be delivered to the liver, and 16 percent was expected to shunted to the nodes. Overall, this indicates that approximately 53 percent less activity than what was intended reached the liver. There is uncertainty in this estimate.

"The dose to extrahepatic tissue (lymph nodes) differs from what was intended/expected by more than 50 Rem (0.5 Gy)."

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.

Non-Agreement State	Event Number: 54765
Rep Org: TTL ASSOCIATES, INC Licensee: TTL Associates, INC Region: 3 City: Romulus State: MI County: License #: 21-2666601 Agreement: N Docket: NRC Notified By: Jeffrey Elliott HQ OPS Officer: Ossy Font	Notification Date: 07/07/2020 Notification Time: 14:38 [ET] Event Date: 07/07/2020 Event Time: 14:00 [EDT] Last Update Date: 07/07/2020
Emergency Class: Non Emergency 10 CFR Section: 30.50(b)(2) - Safety Equipment Failure	Person (Organization): KARLA STOEDTER (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

SOURCE DISLODGED FROM DAMAGED GAUGE

The following is a summary of a phone call received from the licensee:

A technician was at a job site taking measurements with a Troxler 3430 density gauge (S/N: 23216). The gauge contains an 8 mCi Cs-137 source and a 40 mCi Am-Be source. While the source rod was extended into the ground, the technician, along with others, attempted to get the attention of the driver of a pickup truck backing up into the work area. They were unsuccessful, and the truck backed into the gauge, bending the rod, preventing it from being retracted. The technician attempted to straighten the rod, but was unsuccessful. Then the rod was bent in the other direction and the Cs-137 source became dislodged. It was placed in a plastic container and the area was cordoned off.

The Radiation Safety Officer (RSO) was en route, and with guidance from the service company, will place the source in a bucket and fill it with sand, survey the area for any contamination, return the source to the facility for a leak test, and store the gauge. The RSO will determine how to dispose of the source and gauge once the leak test results are received.

The technician was wearing dosimetry and it will be sent in for analysis. It is not expected that there was much additional exposure received.

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