Event Notification Report for April 06, 2026

AGREEMENT STATE REPORT - MEDICAL EVENT

The following information was provided by the Connecticut Department of Energy and Environmental Protection via phone and email:

"On March 25, 2026, at 1511 EDT, a patient was planned for coronary brachytherapy for treatment to the proximal left circumflex coronary artery for an injury 30 millimeter (mm) in length and a target vessel mean luminal diameter of 3 mm. A proximal margin into the left main coronary artery and a distal margin further into the left circumflex vessel were also included. The planned treatment was to deliver 18.4 Gy at 2 mm depth using the 60 mm BetaCath source train. During catheter placement and wire test, the radiation oncologist (authorized user) noticed some friction in the catheter. Since the wire could still move through the catheter, the decision was made to attempt source deployment. Under fluoroscopy, it was observed that the 60 mm source did not fully deploy into the left circumflex but was stuck within the distal aspect in the left main coronary artery. This was likely due to an obstruction in the treatment catheter at the ostium of the left circumflex coronary artery where the left main coronary artery bifurcates at an acute angle in this patient. The radiation oncologist attempted to finish source deployment, which was unsuccessful.

"The source return to the transfer device was also unsuccessful. Emergency bailout was declared after approximately 16 seconds after sources arrived at the stuck location. After the device and treatment catheter were secured in the bailout box, the authorized medical physicist surveyed the patient, room, and bailout box and confirmed sources were located within the catheter in the bailout box. The decision was made to treat the patient with the 40 mm source, which was determined to provide adequate margin of the lesion, and a new treatment catheter was placed in the patient. After approval of the new treatment plan, and catheter wire test, the radiation oncologist attempted to deploy the 40 mm source, however this source also became stuck in the same location at the left circumflex ostium. The cardiologist pulled the treatment catheter back slightly to allow source return to the transfer device, which was successful. Dwell time at stuck position estimated at 16 seconds based on stopwatch time.

"The estimated dose was as follows:
40 mm: 0.058 Gy/sec x 16 sec = 0.928 Gy at 2 mm depth
60 mm: 0.059 Gy/sec x 16 sec = 0.944 Gy at 2 mm depth
Total dose (assuming full overlap of source trains): 1.872 Gy at 2 mm depth.

"The target lesion did not receive the intended treatment dose (18.4 Gy at 2 mm depth)."

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 REPORT - MEDICAL EVENT

The following is a summary of information provided by the New Jersey Radiation Protection and Reliability Prevention (NJDEP) Program via email:

Summit Health Cancer Center reported that a patient scheduled to receive a 200 mCi Lu-177 Pluvicto treatment only received 150 mCi. The underdose was due to either faulty or improperly connected tubing. The licensee is investigating and will forward a full report.

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 REPORT - STUCK SHUTTER

The following is a summary of information provided by the Georgia Radioactive Material Program via email:

The licensee reported that a normally open Berthold model P2623-100 fixed gauge (S/N 2571-8-90) with a 250 mCi Cs-137 source was found stuck in the open position during an annual maintenance shutdown. After the shutdown the licensee plans to move the source to their radiation storage trailer. The source will ultimately be sent for proper disposal.

Georgia incident number: 118

AGREEMENT STATE REPORT - LOST I-125 SEED

The following information was provided by the Arizona Department of Health Services (the Department) via email:

"The Department received notification from the licensee of a lost I-125 seed used for localization. A patient was implanted with a 0.133 millicurie I-125 seed on March 18, 2026, with the placement of the seed verified by x-ray. The patient returned on March 27, 2026, to have the tissue and seed removed. The tissue with seed was verified by x-ray and then sent to pathology, where no seed was [found]. The operating room was surveyed, but the seed was not located. The Department has requested additional information and continues to investigate the event."

THIS MATERIAL EVENT CONTAINS A 'Less than Cat 3' LEVEL OF RADIOACTIVE MATERIAL

Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. For additional information go to http://www-pub.iaea.org/MTCD/publications/PDF/Pub1227_web.pdf

UNPLANNED CONTAMINATION

The following is a summary of information provided by the Defense Health Agency via phone:

On March 30, 2026, at 0730 MDT, a nuclear technician dropped a vial containing 200 millicuries of technetium-99m in the hot lab. The technician's shoes, lab floor, and surrounding areas were contaminated. The technician's shoes and the lab floor were decontaminated. Areas that still had detectable levels of contamination were covered with a lead apron. The spread of contamination was limited to the hot lab. Access to the hot lab has been restricted.

* * * RETRACTION ON 03/31/2026 AT 0913 EDT FROM RICARDO REYES TO ROBERT THOMPSON * * *

The following information was provided by the licensee via phone and email:

"Based on reporting requirements in 10CFR30.50(b), the spill does not meet the criteria for reporting an unplanned contamination event. Please retract event notification EN 58223."

Notified R4DO (Deese), R1DO (Bickett), NMSS Events Notification (email).