Event Notification Report for October 22, 2026

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the Oregon Health Authority's Radiation Protection Services (RPS) via phone and email:

On October 13, 2026, RPS was notified by the licensee of activity delivered outside the intended target during a Y-90 microsphere treatment for liver cancer.

The written directive prescribed administration of 5.67 GBq to the right lobe of the liver for a target dose of 120 Gy. The licensee estimated the delivered dose to be approximately 123 Gy.

A post-treatment Bremsstrahlung scan indicated that delivery was segmental to the caudate lobe of the liver and surrounding tissue. Two SPEC-CT scans were performed and revealed delivery near the gallbladder fossa (patient does not have a gallbladder). The authorized user determined that activity was delivered outside the intended area, with some in the liver and some in the tissue or ductal interworking around the liver.

The patient was informed of the findings. A written report, containing all information required under 10 CFR 35.3045(d), will be submitted within 15 days of discovery.

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 information was provided by the Tennessee Division of Radiation Health via email:

"During a scheduled six-month shutter check, it was discovered that a gauge shutter was stuck in the open position. No abnormal levels of radiation were detected. Open is the normal operating position since the unit is in operation 24 hours a day. A vendor field technician has been contacted to repair the gauge on October 20, 2026.

"Corrective actions or reports, as well as additional information, will be updated with a NMED report within 30 days."

Gauge: Ohmart/VEGA source holder model SH-F1
Source: 50 mCi Cs-137 (S/N 01908)

Tennessee incident number: TN-26-081

AGREEMENT STATE REPORT - MEDICAL EVENT

The following is a summary of information provided by the Maryland Department of the Environment, Radiological Health Program (MDE/RHP) via email:

On October 13, 2026, at 1659 EDT, staff from MDE/RHP received a call from the licensee regarding a Y-90 microsphere medical event that occurred on October 12, 2026, at 0915 EDT.

The patient was prescribed approximately 60.1 mCi for treatment of liver cancer in segments 2 and 3, with an intended dose to the liver of 370 Gy.

The licensee reported performing pre-treatment scans that showed no significant concern for shunting. Post-treatment imaging identified unintended activity in the left gastric artery and gastric fundus/cardia, indicating that an estimated 2 to 2.5 percent of the administered activity refluxed into the area of the left gastric artery.

Preliminary dose estimates indicate the unintended exposure may have delivered approximately 56 to 93 Gy to the stomach (fundus/cardia region), about 19 Gy to the stomach wall, and 1,390 to 2,800 Gy to the left gastric artery wall.

The patient and referring physician were notified. The patient was started on a prophylactic proton pump inhibitor (PPI) therapy.

MDE/RHP is evaluating the event and will provide additional information as it becomes available.

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.