Information Notice No. 80-35: Leaking and Dislodged Iodine-125 Implant Seeds
SSINS No.: 6870
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
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 275F (135C)
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.
Page Last Reviewed/Updated Thursday, March 25, 2021