Information Notice No. 80-35, Supplement No. 1: Leaking and Dislodged Iodine-125 Implant Seeds
SSINS No.: 6835
IN 80-35, Supp. 1
NUCLEAR REGULATORY COMMISSION
OFFICE OF INSPECTION AND ENFORCEMENT
WASHINGTON, D.C. 20555
October 6, 1982
Information Notice No. 80-35, SUPPLEMENT NO. 1: LEAKING AND DISLODGED
Medical licensees holding specific licenses for human use of byproduct
material in sealed sources.
This information notice is a supplement to Information Notice No. 80-35,
"Leaking and Dislodged Iodine-125 Implant Seeds" (Attachment 1). This
information should serve as a reminder for licensees to review the
suppliers' guidance accompanying the radioactive sources and the applicators
used to implant the sources. No response to this notice is required.
Since issuance of Information Notice 80-35 on October 10, 1980, the NRC has
reviewed reports of five additional incidents involving uptakes of
iodine-125 resulting from leaking and dislodged implant seeds. These
incidents are described below.
1. Forty iodine-125 seeds were implanted in a patient. The seeds were
inserted with difficulty into the plastic tubes used in the implant
instrument. There was no apparent difficulty in feeding the sterilized
seeds from the plastic tubes into the implant instrument; however,
during the process a few seeds were slightly crimped by the forceps
causing damage to the seeds. Subsequent surveys detected iodine-125 in
the urine and thyroid of the patient. The dose to the thyroid was
estimated to be 9 rads.
2. An applicator being used during a prostate implant jammed during the
procedure. The physician tried to free the applicator and subsequently
ruptured one of the seeds. Subsequent surveys detected iodine-125 only
in the physician's thyroid who performed the implant. The dose to the
thyroid was estimated to be 120 millirads.
3. The radiation therapy physician felt some resistance while inserting
one of the iodine-125 seeds. Rather than force the applicator being
used to perform the prostate implant, the physician pulled back on the
inserting rod of the applicator a second time and then continued to
insert the seed without further difficulty. Subsequent surveys detected
iodine-125 in the urine and thyroid of the patient. The dose to the
thyroid was estimated to be 22 rads.
IN 80-35, Supp. 1
October 6, 1982
Page 2 of 2
4. Iodine-125 was detected in the urine and thyroid of a patient during
surveys performed following implantation of iodine-125 seeds for inter-
stitial treatment of cancer of the prostate. Faulty (leaking) seeds
were determined to be the cause of the iodine-125 uptake. The dose to
the thyroid was estimated to be 10 rads.
5. Iodine-125 was detected in the urine and thyroid of two patients during
surveys following transurethral resection procedures. In both cases,
the use of electronic cauterization was determined to be the cause for
the loss of integrity of the seeds. The dose to the thyroid in this
incident was estimated to be 6.5 and 0.44 rads respectively.
No written response to this information notice is required. If you need
additional information regarding this subject, contact the Administrator of
the appropriate NRC Regional Office.
L. I. Cobb, Director,
Division of Fuel Facilities, Materials
Office of Inspection and Enforcement
1. Information Notice No. 80-35
2. List of Recently Issued Information Notices
CONTACT: H. Karagiannis
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