Information Notice No. 80-35, Supplement No. 1: Leaking and Dislodged Iodine-125 Implant Seeds

                                                       SSINS No.: 6835  
                                                       IN 80-35, Supp. 1 

                               UNITED STATES 
                       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 
                                                       IODINE-125 IMPLANT 
                                                       SEEDS 

Addressees: 

Medical licensees holding specific licenses for human use of byproduct 
material in sealed sources. 

Purpose: 

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. 

Discussion: 

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. 

8208190233 
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                                                  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  
                                     and Safeguards 
                                   Office of Inspection and Enforcement 

Attachments: 
1.   Information Notice No. 80-35 
2.   List of Recently Issued Information Notices 

CONTACT:  H. Karagiannis
          301-492-9655