Extravasation Physics Assessment

Facility

Example Medical Center (fictional)

Case reference

INC-SAMPLE-0001 (no patient identifiers are used)

Radiopharmaceutical

Pluvicto (Lu-177 vipivotide tetraxetan)

Prescribed / administered activity

7,400 MBq / 7,400 MBq (fictional)

Incident

Suspected extravasation at the injection site

Requested by

Nuclear medicine technologist, on behalf of the Authorized User

Administration timeline

Start and end times, and when the extravasation was suspected

Injection site

Location, vascular access, dimensions and how they were measured

Clinical observations

As reported by the facility

Measurements

Imaging, survey and probe readings, each with its time and instrument

Status

Awaiting measurements

Absorbed dose to the tissue at the site is estimated with the MIRD formalism: the time-integrated activity in the source region multiplied by the S-value for the target and source geometry. Each S-value is cited with its units, reference geometry and source. No mass scaling is applied to a value outside the geometry it was derived for.

The activity-versus-time curve is built from the measurements received. Where clearance was not measured, the report names the scenario used and treats it as an assumption, not a measurement.

• Each assumption is listed with the result it affects.
• Activity before the first measurement, and the geometry of the deposited activity, are stated as assumptions unless they were measured.
• Skin dose is reported at a stated depth, only with validated depth-dose data.

Extravasated activity

Pending assessment

Time-integrated activity

Quantitative estimate unavailable — validated source data required.

Local tissue absorbed dose

Quantitative estimate unavailable — validated source data required.

Skin dose at stated depth

Quantitative estimate unavailable — validated source data required.

The spread of the estimate across clearance scenarios and input ranges is reported here, with the main contributors named.

Reportability requires assessment of the applicable regulatory criteria, clinical circumstances, license conditions, and jurisdiction. Absorbed dose alone does not automatically determine Medical Event status.

This report supports the facility’s review. It does not classify the event, and the decision on reporting rests with the licensee.

Prepared by

Medical physicist (name and credentials on a signed report)

Reviewed by

Qualified medical physicist

Signature

Unsigned sample