Pacemaker malfunction associated with proton beam therapy: a report of two cases and review of literature—does field-to-generator distance matter?

Ueyama, T.; Arimura, Takeshi; Ogino, Takashi; Kondo, Naoaki; Higashi, Ryutaro; Nakamura, Fumihiko; Ito, Shigeaki; Yamada, Takashi; Hishikawa, Yoshio

doi:10.1093/omcr/omw049

Cited by 11 publications

(24 citation statements)

References 6 publications

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“…To our knowledge this is the first cohort reporting management of CIED patients undergoing carbon ion radiotherapy and one of the largest cohorts reported on patients with CIED undergoing proton radiotherapy. According to our experience the active scanning beam application mode can be applied with a high grade of safety compared to passive scattering where device malfunction rates of ~20 to 28.6% have been reported previously by others under similar treatment set-up conditions [with pulse generators outside the treatment fields in all cases and restriction to 2 Gy(RBE) and below by Gomez et al (10)] (10–12).…”

Section: Discussionsupporting

confidence: 58%

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Active-Scanned Protons and Carbon Ions in Cancer Treatment of Patients With Cardiac Implantable Electronic Devices: Experience of a Single Institution

et al. 2019

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Background: Ionizing radiation was shown to be able to influence the function of cardiac implantable electronic devices (CIED's) leading to malfunctions with potentially severe consequences. Those effects presumably correlate with beam energy and neutron production. Thus, particle facilities are commonly cautious to treat patients with CIED's with particles, but substantial evidence is lacking. Methods and Materials: In total 31 patients were investigated, who have been treated at the Heidelberg Ion-Beam Therapy Center (HIT) from September 2012 to February 2019 with protons and carbon ions in active-scanning technique. All CIED's were checked after every single irradiation by the department of cardiology. The minimum distance between the CIED and the planning target volume (PTV), the 10% isodose and the single beam in Beam's Eye View (BEV) was analyzed for 12 patients. Results: In total, 31 patients received 32 courses of radiotherapy (RT). Twenty-two received treatment with carbon ion beam and ten with proton beam. The cumulative number of fractions was 582, the cumulative number of documented controls after RT was 504 (87%). Three patients had an implantable cardioverter-defibrillator (ICD) and 28 patients had a pacemaker at the time of treatment. Seven patients had a heart rate of ≤30/min. The majority of patients (69%) were treated for tumors of the head and neck. The median minimum distance between CIED and PTV, 10% isodose and the single beam on BEV was 13.4, 11.6, and 8.3 cm, respectively. There were no registered events associated with the treatment in this evaluation. Conclusion: Treatment of CIED-patients with protons and carbon ions applied with active raster scanning technique was safe without any incidents in our single center experience. Monitoring after almost every fraction provided systematic and extensive data. Further investigations are necessary in order to form reliable guidelines, which should consider different modes of beam application, as active scanning supposedly provides a greater level of safety from malfunctions for patients with CIED undergoing particle irradiation.

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Section: Discussionsupporting

confidence: 58%

“…Ueyama et al (12) reported two cases of resets to VVI backup mode in a series of seven patients treated by passive scattered protons. One patient received thoracic radiotherapy for bronchial cancer and one abdominal for pancreatic cancer and in both cases resets were not detected by ECG and were not clinically apparent otherwise (12).…”

Section: Discussionmentioning

confidence: 99%

Active-Scanned Protons and Carbon Ions in Cancer Treatment of Patients With Cardiac Implantable Electronic Devices: Experience of a Single Institution

et al. 2019

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“…Hazards linked to the effects of secondary neutrons on CIEDs may cause clinical problems in CIED-wearing patients. Current data about particle therapy with CIEDs carriers originate from in vitro experiments and clinical studies that are from single institutions and usually include a limited number of patients [9][10][11][12]. Recently, recommendations from AAPM have stated that particle beam therapy should be avoided for patients with CIED since it produces secondary neutrons [13].…”

Section: Introductionmentioning

confidence: 99%

Particle therapy using protons or carbon ions for cancer patients with cardiac implantable electronic devices (CIED): a retrospective multi-institutional study

et al. 2021

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Purpose To evaluate the outcomes of particle therapy in cancer patients with cardiac implantable electronic devices (CIEDs). Materials and methods From April 2001 to March 2013, 19,585 patients were treated with proton beam therapy (PBT) or carbon ion therapy (CIT) at 8 institutions. Of these, 69 patients (0.4%, PBT 46, CIT 22, and PBT + CIT 1) with CIEDs (64 pacemakers, 4 implantable cardioverter defibrillators, and 1 with a cardiac resynchronization therapy defibrillator) were retrospectively reviewed. All the patients with CIEDs in this study were treated with the passive scattering type of particle beam therapy. Results Six (13%) of the 47 PBT patients, and none of the 23 CIT patients experienced CIED malfunctions (p = 0.105). Electrical resets (7) and over-sensing (3) occurred transiently in 6 patients. The distance between the edge of the irradiation field and the CIED was not associated with the incidence of malfunctions in 20 patients with lung cancer. A larger field size had a higher event rate but the test to evaluate trends as not statistically significant (p = 0.196). Conclusion Differences in the frequency of occurrence of device malfunctions for patients treated with PBT and patients treated with CIT did not reach statistical significance. The present study can be regarded as a benchmark study about the incidence of malfunctioning of CIED in passive scattering particle beam therapy and can be used as a reference for active scanning particle beam therapy.

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“… 45 There was also a report that CIED reset can occur despite not being detected by electrocardiogram monitoring; instead, it was uncovered by posttreatment programmer analysis. 46 Modern CIEDs have CMOS which can tolerate doses of more than 2 Gy 47 , 48 ; however, the proton machine design has an effect on the CIED due to the overall physical environment around the patient. The pencil beam scanning system snout creates a relatively strong magnetic field around the patient, which may induce CIED malfunction.…”

Section: Management Of Commonly Seen Implanted Devices In Rt Patientsmentioning

confidence: 99%

“…17 Therefore, each patient needs to be considered individually and recognition of the patient's dependence on the CIED identified. If the patient is pacing-dependent, it is usually not recommended to treat them with proton therapy, 45 , 46 , 49 especially in standalone centers with limited resources. Likewise, for the pacing independent patient, risks should be evaluated before delivering proton therapy.…”

Section: Management Of Commonly Seen Implanted Devices In Rt Patientsmentioning

confidence: 99%

A Review and Analysis of Managing Commonly Seen Implanted Devices for Patients Undergoing Radiation Therapy

Chan

Young

Gelblum

et al. 2021

Advances in Radiation Oncology

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Purpose This review article aims to consolidate information regarding existing and emerging implanted devices used in patients undergoing radiation therapy and to categorize levels of attention needed for each device, including which devices require monitoring throughout treatment. Methods and Materials Based on the collective information from scholar searches, manufacturers’ technical reports, and institutional experiences in the past years, commonly present devices in patients with cancer are compiled. This work summarizes cardiac pacemaker, implanted cardiac defibrillator, hepatic pump, intrathecal pain pump, neurostimulator, shunt, loop recorder, and mediport. Three different classifications of implanted devices can be made based on the potential effect of radiation: life-dependent, nonlife-dependent but with adverse effects if overdosed, and devices without electronic circuits. Implanted devices that contain electronic circuits that would be life-dependent or have adverse effects if overdosed, include cardiac pacemakers, implanted cardiac defibrillators, programmable hepatic pumps, pain pumps, neurostimulators, and loop recorders. Results Dose exposure to these devices need to be calculated or measured in vivo , especially for cardiac implanted devices, and they should be minimized to assure continued healthy functioning. Treatment planning techniques should be chosen to reduce entry, exit and internal scatter dose. Lower energy photon beams should be used to decrease potential neutron contamination. Implanted devices without electronic circuits are less of a concern. If a patient is life-dependent on the implanted device, it is not recommended to treat the patient with proton therapy. Conclusions This study reviewed the management of patients with commonly seen implanted devices and summarized a workflow for identifying and planning when a patient has implanted devices. Classifications of implanted devices could help clinicians make proper decisions in regard to patients with specific implanted devices. Lastly, the management of such devices in the era of the pandemic is also discussed in this review article.

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Pacemaker malfunction associated with proton beam therapy: a report of two cases and review of literature—does field-to-generator distance matter?

Cited by 11 publications

References 6 publications

Active-Scanned Protons and Carbon Ions in Cancer Treatment of Patients With Cardiac Implantable Electronic Devices: Experience of a Single Institution

Active-Scanned Protons and Carbon Ions in Cancer Treatment of Patients With Cardiac Implantable Electronic Devices: Experience of a Single Institution

Particle therapy using protons or carbon ions for cancer patients with cardiac implantable electronic devices (CIED): a retrospective multi-institutional study

A Review and Analysis of Managing Commonly Seen Implanted Devices for Patients Undergoing Radiation Therapy

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