The effect of stereotactic body radiotherapy (SBRT) using flattening filter‐free beams on cardiac implantable electronic devices (CIEDs) in clinical situations

Aslian, Hossein; Kron, Tomas; Watts, Troy; Akalanli, Cagla; Hardcastle, Nicholas; Lonski, Peta; Montaseri, Atousa; Hay, Barry; Korte, J.; Berk, Kemal; Longo, F.; Severgnini, Mara

doi:10.1002/acm2.12873

Cited by 13 publications

(10 citation statements)

References 40 publications

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“…While a local ICD dose rate of less than 1200 cGy/min may be applied for a short period [4], our data suggest in comparison that with increasing time and radiation dose, much lower dose rates already result in ICD errors. Hurkmans et al have suggested for FFF beams, that at the location of a CIED outside of the target volume, the LDR would be lower than 100 cGy/min and therefore dose-rate effects are rare [16].…”

Section: Discussionmentioning

confidence: 68%

“…A recent review on 13 lung cancer SBRT cases and a phantom study with explanted ICDs showed that even though no CIED failures were reported on the historical SBRT cohort, in vitro data suggest inappropriate sensing (IS) starting at a dose rate (DR) of 1200 cGy/min (200 mGy/s) when CIEDs were placed within the radiation field. Nevertheless, in the same phantom study, no radiation-induced effects were observed in 6 MV photon beams when a total number of 10 ICDs were placed up to 3 cm away from the PTV in clinical lung cancer SBRT scenarios [ 4 ]. In this study, specific DR effects in ICDs were not investigated.…”

Section: Introductionmentioning

confidence: 99%

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Local dose rate effects in implantable cardioverter–defibrillators with flattening filter free and flattened photon radiation

et al. 2022

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Purpose In the beam penumbra of stereotactic body radiotherapy volumes, dose rate effects in implantable cardioverter–defibrillators (ICDs) may be the predominant cause for failures in the absence of neutron-generating photon energies. We investigate such dose rate effects in ICDs and provide evidence for safe use of lung tumor stereotactic radioablation with flattening filter free (FFF) and flattened 6 Megavolt (MV) beams in ICD-bearing patients. Methods Sixty-two ICDs were subjected to scatter radiation in 1.0, 2.5, and 7.0 cm distance to 100 Gy within a 5 × 5 cm2 radiation field. Radiation was applied with 6 MV FFF beams (constant dose rate of 1400 cGy/min) and flattened (FLAT) 6 MV beams (430 cGy/min). Local dose rates (LDR) at the position of all ICDs were measured. All ICDs were monitored continuously. Results With 6 MV FFF beams, ICD errors occurred at distances of 1.0 cm (LDR 46.8 cGy/min; maximum ICD dose 3.4 Gy) and 2.5 cm (LDR 15.6 cGy/min; 1.1 Gy). With 6 MV FLAT beams, ICD errors occurred only at 1 cm distance (LDR 16.8 cGy/min; 3.9 Gy). No errors occurred at an LDR below 7 cGy/min, translating to a safe distance of 2.5 cm (1.5 Gy) in flattened and 7 cm (0.4 Gy) in 6 MV FFF beams. Conclusion A LDR in ICDs larger than 7 cGy/min may cause ICD malfunction. At identical LDR, differences between 6 MV FFF and 6 MV FLAT beams do not yield different rates of malfunction. The dominant reason for ICD failures could be the LDR and not the total dose to the ICD. For most stereotactic treatments, it is recommended to generate a planning risk volume around the ICD in which LDR larger than 7 cGy/min are avoided.

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Section: Discussionmentioning

confidence: 68%

Section: Introductionmentioning

confidence: 99%

Local dose rate effects in implantable cardioverter–defibrillators with flattening filter free and flattened photon radiation

et al. 2022

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“…in which severe failures occurred in the ICP, such as pulse-amplitude changes >25% at cumulative doses of 120 Gy and the loss of telemetry capability at cumulative doses of 130 Gy [ 13 ]. However, in a similar study with 10 MV-FFF, CIEDs included in a portion of the irradiated field were observed to have pacing rate reprogramming, pacing threshold reprogramming, and pulse width reduction, at a cumulative dose of 26, 42.7 and 46.4 Gy, respectively [ 20 ]. It was different from ICP failure and the cumulative dose at which ICP failure was induced, compared to our study.…”

Section: Discussionmentioning

confidence: 99%

“…Aslian et al. performed a partial direct irradiation of CIED with FFF beams using VMAT [ 20 ]. No abnormality was observed with 6 MV-FFF in all CIEDs, whereas reprogramming and reduction of pacing pulse width were observed with 10 MV-FFF at cumulative doses of <50 Gy in less than half the CIEDs.…”

Section: Introductionmentioning

confidence: 99%

Implantable cardiac pacemaker failure by cumulative dose effects of flattening filter free beams

Nakamura

Aoyama

Kaneda

et al. 2021

Journal of Radiation Research

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Cumulative dose effects, which are one of the main causes of errors that occur when an implantable cardiac pacemaker (ICP) is irradiated with ionizing radiation, induce permanent failure in ICPs. Although flattening filter free (FFF) beams, which are often used in stereotactic radiotherapy, are known to have different characteristics from conventional (with flattening filter [WFF]) beams, the cumulative dose effects on ICPs with FFF beams have been under-investigated. This study investigates ICP failure induced by cumulative dose effects of FFF beams. When the ICP placed in the center of the irradiation field was irradiated with 10 MV-FFF at 24 Gy/min, the cumulative dose at which failure occurred was evaluated on the basis of the failure criteria associated with high cumulative dose as described in the American Association of Physicists in Medicine Task Group 203. The ICP failures such as a mild battery depletion at a cumulative dose of 10 Gy, pacing-output voltage change >25% at a cumulative dose of 122 Gy, and the loss of telemetry capability at cumulative dose 134 Gy were induced by cumulative dose effects. The cumulative doses by which the cumulative dose effects of FFF beams induced ICP failure were not very different from those reported in previous studies with WFF beams. Therefore, radiotherapy with FFF beams (and WFF beams) for patients with ICP requires appropriate management for minimizing the cumulative dose effects.

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“…Previous studies have revealed that higher energy radiation (ie, >10 MV) will cause more IDs to experience electric malfunction 14 , 15 , 16 , 17 , 18 , 19 , 31 , 32 , 33 , 34 , 35 , 37 , 38 , 39 ; as a result, devices with electronic circuits should be treated with low energy (ie, <10 MV photons) only. 40 Because both severity and risk of failure of devices from dose rate effects are mild and low, 41 the AAPM TG-203 recommends a dose rate of <0.2 Gy/min as guidance. A recent study investigated the effects of x-ray dose rates of 4 to 24 Gy/min on CIED function and found that a dose rate >8 Gy/min would cause a temporary malfunction due to interference.…”

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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The effect of stereotactic body radiotherapy (SBRT) using flattening filter‐free beams on cardiac implantable electronic devices (CIEDs) in clinical situations

Cited by 13 publications

References 40 publications

Local dose rate effects in implantable cardioverter–defibrillators with flattening filter free and flattened photon radiation

Local dose rate effects in implantable cardioverter–defibrillators with flattening filter free and flattened photon radiation

Implantable cardiac pacemaker failure by cumulative dose effects of flattening filter free beams

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

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