In this particular scenario, a patient presented with a left upper lobe lung lesion, localized

directly posterior to the patients implanted pacemaker. The physician order calls for a

stereotactic body radiotherapy (SBRT) treatment, which typically consists of 1 to 5 treatments at

elevated daily doses.1 This situation presents several concerns and difficulties, as it is very

important to maintain patient safety when designing and implementing a treatment plan with

curative intent.

The location of pacemakers must be strongly considered as they contain and make use of

complementary metal oxide semiconductors (CMOS), which are highly susceptible to ionizing

and electromagnetic radiation.2 At my clinical site, AAPM TG-34 recommendations are followed

which suggest that radiation therapy patients with implanted pacemakers be planned so as to

limit accumulated dose to the pacemaker to 2 gray.3 There is also communication with nursing

and physics to determine the specific device model and whether or not more stringent dose

restrictions must be followed. Physicians will often determine that the device can or cannot be

moved prior to the CT simulation for planning. In the event that the device could be moved

superiorly, full arcs could be used with heavily restrictive constraints on the pacemaker to reduce

the dose to the lowest reasonable amount possible in case there is future need for radiotherapy. In

the event that the device could not be moved, I would consider several other options.

In planning this SBRT case where there is no option to move the device, I would first

ensure that all of the fields used were low energy photons less than or equal to 10 MV in order to

lower the risk for neutron contamination. It is understood with some evidence that there is a
 correlation between high energy photons and complications in cardiac implantable electronic

devices.4 Next, I would consider designing beams with partial arcs in order to create fields that

limit entrance and exit dose to device. Following the planning process and approval by physics

and the physician, thermoluminescent dosimeters (TLDs) would be placed on the first day of

treatment over the area of the device. TLD measurements will be read by physics, who will then

determine whether or not the dose is within tolerance from that seen in the treatment planning

system and not overdosing the implanted device. In order to provide a patient with a safe and

quality treatment plan, we as dosimetrists must be cognizant of limiting factors introduced by

implanted devices.

1. Radiological Society of North America, RSNA, American College of Radiology. Stereotactic Radiosurgery (SRS)
and Stereotactic Body Radiotherapy (SBRT). Stereotactic Radiosurgery (SRS) | Stereotactic Body Radiotherapy
(SBRT). https://www.radiologyinfo.org/en/info.cfm?pg=stereotactic. Accessed November 5, 2018.
2. Prisciandaro J, Makkar A, Dox C, et al. Dosimetric review of cardiac implantable electronic device patients
receiving radiotherapy. J Appl Clin Med Phys. 2015;16(1):254-263. https://dx.doi.org/10.1120/jacmp.v16i1.5189
3. Management of Radiation Oncology Patients. American Association of Physicists in Medicine.
https://www.aapm.org/pubs/reports/RPT_45.pdf. Accessed November 5, 2018.
4. Hurkmans CW, Knegjens JL. Management of radiation oncology patients with a pacemaker or ICD: A new
comprehensive practical guideline in The Netherlands. NCBI.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3528416/. Published November 24, 2012. Accessed November 5,
2018.