Part II Peer Reviewed Research Article

Dosimetric Review of Cardiac Implantable electronic device patients receiving

radiotherapy.
Peter S Metuge
Peer reviewed research articles are written by professionals employed in the field,
academic researchers and involves formal writing.1 The author(s) of the article submits to
the journal editor who then forwards the article to reviewers with the same scholarly
background as the author(s) to review the article before the article can be published. The
main goal of the research article is to seek answers to issues in the field by formulating a
hypothesis for research, or carry debates on the professional issue. References are usually
drawn from other scholarly journals or statistical methods.2 The article I will be analyzing
is titled Dosimetric review of cardiac implantable electronic device patients receiving
radiotherapy; written by Prisciandaro J, Makkar A, Fox C, et al and recently published in
the Journal of Applied Clinical Medical Physics. I will be critiquing this peer review
article to evaluate how the information was presented, the research design, results
reported, what conclusions were made and my overall impression of the research.
Radiation Therapy (RT) has seen an increase in the number of patients with cardiac
implantable electronic devices (CIED) e.g. implantable cardiac pacemaker (ICP) and
cardioverter defibrillator (ICD). With this increase, there was the need to know how
radiation affects these devices. The goal of this study was to investigate the dosimetric
parameters for cardiac implantable devices for patients receiving RT and to investigate
whether there is a correlation between treatment techniques ( 3D, IMRT, SBRT) and
CIED events can be identified, and to determine if current protocol is appropriate and
necessary.2 One of the issues that was encountered was that CIEDs were mostly located
at the periphery of the treatment field; an area where clinical dose calculation algorithms
are not accurate. Since treatment planning computers are not commissioned to calculate
peripheral dose, physicists rely mostly on published data. Peripheral dose consist of
mostly dose from leakage radiation, collimator scatter and internal scatter.
This article presented some background information to tie into why this study was
conducted. Treating patient with a CIED is a physics nightmare especially if the the

radiation dose tolerance is not stated. Any mistakes made can cause harm to the patient. It
make sense to keep this research going as it will provide clinicians with the current
information on how to manage these patients. Before the investigation, the article
provided recommendations from AAPM task group which gave recommendations on
how to deal with patients who have ICP and need to receive RT. They recommend that
the ICP not be in the treatment field, that the dose to the ICP be estimated prior to RT and
that the total dose to the ICP not be greater than 2Gy. 2
The research was carried out with a total of 69 patients from the Radiation oncology
department at the University of Michigan between 2005 and 2011. Since the research was
based on how treatment techniques affected dose to CIEDs, 35 patients were treated with
3D conformal therapy, 13 patients with Intensity modulated radiotherapy, 6 with
stereotactic radiotherapy and one with stereotactic radiosurgery. Also, 36 patients (24
with ICP and12 with ICDs) were treated with a plan that had 16MV photon beam. The
typical distance from the CIED to the edge of the treatment field was from 1.5cm to
40cm. If the dose to the CIED is expected to receive more than 1Gy for ICDs or 2Gy for
ICP or if the device is was less than 10cm from the field edge, that dose was measured by
a TLD-10disk.2
For this study, the TLD measurements were compared with published data and the
variations were noted and compared. The TLD measurements and published data results
ranged from 0.9 to 506cGy for ICPs and 4 to 169cGy for ICDs. For distances less than
2.5cm, the difference between TLD measurements and published data average 0.94Gy
and for distances between 2.5cm and 10cm, and the difference was 0.5Gy. Of the 69
patients that were evaluated, only two patients require a reset of their ICD and this was
because of the high energy beam used (16 MV) and also because of the ICD was 2.5cm
from the treatment field.
After the investigation was concluded, the only dosimetric correlation with CIEDs was
with the use of high energy. The use of high energy have been discouraged on patients
who have CIED because of the effect of neutrons on the circuits of these devices. Also,
differences were noted between the peripheral dose of published data and that of
treatment planning system calculations. This was because of the inaccuracy of the
calculated dose outside the treatment field. Because of this inconsistencies, TLD

measurement were taken when the CIED was within 10cm of the treatment field or if the
dose to the CIED is estimated to receive 2Gy for ICP and 1Gy for ICD.
In conclusion, this article was very informative and it really provided reasons why
physicist discourage the use of high energy when a patient has a pacemaker. I have
always been told to avoid using it but was never given a concrete explanation why. This
article has help cleared those doubts. Also, I learned something new about not using
physical wedges with patients who have CIEDs especially if the treatment area is in
close proximity to the CIED. This could be detrimental to the device because of the
scatter caused by the wedge.

1. Lenards N, Weege M. Radiation Therapy and Medical Dosimetry Reading.

[PowerPoint]. La Crosse, WI UW-L Medical Dosimetry Program; 2012
2. Prisciandaro J, Makkar A, Fox C, et al. Dosimetric review of cardiac
implantable electronic devices patients receiving radiotherapy. J of App Clin

Med Phys 2015;16 (1): 254-263. Accessed 3/23/2015,

http://www.jacmp.org/index.php/jacmp/article/view/5189
16( Vol number) (1) Number 254-263 page number