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Liulu X, Balaji P, Barber J, De Silva K, Murray T, Hickey A, Campbell T, Harris J, Gee H, Ahern V, Kumar S, Hau E, Qian PC. Radiation therapy for ventricular arrhythmias. J Med Imaging Radiat Oncol 2024. [PMID: 38698577 DOI: 10.1111/1754-9485.13662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Ventricular arrhythmias (VA) can be life-threatening arrhythmias that result in significant morbidity and mortality. Catheter ablation (CA) is an invasive treatment modality that can be effective in the treatment of VA where medications fail. Recurrence occurs commonly following CA due to an inability to deliver lesions of adequate depth to cauterise the electrical circuits that drive VA or reach areas of scar responsible for VA. Stereotactic body radiotherapy is a non-invasive treatment modality that allows volumetric delivery of energy to treat circuits that cannot be reached by CA. It overcomes the weaknesses of CA and has been successfully utilised in small clinical trials to treat refractory VA. This article summarises the current evidence for this novel treatment modality and the steps that will be required to bring it to the forefront of VA treatment.
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Affiliation(s)
- Xingzhou Liulu
- Cardiology Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jeffrey Barber
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Kasun De Silva
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Tiarne Murray
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Hickey
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Jill Harris
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Harriet Gee
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Verity Ahern
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Hau
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, New South Wales, Australia
- Blacktown Hematology and Cancer Centre, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Webster M, Dona Lemus OM, Zheng D, Wancura JN, Tanny S, Sakthivel G, Constine L. Case study with dosimetric analysis: Total body irradiation to a patient with a left ventricular assist device. Clin Case Rep 2024; 12:e8868. [PMID: 38756618 PMCID: PMC11096280 DOI: 10.1002/ccr3.8868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 05/18/2024] Open
Abstract
Key Clinical Message A patient presented with cardiogenic shock, requiring the implantation of a left ventricular assist device (LVAD), and acute myeloblastic leukemia. This necessitated total body irradiation (TBI) while balancing dose reduction to the LVAD components to avoid potential radiation damage. Here we outline our treatment approach and dose estimates to the LVAD. Abstract This case report discusses the delivery of TBI to a patient with an LVAD. This treatment required radiation-dose determinations and consequential reductions for the heart, LVAD, and an external controller connected to the LVAD. The patient was treated using a traditional 16MV anterior posterior (AP)/posterior anterior (PA) technique at a source-to-surface-distance of 515 cm for 400 cGy in two fractions. A 3 cm thick Cerrobend block was placed on the beam spoiler to reduce dose to the heart and LVAD to 150 cGy. The external controller was placed in a 1 cm thick acrylic box to reduce neutron dose and positioned as far from the treatment fields as achievable. In vivo measurements were made using optically stimulated luminescence dosimeters (OSLDs) placed inside the box at distances of 2 cm, 8.5 cm, and 14 cm from the field edge, and on the patient along the central axis and centered behind the LVAD block. Further ion chamber measurements were made using a solid water phantom to more accurately estimate the dose delivered to the LVAD. Neutron dose measurements were also conducted. The total estimated dose to the controller ranged from 135.3 cGy to 91.5 cGy. The LVAD block reduced the surface dose to the patient to 271.6 cGy (68.1%). The block transmission factors of the 3 cm Cerrobend block measured in the phantom were 45% at 1 cm depth and decreased asymptotically to around 30% at 3 cm depth. Applying these transmission factors to the in vivo measurements yielded a dose of 120 cGy to the implanted device. The neutron dose the LVAD region is estimated around 0.46 cGy. Physical limitations of the controller made it impossible to completely avoid dose. Shielding is recommended. The block had limited dose reduction to the surface, due to secondary particles, but appropriately reduced the dose at 3 cm and beyond. More research on LVADs dose limits would be beneficial.
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Affiliation(s)
- Matthew Webster
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Olga M. Dona Lemus
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Dandan Zheng
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Joshua N. Wancura
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Sean Tanny
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Gukan Sakthivel
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Louis Constine
- Department of Radiation OncologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
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Decker SM, Bruza P, Zhang R, Williams BB, Jarvis LA, Pogue BW, Gladstone DJ. Technical note: Visual, rapid, scintillation point dosimetry for in vivo MV photon beam radiotherapy treatments. Med Phys 2024. [PMID: 38598093 DOI: 10.1002/mp.17071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/07/2024] [Accepted: 03/26/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND While careful planning and pre-treatment checks are performed to ensure patient safety during external beam radiation therapy (EBRT), inevitable daily variations mean that in vivo dosimetry (IVD) is the only way to attain the true delivered dose. Several countries outside the US require daily IVD for quality assurance. However, elsewhere, the manual labor and time considerations of traditional in vivo dosimeters may be preventing frequent use of IVD in the clinic. PURPOSE This study expands upon previous research using plastic scintillator discs for optical dosimetry for electron therapy treatments. We present the characterization of scintillator discs for in vivo x-ray dosimetry and describe additional considerations due to geometric complexities. METHODS Plastic scintillator discs were coated with reflective white paint on all sides but the front surface. An anti-reflective, matte coating was applied to the transparent face to minimize specular reflection. A time-gated iCMOS camera imaged the discs under various irradiation conditions. In post-processing, background-subtracted images of the scintillators were fit with Gaussian-convolved ellipses to extract several parameters, including integral output, and observation angle. RESULTS Dose linearity and x-ray energy independence were observed, consistent with ideal characteristics for a dosimeter. Dose measurements exhibited less than 5% variation for incident beam angles between 0° and 75° at the anterior surface and 0-60∘ $^\circ $ at the posterior surface for exit beam dosimetry. Varying the angle between the disc surface and the camera lens did not impact the integral output for the same dose up to 55°. Past this point, up to 75°, there is a sharp falloff in response; however, a correction can be used based on the detected width of the disc. The reproducibility of the integral output for a single disc is 2%, and combined with variations from the gantry angle, we report the accuracy of the proposed scintillator disc dosimeters as ±5.4%. CONCLUSIONS Plastic scintillator discs have characteristics that are well-suited for in vivo optical dosimetry for x-ray radiotherapy treatments. Unlike typical point dosimeters, there is no inherent readout time delay, and an optical recording of the measurement is saved after treatment for future reference. While several factors influence the integral output for the same dose, they have been quantified here and may be corrected in post-processing.
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Affiliation(s)
- Savannah M Decker
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - Rongxiao Zhang
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
| | | | - Lesley A Jarvis
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
- Dartmouth Cancer Center, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
| | - David J Gladstone
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire, USA
- Dartmouth Cancer Center, Dartmouth Health, Lebanon, New Hampshire, USA
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Akdag O, Borman PTS, Mandija S, Woodhead PL, Uijtewaal P, Raaymakers BW, Fast MF. Experimental demonstration of real-time cardiac physiology-based radiotherapy gating for improved cardiac radioablation on an MR-linac. Med Phys 2024; 51:2354-2366. [PMID: 38477841 DOI: 10.1002/mp.17024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/09/2024] [Accepted: 02/23/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Cardiac radioablation is a noninvasive stereotactic body radiation therapy (SBRT) technique to treat patients with refractory ventricular tachycardia (VT) by delivering a single high-dose fraction to the VT isthmus. Cardiorespiratory motion induces position uncertainties resulting in decreased dose conformality. Electocardiograms (ECG) are typically used during cardiac MRI (CMR) to acquire images in a predefined cardiac phase, thus mitigating cardiac motion during image acquisition. PURPOSE We demonstrate real-time cardiac physiology-based radiotherapy beam gating within a preset cardiac phase on an MR-linac. METHODS MR images were acquired in healthy volunteers (n = 5, mean age = 29.6 years, mean heart-rate (HR) = 56.2 bpm) on the 1.5 T Unity MR-linac (Elekta AB, Stockholm, Sweden) after obtaining written informed consent. The images were acquired using a single-slice balance steady-state free precession (bSSFP) sequence in the coronal or sagittal plane (TR/TE = 3/1.48 ms, flip angle = 48∘ $^{\circ }$ , SENSE = 1.5,field-of-view = 400 × 207 $\text{field-of-view} = {400}\times {207}$ mm 2 ${\text{mm}}^{2}$ , voxel size =3 × 3 × 15 $3\times 3\times 15$ mm 3 ${\rm mm}^{3}$ , partial Fourier factor = 0.65, frame rate = 13.3 Hz). In parallel, a 4-lead ECG-signal was acquired using MR-compatible equipment. The feasibility of ECG-based beam gating was demonstrated with a prototype gating workflow using a Quasar MRI4D motion phantom (IBA Quasar, London, ON, Canada), which was deployed in the bore of the MR-linac. Two volunteer-derived combined ECG-motion traces (n = 2, mean age = 26 years, mean HR = 57.4 bpm, peak-to-peak amplitude = 14.7 mm) were programmed into the phantom to mimic dose delivery on a cardiac target in breath-hold. Clinical ECG-equipment was connected to the phantom for ECG-voltage-streaming in real-time using research software. Treatment beam gating was performed in the quiescent phase (end-diastole). System latencies were compensated by delay time correction. A previously developed MRI-based gating workflow was used as a benchmark in this study. A 15-beam intensity-modulated radiotherapy (IMRT) plan (1 × 6.25 ${1}\times {6.25}$ Gy) was delivered for different motion scenarios onto radiochromic films. Next, cardiac motion was then estimated at the basal anterolateral myocardial wall via normalized cross-correlation-based template matching. The estimated motion signal was temporally aligned with the ECG-signal, which were then used for position- and ECG-based gating simulations in the cranial-caudal (CC), anterior-posterior (AP), and right-left (RL) directions. The effect of gating was investigated by analyzing the differences in residual motion at 30, 50, and 70% treatment beam duty cycles. RESULTS ECG-based (MRI-based) beam gating was performed with effective duty cycles of 60.5% (68.8%) and 47.7% (50.4%) with residual motion reductions of 62.5% (44.7%) and 43.9% (59.3%). Local gamma analyses (1%/1 mm) returned pass rates of 97.6% (94.1%) and 90.5% (98.3%) for gated scenarios, which exceed the pass rates of 70.3% and 82.0% for nongated scenarios, respectively. In average, the gating simulations returned maximum residual motion reductions of 88%, 74%, and 81% at 30%, 50%, and 70% duty cycles, respectively, in favor of MRI-based gating. CONCLUSIONS Real-time ECG-based beam gating is a feasible alternative to MRI-based gating, resulting in improved dose delivery in terms of highγ -pass $\gamma {\text{-pass}}$ rates, decreased dose deposition outside the PTV and residual motion reduction, while by-passing cardiac MRI challenges.
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Affiliation(s)
- Osman Akdag
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pim T S Borman
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Stefano Mandija
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Computational Imaging Group for MR Diagnostics and Therapy, Center for Image Sciences, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peter L Woodhead
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
- Elekta AB, Stockholm, Sweden
| | - Prescilla Uijtewaal
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas W Raaymakers
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martin F Fast
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
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Pepin MD, Brost EE, Klein KA, Garces YI, Brinkmann DH. A script-enabled interactive checklist document for efficient management of electronic devices in a busy multimodality radiotherapy clinic. J Appl Clin Med Phys 2024; 25:e14302. [PMID: 38368613 DOI: 10.1002/acm2.14302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
PURPOSE Develop an efficient, interactive, and instructive checklist document for the management of implanted electronic medical devices in a multimodality radiotherapy clinic. METHODS The built-in scripting and interactivity of a popular commercial word processor was used to develop an interactive document that changes the information presented to the user based on drop-down selections. The interactivity and scripting were compatible with the radiation oncology information system (ROIS) which allows the document to be accessible by all team members and serve as a permanent record in a patient's electronic chart. RESULTS The final interactive document, which was clinically deployed after beta testing with a group consisting of nurses and medical physicists, presents information and action plans to the user based on multiple departmental medical device decision trees that are specific to the combination of device, treatment modality, rhythm-pacing dependence for cardiac devices, and distance from the device to the treatment volume. CONCLUSION A script-enabled interactive document was developed for a busy multimodality clinic, condensing multiple comprehensive departmental guidelines spanning multiple device types and treatment modalities into a single interactive checklist accessible within the ROIS. Given the wide accessibility of the commercial word processor, this approach could be adopted by other clinics to streamline their own respective workflows.
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Affiliation(s)
- Mark D Pepin
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric E Brost
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristi A Klein
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yolanda I Garces
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Debra H Brinkmann
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota, USA
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Mircea AA, Donisan T, Feigenberg S, Fradley MG. What do national radiotherapy guidelines for patients with cardiac devices teach us? Heart Rhythm O2 2024; 5:189-193. [PMID: 38560371 PMCID: PMC10980919 DOI: 10.1016/j.hroo.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
The incidence of cardiac implantable electronic device (CIED) malfunctions caused by radiotherapy (RT) is approximately 5%. Although individual national guidelines and expert consensus documents exist, the increased use of RT to treat various cancers points out the need for a standardized document to guide risk assessment and management of CIEDs during RT. We describe potential adverse RT-related events on CIEDs as well as the proposed mechanism of dysfunction. We review the main current guidelines and recommendations, emphasizing similarities and differences.
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Affiliation(s)
- Andrei Alexandru Mircea
- Electrophysiology and Heart Modeling Institute, Heart Rhythm Disease Institute, Bordeaux, France
| | - Teodora Donisan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Steven Feigenberg
- Radiation Oncology Department, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G. Fradley
- Thalheimer Center for Cardio-Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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Gauter-Fleckenstein B, Schönig S, Mertens L, Oppitz H, Siebenlist K, Ehmann M, Fleckenstein J. Effect of simultaneous integrated boost concepts on photoneutron and distant out-of-field doses in VMAT for prostate cancer. Strahlenther Onkol 2024; 200:219-229. [PMID: 37707518 PMCID: PMC10876496 DOI: 10.1007/s00066-023-02138-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND A simultaneous integrated boost (SIB) may result in increased out-of-field (DOOF) and photoneutron (HPN) doses in volumetric modulated arc therapy (VMAT) for prostate cancer (PCA). This work therefore aimed to compare DOOF and HPN in flattened (FLAT) and flattening filter-free (FFF) 6‑MV and 10-MV VMAT treatment plans with and without SIB. METHODS Eight groups of 30 VMAT plans for PCA with 6 MV or 10 MV, with or without FF and with uniform (2 Gy) or SIB target dose (2.5/3.0 Gy) prescriptions (CONV, SIB), were generated. All 240 plans were delivered on a slab-phantom and compared with respect to measured DOOF and HPN in 61.8 cm distance from the isocenter. The 6‑ and 10-MV flattened VMAT plans with conventional fractionation (6- and 10-MV FLAT CONV) served as standard reference groups. Doses were analyzed as a function of delivered monitor units (MU) and weighted equivalent square field size Aeq. Pearson's correlation coefficients between the presented quantities were determined. RESULTS The SIB plans resulted in decreased HPN over an entire prostate RT treatment course (10-MV SIB vs. CONV -38.2%). Omission of the flattening filter yielded less HPN (10-MV CONV -17.2%; 10-MV SIB -22.5%). The SIB decreased DOOF likewise by 39% for all given scenarios, while the FFF mode reduced DOOF on average by 60%. A strong Pearson correlation was found between MU and HPN (r > 0.9) as well as DOOF (0.7 < r < 0.9). CONCLUSION For a complete treatment, SIB reduces both photoneutron and OOF doses to almost the same extent as FFF deliveries. It is recommended to apply moderately hypofractionated 6‑MV SIB FFF-VMAT when considering photoneutron or OOF doses.
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Affiliation(s)
- Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany.
| | - Sebastian Schönig
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Lena Mertens
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Hans Oppitz
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Kerstin Siebenlist
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Michael Ehmann
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Uzun DD, Salatzki J, Xynogalos P, Frey N, Debus J, Lang K. Effects of Ionizing Radiation on Cardiac Implantable Electronic Devices (CIEDs) in Patients with Esophageal Cancer Undergoing Radiotherapy: A Pilot Study. Cancers (Basel) 2024; 16:555. [PMID: 38339306 PMCID: PMC10854512 DOI: 10.3390/cancers16030555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: The prevalence of cancer patients relying on cardiac implantable electronic device (CIED) is steadily rising. The aim of this study was to evaluate RT-related malfunctions of CIEDs. (2) Methods: We retrospectively analyze sixteen patients with esophageal cancer who were treated with radiotherapy between 2012 and 2022 at the University Hospital Heidelberg. All patients underwent systemic evaluation including pre-therapeutic cardiological examinations of the CIED functionality and after every single irradiation. (3) Results: Sixteen patients, predominantly male (14) with a mean age of 77 (range: 56-85) years were enrolled. All patients received 28 fractions of radiotherapy with a cumulative total dose 58.8 Gy. The mean maximum dose at the CIEDs was 1.8 Gy. Following radiotherapy and during the one-year post-radiation follow-up period, there were no registered events associated with the treatment in this evaluation. (4) Conclusion: The study did not observe any severe CIED malfunctions following each radiation fraction or after completion of RT. Strict selection of photon energy and alignment with manufacturer-recommended dose limits appear to be important. Our study showed no major differences in the measured values of the pacing threshold, sensing threshold and lead impedance after RT.
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Affiliation(s)
- Davut D. Uzun
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Heidelberg Center for Heart Rhythm Disorders (HCR), 69120 Heidelberg, Germany; (J.S.); (P.X.); (N.F.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Janek Salatzki
- Heidelberg Center for Heart Rhythm Disorders (HCR), 69120 Heidelberg, Germany; (J.S.); (P.X.); (N.F.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Panagiotis Xynogalos
- Heidelberg Center for Heart Rhythm Disorders (HCR), 69120 Heidelberg, Germany; (J.S.); (P.X.); (N.F.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Norbert Frey
- Heidelberg Center for Heart Rhythm Disorders (HCR), 69120 Heidelberg, Germany; (J.S.); (P.X.); (N.F.)
- Department of Cardiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Juergen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
- Department of Radiation Oncology, Heidelberg Ion-Beam Therapy Center (HIT), Heidelberg University Hospital, 69120 Heidelberg, Germany
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Heidelberg, 69120 Heidelberg, Germany
| | - Kristin Lang
- Department of Radiation Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
- Heidelberg Institute of Radiation Oncology (HIRO), 69120 Heidelberg, Germany
- National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany
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Tajstra M, Dyrbuś M, Stąpór-Fudzińska M, Rutkowski T, Gąsior M, Blamek S. Safety and Feasibility Concerns of Radiotherapy in the Presence of Subcutaneous Implantable Cardioverter-Defibrillator. JACC Clin Electrophysiol 2024:S2405-500X(23)00909-X. [PMID: 38276926 DOI: 10.1016/j.jacep.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Mateusz Tajstra
- 3rd Department of Cardiology, School of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.
| | - Maciej Dyrbuś
- 3rd Department of Cardiology, School of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Małgorzata Stąpór-Fudzińska
- Department of Radiotherapy Planning, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Tomasz Rutkowski
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, School of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sławomir Blamek
- Department of Radiotherapy, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
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van der Ree MH, Hoeksema WF, Luca A, Visser J, Balgobind BV, Zumbrink M, Spier R, Herrera-Siklody C, Lee J, Bates M, Daniel J, Peedell C, Boda-Heggemann J, Rudic B, Merten R, Dieleman EM, Rinaldi CA, Ahmad S, Whitaker J, Bhagirath P, Hatton MQ, Riley S, Grehn M, Schiappacasse L, Blanck O, Hohmann S, Pruvot E, Postema PG. Stereotactic arrhythmia radioablation: A multicenter pre-post intervention safety evaluation of the implantable cardioverter-defibrillator function. Radiother Oncol 2023; 189:109910. [PMID: 37709052 DOI: 10.1016/j.radonc.2023.109910] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/08/2023] [Accepted: 09/08/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Stereotactic arrhythmia radioablation (STAR) appears to be beneficial in selected patients with therapy-refractory ventricular tachycardia (VT). However, high-dose radiotherapy used for STAR-treatment may affect functioning of the patients' implantable cardioverter defibrillator (ICD) by direct effects of radiation on ICD components or cardiac tissue. Currently, the effect of STAR on ICD functioning remains unknown. METHODS A retrospective pre-post multicenter study evaluating ICD functioning in the 12-month before and after STAR was performed. Patients with (non)ischemic cardiomyopathies with therapy-refractory VT and ICD who underwent STAR were included and the occurrence of ICD-related adverse events was collected. Evaluated ICD parameters included sensing, capture threshold and impedance. A linear mixed-effects model was used to investigate the association between STAR, radiotherapy dose and changes in lead parameters over time. RESULTS In total, 43 patients (88% male) were included in this study. All patients had an ICD with an additional right atrial lead in 34 (79%) and a ventricular lead in 17 (40%) patients. Median ICD-generator dose was 0.1 Gy and lead tip dose ranged from 0-32 Gy. In one patient (2%), a reset occurred during treatment, but otherwise, STAR and radiotherapy dose were not associated with clinically relevant alterations in ICD leads parameters. CONCLUSIONS STAR treatment did not result in major ICD malfunction. Only one radiotherapy related adverse event occurred during the study follow-up without patient harm. No clinically relevant alterations in ICD functioning were observed after STAR in any of the leads. With the reported doses STAR appears to be safe.
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Affiliation(s)
- Martijn H van der Ree
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Heart Failure and Arrhythmias, Amsterdam, the Netherlands; Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Wiert F Hoeksema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Adrian Luca
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Jorrit Visser
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Brian V Balgobind
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel Zumbrink
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | - Raymond Spier
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands
| | | | - Justin Lee
- Department of Cardiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Matthew Bates
- Department of Cardiology, South Tees Hospitals NHS Foundation Trust, Middleborough, UK
| | - Jim Daniel
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Clive Peedell
- Department of Radiation Oncology, South Tees Hospitals NHS Foundation Trust, Middlesborough, UK
| | - Judit Boda-Heggemann
- Department of Radiation Oncology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Boris Rudic
- Department of Cardiology, University Medical Center Mannheim University of Heidelberg, Mannheim, Germany
| | - Roland Merten
- Department of Radiation Oncology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Edith M Dieleman
- Amsterdam UMC location University of Amsterdam, Department of Radiation Oncology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Cristopher A Rinaldi
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Shahreen Ahmad
- Department of Radiation Oncology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - John Whitaker
- Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Pranav Bhagirath
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands; Department of Cardiology, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Matthew Q Hatton
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Stephen Riley
- Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK
| | - Melanie Grehn
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Luis Schiappacasse
- Department of Radiation Oncology, Lausanne University Hospital, Lausanne, Switzerland
| | - Oliver Blanck
- Department of Radiation Oncology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Stephan Hohmann
- Hannover Heart Rhythm Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pieter G Postema
- Amsterdam UMC location University of Amsterdam, Department of Cardiology, Meibergdreef 9, Amsterdam, the Netherlands.
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11
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Fagerstrom JM, Marotta JE. Example Radiation Oncology Policy for Managing Patients With Implanted Electronic Devices Other Than Implantable Cardiac Pacemakers or Defibrillators. Pract Radiat Oncol 2023; 13:558-564. [PMID: 37578411 DOI: 10.1016/j.prro.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/23/2023] [Accepted: 07/13/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE This article describes a community-based hospital's policy for the management of patients with medical implanted electronic devices other than pacemakers or implanted cardiac defibrillators (ICDs). The policy may be adapted as needed for other radiation oncology groups requiring a practical solution for managing the care of patients with implanted devices, noting the need for changes for departments offering proton, neutron, heavy ion, or magnetic resonance-guided linear accelerator (MR-linac) treatment modalities. METHODS AND MATERIALS The policy was developed using a risk-based approach, with each patient's risk level determined based on the patient's dependence on the device, the anticipated dose to the device, and the type of treatment used. A similar approach is used for patients with pacemakers or ICDs, but this policy was designed to accommodate patients with other types of devices with care managed outside the department. Such devices include, but are not limited to, hepatic pumps, intrathecal pain pumps, neurostimulators, cochlear implants, and loop recorders. RESULTS The resulting definitions, guidelines, and proposed workflow were presented at the institution's multidisciplinary radiation oncology quality assurance committee monthly meeting and adopted as department policy in 2022. Recommendations incorporated in the policy include levels of patient monitoring and timing of device interrogation to minimize the risk of device malfunction. CONCLUSIONS The policy was written to guide the management of treatment of patients with a range of medical implanted electronic devices. This policy is currently in operation at a community-based hospital.
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Affiliation(s)
- Jessica M Fagerstrom
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
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12
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Lisowski D, Lutyj P, Abazari A, Weick S, Traub J, Polat B, Flentje M, Kraft J. Impact of Radiotherapy on Malfunctions and Battery Life of Cardiac Implantable Electronic Devices in Cancer Patients. Cancers (Basel) 2023; 15:4830. [PMID: 37835524 PMCID: PMC10571836 DOI: 10.3390/cancers15194830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/15/2023] Open
Abstract
PURPOSE This study analyses a large number of cancer patients with CIEDs for device malfunction and premature battery depletion by device interrogation after each radiotherapy fraction and compares different guidelines in regard to patient safety. METHODS From 2007 to 2022, a cohort of 255 patients was analyzed for CIED malfunctions via immediate device interrogation after every RT fraction. RESULTS Out of 324 series of radiotherapy treatments, with a total number of 5742 CIED interrogations, nine device malfunctions (2.8%) occurred. Switching into back-up/safety mode and software errors occurred four times each. Once, automatic read-out could not be performed. The median prescribed cumulative dose at planning target volume (PTV) associated with CIED malfunction was 45.0 Gy (IQR 36.0-64.0 Gy), with a median dose per fraction of 2.31 Gy (IQR 2.0-3.0 Gy). The median maximum dose at the CIED at time of malfunction was 0.3 Gy (IQR 0.0-1.3 Gy). No correlation between CIED malfunction and maximum photon energy (p = 0.07), maximum dose at the CIED (p = 0.59) nor treatment localization (p = 0.41) could be detected. After excluding the nine malfunctions, premature battery depletion was only observed three times (1.2%). Depending on the national guidelines, 1-9 CIED malfunctions in this study would have been detected on the day of occurrence and in none of the cases would patient safety have been compromised. CONCLUSION Radiation-induced malfunctions of CIEDs and premature battery depletion are rare. If recommendations of national safety guidelines are followed, only a portion of the malfunctions would be detected directly after occurrence. Nevertheless, patient safety would not be compromised.
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Affiliation(s)
- Dominik Lisowski
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Paul Lutyj
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Arya Abazari
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Stefan Weick
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Jan Traub
- Department of Internal Medicine I, Division of Cardiology, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Bülent Polat
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Michael Flentje
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
| | - Johannes Kraft
- Department of Radiation Oncology, University Hospital Würzburg, 97080 Würzburg, Germany (J.K.)
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13
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Yoshida T, Murayama S, Yasui K, Tomida T, Urikura A. Pacemaker Malfunction During Passive Proton Beam Therapy for Localized Prostate Cancer: Case Reports and a Literature Review. Cureus 2023; 15:e46223. [PMID: 37908917 PMCID: PMC10613830 DOI: 10.7759/cureus.46223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2023] [Indexed: 11/02/2023] Open
Abstract
We report two cases of pacemaker malfunction occurring during proton beam therapy (PBT) for localized prostate cancer treatment. The first case involved mode changes in the pacemaker, while the second exhibited prolongation of the RR interval. Remarkably, both cases did not manifest significant clinical changes. Our findings indicate that careful consideration should be given to passive PBT in patients with localized prostate cancer who have pacemakers, like the considerations in patients with thoracic and abdominal cancers. Moreover, our report highlights the importance of recognizing potential cardiac implantable electronic devices malfunction in various PBT scenarios.
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Affiliation(s)
- Tsukasa Yoshida
- Department of Diagnostic Radiology, Shizuoka Cancer Center, Shizuoka, JPN
| | - Shigeyuki Murayama
- Department of Radiation and Proton Therapy, Shizuoka Cancer Center, Shizuoka, JPN
| | - Kazuaki Yasui
- Department of Radiation and Proton Therapy, Shizuoka Cancer Center, Shizuoka, JPN
| | - Tetsuya Tomida
- Department of Radiation and Proton Therapy, Shizuoka Cancer Center, Shizuoka, JPN
| | - Atsushi Urikura
- Department of Radiological Technology, Radiological Diagnosis, National Cancer Center Hospital, Tokyo, JPN
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14
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Petit C, Escande A, Sarrade T, Vaugier L, Kirova Y, Tallet A. Radiation therapy in the thoracic region: Radio-induced cardiovascular disease, cardiac delineation and sparing, cardiac dose constraints, and cardiac implantable electronic devices. Cancer Radiother 2023; 27:588-598. [PMID: 37648559 DOI: 10.1016/j.canrad.2023.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 09/01/2023]
Abstract
Radiation therapy in the thoracic region may deliver incidental ionizing radiation to the surrounding healthy structures, including the heart. Radio-induced heart toxicity has long been a concern in breast cancer and Hodgkin's lymphoma and was deemed a long-term event. However, recent data highlight the need to limit the dose to the heart in less favorable thoracic cancers too, such as lung and esophageal cancers in which incidental irradiation led to increased mortality. This article will summarize available cardiac dose constraints in various clinical settings and the types of radio-induced cardiovascular diseases encountered as well as delineation of cardiac subheadings and management of cardiac devices. Although still not completely deciphered, heart dose constraints remain intensively investigated and the mean dose to the heart is no longer the only dosimetric parameter to consider since the left anterior descending artery as well as the left ventricle should also be part of dosimetry constraints.
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Affiliation(s)
- C Petit
- Radiation Oncology Department, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille cedex 09, France
| | - A Escande
- Service de radiothérapie, centre Léonard-de-Vinci, Dechy, France; UMR 9189, laboratoire Cristal, université de Lille, Villeneuve-d'Ascq, France
| | - T Sarrade
- Department of Radiation Oncology, hôpital Tenon, Sorbonne université, 75020 Paris, France
| | - L Vaugier
- Department of Radiation Oncology, institut de cancérologie de l'Ouest, Saint-Herblain, France
| | - Y Kirova
- Department of Radiation Oncology, institut Curie, Paris, France
| | - A Tallet
- Radiation Oncology Department, institut Paoli-Calmettes, 232, boulevard Sainte-Marguerite, 13273 Marseille cedex 09, France; UMR 1068, CRCM Inserm, Marseille, France.
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15
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Wijesuriya N, Galante JR, Sisodia C, Whitaker J, Ahmad S, Rinaldi CA. Increase in right ventricular lead pacing threshold following stereotactic ablative therapy for ventricular tachycardia. HeartRhythm Case Rep 2023; 9:555-559. [PMID: 37614389 PMCID: PMC10444549 DOI: 10.1016/j.hrcr.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Affiliation(s)
- Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Joao R. Galante
- Guy’s Cancer Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Caroline Sisodia
- Guy’s Cancer Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Shahreen Ahmad
- Guy’s Cancer Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Department of Cardiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
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16
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Stefan MF, Herghelegiu CG, Magda SL. Accelerated Atherosclerosis and Cardiovascular Toxicity Induced by Radiotherapy in Breast Cancer. Life (Basel) 2023; 13:1631. [PMID: 37629488 PMCID: PMC10455250 DOI: 10.3390/life13081631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/27/2023] Open
Abstract
The number of patients diagnosed with breast cancer and cardiovascular disease is continuously rising. Treatment options for breast cancer have greatly evolved, but radiotherapy (RT) still has a key role in it. Despite many advances in RT techniques, cardiotoxicity is one of the most important side effects. The new cardio-oncology guidelines recommend a baseline evaluation, risk stratification and follow-up of these patients. Cardiotoxicity induced by RT can be represented by almost all forms of cardiovascular disease, with atherosclerosis being the most frequent. An interdisciplinary team should manage these patients, in order to have maximum therapeutic effect and minimum cardiovascular toxicity. This review will summarize the current incidence, risk factors, mechanisms and follow-up of RT-induced cardiovascular toxicity.
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Affiliation(s)
- Miruna Florina Stefan
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
| | - Catalin Gabriel Herghelegiu
- Institutul National Pentru Sanatatea Mamei si a Copilului “Alessandrescu Rusescu”, 020395 Bucharest, Romania;
| | - Stefania Lucia Magda
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania;
- Department of Cardiology and Cardiovascular Surgery, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania
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17
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Mirzaei M, Rowshanfarzad P, Gill S, Ebert MA, Dass J. Risk of cardiac implantable device malfunction in cancer patients receiving proton therapy: an overview. Front Oncol 2023; 13:1181450. [PMID: 37469405 PMCID: PMC10352826 DOI: 10.3389/fonc.2023.1181450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023] Open
Abstract
Age is a risk factor for both cardiovascular disease and cancer, and as such radiation oncologists frequently see a number of patients with cardiac implantable electronic devices (CIEDs) receiving proton therapy (PT). CIED malfunctions induced by PT are nonnegligible and can occur in both passive scattering and pencil beam scanning modes. In the absence of an evidence-based protocol, the authors emphasise that this patient cohort should be managed differently to electron- and photon- external beam radiation therapy (EBRT) patients due to distinct properties of proton beams. Given the lack of a PT-specific guideline for managing this cohort and limited studies on this important topic; the process was initiated by evaluating all PT-related CIED malfunctions to provide a baseline for future reporting and research. In this review, different modes of PT and their interactions with a variety of CIEDs and pacing leads are discussed. Effects of PT on CIEDs were classified into a variety of hardware and software malfunctions. Apart from secondary neutrons, cumulative radiation dose, dose rate, CIED model/manufacturer, distance from CIED to proton field, and materials used in CIEDs/pacing leads were all evaluated to determine the probability of malfunctions. The importance of proton beam arrangements is highlighted in this study. Manufacturers should specify recommended dose limits for patients undergoing PT. The establishment of an international multidisciplinary team dedicated to CIED-bearing patients receiving PT may be beneficial.
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Affiliation(s)
- Milad Mirzaei
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Department of Medical Imaging and Radiation Sciences, School of Biomedical Sciences, Monash University, Clayton, VIC, Australia
| | - Pejman Rowshanfarzad
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia
| | - Suki Gill
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia
| | - Martin A. Ebert
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- School of Physics, Mathematics and Computing, The University of Western Australia, Crawley, WA, Australia
| | - Joshua Dass
- Department of Radiation Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
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18
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Safavi AH, Louie AV, Elzibak AH, Warner A, Donovan EK, Detsky JS. Management of Patients with Cardiovascular Implantable Electronic Devices Undergoing Radiation Therapy: A National Survey of Canadian Multidisciplinary Radiation Oncology Professionals. Adv Radiat Oncol 2023; 8:101184. [PMID: 36874173 PMCID: PMC9975614 DOI: 10.1016/j.adro.2023.101184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/11/2023] [Indexed: 01/26/2023] Open
Abstract
Purpose This study aimed to characterize contemporary management of Canadian patients with cardiovascular implantable electronic devices (CIEDs) undergoing radiation therapy (RT) in light of updated American Association of Physicists in Medicine guidelines. Methods and Materials A 22-question web-based survey was distributed to members of the Canadian Association of Radiation Oncology, Canadian Organization of Medical Physicists, and Canadian Association of Medical Radiation Technologists from January to February 2020. Respondent demographics, knowledge, and management practices were elicited. Statistical comparisons by respondent demographics were performed using χ2 and Fisher exact tests. Results In total, 155 surveys were completed by 54 radiation oncologists, 26 medical physicists, and 75 radiation therapists in academic (51%) and community (49%) practices across all provinces. The majority of respondents (77%) had managed >10 patients with CIEDs in their career. Most respondents (70%) reported using risk-stratified institutional management protocols. Respondents used manufacturer recommendations, rather than American Association of Physicists in Medicine or institutionally recommended dose limits, when the manufacturer limit was 0 Gy (44%), 0 to 2 Gy (45%), or >2 Gy (34%). The majority of respondents (86%) reported institutional policies to refer to a cardiologist for CIED evaluation both before and after completion of RT. Cumulative dose to CIED, pacing dependence, and neutron production were considered during risk stratification by 86%, 74%, and 50% of participants, respectively. Dose and energy thresholds for high-risk management were not known by 45% and 52% of respondents, with radiation oncologists and radiation therapists significantly less likely to report thresholds than medical physicists (P < .001). Although 59% of respondents felt comfortable managing patients with CIEDs, community respondents were less likely to feel comfortable than academic respondents (P = .037). Conclusions The management of Canadian patients with CIEDs undergoing RT is characterized by variability and uncertainty. National consensus guidelines may have a role in improving provider knowledge and confidence in caring for this growing population.
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Affiliation(s)
- Amir H. Safavi
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Alexander V. Louie
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Alyaa H. Elzibak
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andrew Warner
- Department of Radiation Oncology, London Health Sciences Centre, London, Ontario, Canada
| | - Elysia K. Donovan
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Jay S. Detsky
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada
- Odette Cancer Centre – Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Corresponding author: Jay S. Detsky, MD, PhD
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19
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Carlone M, Yang R, Hyde D, Becker N, Cocarell J. Measurement of neutron yield for a medical linear accelerator below 10 MV. Med Phys 2023. [PMID: 37060574 DOI: 10.1002/mp.16416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND The recent trend toward 10 MV for volumetric radiotherapy treatment such as volumetric modulated arc therapy (VMAT), stereotactic radiosurgery (SRS), and stereotactic ablative body radiotherapy (SABR) introduces photoneutron production, with implications for non-therapeutic patient dose and additional shielding requirements for treatment room design. The sharply nonlinear drop-off in photoneutron production below 10 MV to negligible at 6 MV has scarcely been characterized quantitatively, yet can elucidate important practical insights. PURPOSE To measure photoneutron yields in a medical linac at 8 MV, which may strike a reasonable balance between usefully increased beam penetration and dose rate as compared to 6 MV while reducing photoneutron production which is present at 10 MV. METHODS A Varian iX linear accelerator undergoing decommissioning at our clinic was made to operate over a range of photon energies between 6 and 15 MV by calibrating the bending magnet and adjusting other beam generation parameters. Neutron dose within the treatment room was measured using an Anderson-Braun type detector over a continuum of intermediate energies. RESULTS The photoneutron production for energies below 10 MV was measured, adding to data that is otherwise scarce in the literature. Our results are consistent with previously published results for neutron yield. We found that the photoneutron production at 8 MV was about 1/10 of the value at 10 MV, and about 10 times higher than detector background at 6 MV. CONCLUSIONS Photoneutron production drops off below 10 MV, but is still present at 8 MV. An 8 MV beam is more penetrating than a 6 MV beam, and may offer a suitable tradeoff for modern radiotherapy techniques such as VMAT, SRS, and SABR. Further studies are needed to better understand the impact on treatment plan quality between 8 and 10 MV beams considering the benefits to facility requirements and non-therapeutic patient dose.
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Affiliation(s)
- Marco Carlone
- BC Cancer Kelowna, Kelowna, British Columbia, Canada
| | - Ray Yang
- BC Cancer Kelowna, Kelowna, British Columbia, Canada
| | - Derek Hyde
- BC Cancer Kelowna, Kelowna, British Columbia, Canada
- Department of Physics, University of British Columbia - Okanagan, Kelowna, British Columbia, Canada
| | - Nathan Becker
- BC Cancer Kelowna, Kelowna, British Columbia, Canada
- Department of Physics, University of British Columbia - Okanagan, Kelowna, British Columbia, Canada
| | - John Cocarell
- BC Cancer Kelowna, Kelowna, British Columbia, Canada
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20
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Cook N, Shelton N, Gibson S, Barnes P, Alinaghi-Zadeh R, Jameson MG. ACPSEM position paper: the safety of magnetic resonance imaging linear accelerators. Phys Eng Sci Med 2023; 46:19-43. [PMID: 36847966 PMCID: PMC10030425 DOI: 10.1007/s13246-023-01224-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 03/01/2023]
Abstract
Magnetic Resonance Imaging linear-accelerator (MRI-linac) equipment has recently been introduced to multiple centres in Australia and New Zealand. MRI equipment creates hazards for staff, patients and others in the MR environment; these hazards must be well understood, and risks managed by a system of environmental controls, written procedures and a trained workforce. While MRI-linac hazards are similar to the diagnostic paradigm, the equipment, workforce and environment are sufficiently different that additional safety guidance is warranted. In 2019 the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) formed the Magnetic Resonance Imaging Linear-Accelerator Working Group (MRILWG) to support the safe clinical introduction and optimal use of MR-guided radiation therapy treatment units. This Position Paper is intended to provide safety guidance and education for Medical Physicists and others planning for and working with MRI-linac technology. This document summarises MRI-linac hazards and describes particular effects which arise from the combination of strong magnetic fields with an external radiation treatment beam. This document also provides guidance on safety governance and training, and recommends a system of hazard management tailored to the MRI-linac environment, ancillary equipment, and workforce.
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Affiliation(s)
- Nick Cook
- Christchurch Hospital, Christchurch, New Zealand
| | - Nikki Shelton
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, VIC, Australia
| | | | | | - Reza Alinaghi-Zadeh
- Olivia Newton-John Cancer Wellness and Research Centre, Heidelberg, VIC, Australia
| | - Michael G Jameson
- GenesisCare, Sydney, NSW, Australia.
- University of New South Wales, Sydney, Australia.
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21
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Matsubara H. Neutron dose from a 6-MV X-ray beam in radiotherapy. Radiol Phys Technol 2023; 16:186-194. [PMID: 36780121 DOI: 10.1007/s12194-023-00705-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
Although a 6-MV X-ray beam is employed clinically as a non-neutron-producing beam, no studies have reported how few neutrons are produced from a 6-MV beam. This study aimed to theoretically deduce the neutron dose from a 6-MV beam using Monte Carlo simulations for the notification of safety and risk in radiotherapy. Nuclei from a nuclear database with neutron separation energies below 6 MeV were surveyed, suggesting that the certain content of 2H in the human body may result in some contribution. Thus, Monte Carlo calculation considering 2H in a phantom was performed. The calculation suggested that the distribution of the neutron dose from a 6-MV beam consisted of two components: one had neutrons from 2H concentrated within an irradiation field, and the other had those due to other elements such as 183W spreading from a gantry head to a treatment room. Although uncertainty owing to the normalization factor of the Monte Carlo calculations was a factor of three, the neutron doses at distances of 0 and 50 cm from an irradiation field were calculated as 27 and 1.5 nSv/MU, respectively, under intensity-modulated radiotherapy (IMRT) or volumetric modulated arc therapy (VMAT). The calculations suggest that neutrons produced by a 6-MV beam are approximately 70 and 20 times safer than those by a 10-MV beam in the case of IMRT/VMAT and total body irradiation, respectively. Thus, this study theoretically reported the approximate number of neutrons delivered by a 6-MV beam for the first time.
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Affiliation(s)
- Hiroaki Matsubara
- Department of Radiology, Kyoto Prefectural University of Medicine, Kyoto, 602-8566, Japan. .,Faculty of Radiological Technology, Fujita Health University, Aichi, 470-1192, Japan.
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22
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Mizuno N, Okamoto H, Minemura T, Kawamura S, Tohyama N, Kurooka M, Kawamorita R, Nakamura M, Ito Y, Shioyama Y, Aoyama H, Igaki H. Establishing quality indicators to comprehensively assess quality assurance and patient safety in radiotherapy and their relationship with an institution's background. Radiother Oncol 2023; 179:109452. [PMID: 36572282 DOI: 10.1016/j.radonc.2022.109452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 12/11/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Quality indicators (QIs) for radiotherapy have been proposed by several groups, but no study has been conducted to correlate the implementation of indicators specific to patient safety over the course of the clinical process with an institution's background. An initial large-scale survey was conducted to understand the implementation status of QIs established for quality assurance and patient safety in radiotherapy and the relationship between implementation status and an institutions' background. MATERIALS AND METHOD Overall, 68 QIs that were established by this research team after a pilot survey were used to assess structures and processes for quality assurance and patient safety. Data on the implementation of QIs and the institutions' backgrounds were obtained from designated cancer care hospitals in Japan. RESULTS Overall, 284 institutions (72 %) responded and had a median QI achievement rate of 60.8 %. QIs with low implementation rates, such as the implementation of an error reporting system and establishment of a quality assurance department, were identified. The QI achievement rate and scale of the institution were positively correlated, and the achievement rate of all QIs was significantly higher (p < 0.001) in institutions capable of advanced treatments, such as intensity-modulated radiotherapy, and those with a quality assurance department. CONCLUSION A large-scale survey on QIs revealed their implementation and relationship with a facility's background. QIs that require improvement were identified, and that these QIs might be effective in providing advanced medical care to many patients.
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Affiliation(s)
- Norifumi Mizuno
- Department of Radiation Oncology, St. Luke's International Hospital, Tokyo, Japan.
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan.
| | - Toshiyuki Minemura
- Division of Medical Support and Partnership, Institute for Cancer Control, National Cancer Center, Tokyo, Japan.
| | - Shinji Kawamura
- Graduate School of Health Sciences, Teikyo University, Fukuoka, Japan.
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Makuhari Clinic for Advanced Imaging, Cancer Screening, and High-Precision Radiotherapy, Chiba, Japan.
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Ryu Kawamorita
- Department of Radiation Oncology, Tane General Hospital, Osaka, Japan.
| | - Masaru Nakamura
- Department of Radiology, Aichi Medical University Hospital, Aichi, Japan.
| | - Yoshinori Ito
- Department of Radiation Oncology, Showa University School of Medicine, Tokyo, Japan.
| | | | - Hidefumi Aoyama
- Department of Radiation Oncology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, Tokyo, Japan.
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23
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Xu B, Wang Y, Tse G, Chen J, Li G, Korantzopoulos P, Liu T. Radiotherapy-induced malfunctions of cardiac implantable electronic devices: A meta-analysis. Heart Rhythm 2023; 20:689-698. [PMID: 36708909 DOI: 10.1016/j.hrthm.2023.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/18/2022] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND Radiation therapy (RT) may pose acute and long-term risks for patients with cardiac implantable electronic devices (CIEDs), including pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs). OBJECTIVE We conducted a systematic review and meta-analysis to examine the association between RT and PM/ICD malfunctions in patients with cancer. METHODS We searched the literature using the PubMed, the Cochrane Library the Web of Science, and Embase for relative publications until April 2022. Of the 550 initially identified studies, 17 retrospective observational studies including 2454 patients were finally analyzed. RESULTS The meta-analysis showed that RT was associated with an increased risk of ICD malfunctions (odds ratio [OR] 2.75; 95% confidence interval [CI] 1.74-4.33). Five studies were included in the subgroup analysis regarding photon beam energy, showing that radiation-induced CIED failure was more likely to occur in ICDs when beam energy was ≥10 MV (OR 5.28; 95% CI 2.14-13.03). Neutron-generating RT significantly increased the risk of CIED malfunctions (OR 3.97; 95% CI 1.70-9.26), especially the risk of reset (OR 5.79; 95% CI 2.37-14.12; P = .0001). We did not find significant differences in the risk of CIED failure between chest RT and other RT sites (OR 1.09; 95% CI 0.63-1.88). CONCLUSION Our meta-analysis suggests that ICDs are more likely to be affected by RT than PMs. These adverse events, especially reset, in patients with cancer were associated with neutron-generating RT and beam energy ≥10 MV. Given the increasing requirement for RT in several patients with cancer as well as the increasing implantation rates of CIEDs, a better risk stratification is needed in this setting.
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Affiliation(s)
- Beizheng Xu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Yueying Wang
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China; Epidemiology Research Unit, Cardiovascular Analytics Group, Hong Kong, China-UK Collaboration, Hong Kong; Kent and Medway Medical School, Canterbury, Kent, United Kingdom; School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Jiayi Chen
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guangping Li
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.
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24
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Malavasi VL, Imberti JF, Tosetti A, Romiti GF, Vitolo M, Zecchin M, Mazzeo E, Giuseppina DM, Lohr F, Lopez-Fernandez T, Boriani G. A systematic review and meta-analysis on oncological radiotherapy in patients with a cardiac implantable electronic device: Prevalence and predictors of device malfunction in 3121 patients. Eur J Clin Invest 2023; 53:e13862. [PMID: 36004486 PMCID: PMC10078179 DOI: 10.1111/eci.13862] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The number of patients with cardiac implantable electronic devices (CIEDs) undergoing radiotherapy (RT) for cancer treatment is growing. At present, prevalence and predictors of RT-induced CIEDs malfunctions are not defined. METHODS Systematic review and meta-analysis conducted following the PRISMA recommendations. PubMed, Scopus and Google Scholar were searched from inception to 31/01/2022 for studies reporting RT-induced malfunctions in CIEDs patients. Aim was to assess the prevalence of RT-induced CIEDs malfunctions and identify potential predictors. RESULTS Thirty-two out of 3962 records matched the inclusion criteria and were included in the meta-analysis. A total of 135 CIEDs malfunctions were detected among 3121 patients (6.6%, 95% confidence interval [CI]: 5.1%-8.4%). The pooled prevalence increased moving from pacemaker (PM) to implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy and defibrillator (CRT-D) groups (4.1%, 95% CI: 2.9-5.8; 8.2% 95% CI: 5.9-11.3; and 19.8%, 95% CI: 11.4-32.2 respectively). A higher risk ratio (RR) of malfunctions was found when neutron-producing energies were used as compared to non-neutron-producing energies (RR 9.98, 95% CI: 5.09-19.60) and in patients with ICD/CRT-D as compared to patients with PM/CRT-P (RR 2.07, 95% CI: 1.40-3.06). On the contrary, no association was found between maximal radiation dose at CIED >2 Gy and CIEDs malfunctions (RR 0.93; 95% CI: 0.31-2.76). CONCLUSIONS Radiotherapy related CIEDs malfunction had a prevalence ranging from 4% to 20%. The use of neutron-producing energies and more complex devices (ICD/CRT-D) were associated with higher risk of device malfunction, while the radiation dose at CIED did not significantly impact on the risk unless higher doses (>10 Gy) were used.
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Affiliation(s)
- Vincenzo Livio Malavasi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Alberto Tosetti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Translational and Precision Medicine, Sapienza-University of Rome, Rome, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Massimo Zecchin
- Cardiovascular Department, Ospedali Riuniti, University of Trieste, Trieste, Italy
| | - Ercole Mazzeo
- Radiotherapy Division, Department of Oncology, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - De Marco Giuseppina
- Radiotherapy Division, Department of Oncology, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Frank Lohr
- Radiotherapy Division, Department of Oncology, Policlinico Di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
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25
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Wang Y, Zhao J, He Y, Luo C, Sun Y, Zhou L, Xie L. Safely completed radiotherapy in a patient with breast cancer and right axillary vein approach cardiac pacemaker implantation: A case report. Exp Ther Med 2022; 25:17. [PMID: 36545273 PMCID: PMC9748663 DOI: 10.3892/etm.2022.11716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 10/19/2022] [Indexed: 11/23/2022] Open
Abstract
Pacemaker implantation is becoming increasingly common in patients with breast cancer. Comprehensive treatment options, such as surgery, chemotherapy, radiation therapy, targeted therapy and immunotherapy, have greatly improved the prognosis of patients with breast cancer. In particular, radiotherapy is an important means of comprehensive breast cancer treatment that can reduce recurrence and prolong survival in high-risk patients who underwent mastectomy. The pacemaker electrical pulse generator is typically implanted subcutaneously in the left subclavian area above the pectoral muscle through the subclavian vein. The present report implemented a new method of 'temporary pacemaker electrode and permanent artificial pacemaker placement' through the right axillary vein in a patient with breast cancer. An electrical pulse generator was placed in the right subcutaneous subclavian tissue. The pacemaker was placed under the right clavicle, and the pacemaker was included as organ at risk (OAR). Dose of planning organ at risk volume (PRV) with additional 6 mm margin to the pacemaker was limited during radiotherapy planning design. This patient with breast cancer, who was also complicated with other underlying comorbidities (such as atrial fibrillation, coronary atherosclerosis, cardiac insufficiency, hypertension, type 2 diabetes mellitus) and implanted with a cardiac pacemaker, was treated with safe (means that the patient has not developed heart disease because of the pacemaker problem) and effective (tumor can be effectively controlled under the condition that the pacemaker does not malfunction) radiotherapy. At present, the patient has successfully completed radiation therapy for breast cancer with no recurrence or metastasis. To the best of our knowledge, the present report is the first to document this application, demonstrating the treatment of a patient with breast cancer and cardiac pacemaker implantation, which is worthy of further study and continuous improvement in clinical practice.
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Affiliation(s)
- Yunjuan Wang
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Jianling Zhao
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Yinbo He
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Caiyi Luo
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Yu Sun
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Li Zhou
- Department of Radiology Oncology, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China
| | - Li Xie
- Head and Neck Oncology Ward, Cancer Center, West China Hospital of Sichuan University, Chengdu, Sichuan 610044, P.R. China,Correspondence to: Professor Li Xie, Head and Neck Oncology Ward, Cancer Center, West China Hospital of Sichuan University, 37 Guoxue Lane, Chengdu, Sichuan 610044, P.R. China
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26
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 673] [Impact Index Per Article: 336.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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27
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Azraai M, Miura D, Lin YH, Rodrigues TS, Nadurata V. Incidence and Predictors of Cardiac Implantable Electronic Devices Malfunction with Radiotherapy Treatment. J Clin Med 2022; 11:jcm11216329. [PMID: 36362559 PMCID: PMC9654752 DOI: 10.3390/jcm11216329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 12/01/2022] Open
Abstract
Aims: To investigate the incidence of cardiac implantable electronic devices (CIED) malfunction with radiotherapy (RT) treatment and assess predictors of CIED malfunction. Methods: A 6-year retrospective analysis of patients who underwent RT with CIED identified through the radiation oncology electronic database. Clinical, RT (cumulative dose, dose per fraction, beam energy, beam energy dose, and anatomical area of RT) and CIED details (type, manufacturer, and device malfunction) were collected from electronic medical records. Results: We identified 441 patients with CIED who underwent RT. CIED encountered a permanent pacemaker (PPM) (78%), cardiac resynchronization therapy—pacing (CRT-P) (2%), an implantable cardioverter defibrillator (ICD) (10%), and a CRT-defibrillator (CRT-D) (10%). The mean cumulative dose of RT was 36 gray (Gy) (IQR 1.8–80 Gy) and the most common beam energy used was photon ≥10 megavolt (MV) with a median dose of 7 MV (IQR 5–18 MV). We further identified 17 patients who had CIED malfunction with RT. This group had a higher cumulative RT dose of 42.5 Gy (20–77 Gy) and a photon dose of 14 MV (12–18 MV). None of the malfunctions resulted in clinical symptoms. Using logistic regression, the predictors of CIED malfunction were photon beam energy use ≥10 MV (OR 5.73; 95% CI, 1.58–10.76), anatomical location of RT above the diaphragm (OR 5.2, 95% CI, 1.82–15.2), and having a CIED from the ICD group (OR 4.6, 95% CI, 0.75–10.2). Conclusion: Clinicians should be aware of predictors of CIED malfunction with RT to ensure the safety of patients.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
- Faculty of Medicine, Nursing and Health Sciences, School of Rural Health, Monash University, Melbourne, VIC 3550, Australia
- Correspondence: or ; Tel.: +613-5454-6000
| | - Daisuke Miura
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
| | - Yuan-Hong Lin
- Department of Radiation Oncology, Peter McCallum, Bendigo Health, Bendigo, VIC 3550, Australia
| | - Thalys Sampaio Rodrigues
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, Bendigo, VIC 3550, Australia
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28
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Stühlinger M, Burri H, Vernooy K, Garcia R, Lenarczyk R, Sultan A, Brunner M, Sabbag A, Özcan EE, Ramos JT, Di Stolfo G, Suleiman M, Tinhofer F, Aristizabal JM, Cakulev I, Eidelman G, Yeo WT, Lau DH, Mulpuru SK, Nielsen JC, Heinzel F, Prabhu M, Rinaldi CA, Sacher F, Guillen R, de Pooter J, Gandjbakhch E, Sheldon S, Prenner G, Mason PK, Fichtner S, Nitta T. EHRA consensus on prevention and management of interference due to medical procedures in patients with cardiac implantable electronic devices. Europace 2022; 24:1512-1537. [PMID: 36228183 DOI: 10.1093/europace/euac040] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023] Open
Affiliation(s)
- Markus Stühlinger
- Department of Internal Medicine III - Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rodrigue Garcia
- Department of Cardiology, University Hospital of Poitiers, Poitiers, France
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Medical University of Silesia, Silesian Center of Heart Diseases, Zabrze, Poland
- Medical University of Silesia, Division of Medical Sciences, Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Arian Sultan
- Department of Electrophysiology, Heart Center at University Hospital Cologne, Cologne, Germany
| | - Michael Brunner
- Department of Cardiology and Medical Intensive Care, St Josefskrankenhaus, Freiburg, Germany
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Emin Evren Özcan
- Heart Rhythm Management Center, Dokuz Eylul University, İzmir, Turkey
| | - Jorge Toquero Ramos
- Cardiac Arrhythmia and Electrophysiology Unit, Cardiology Department, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Giuseppe Di Stolfo
- Cardiac Intensive Care and Arrhythmology Unit, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Mahmoud Suleiman
- Cardiology/Electrophysiology, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Ivan Cakulev
- University Hospitals of Cleveland, Case Western University, Cleveland, OH, USA
| | - Gabriel Eidelman
- San Isidro's Central Hospital, Diagnóstico Maipú, Buenos Aires Province, Argentina
| | - Wee Tiong Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders, The University of Adelaide and Royal Adelaide Hospital, Adelaide, SA, Australia
| | | | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Frank Heinzel
- Department of Cardiology, Charité University Medicine, Campus Virchow-Klinikum, 13353 Berlin, Germany
| | - Mukundaprabhu Prabhu
- Associate Professor in Cardiology, In charge of EP Division, Kasturba Medical College Manipal, Manipal, Karnataka, India
| | | | - Frederic Sacher
- Bordeaux University Hospital, Univ. Bordeaux, Bordeaux, France
| | - Raul Guillen
- Sanatorio Adventista del Plata, Del Plata Adventist University Entre Rios Argentina, Entre Rios, Argentina
| | - Jan de Pooter
- Professor of Cardiology, Ghent University, Deputy Head of Clinic, Heart Center UZ Gent, Ghent, Belgium
| | - Estelle Gandjbakhch
- AP-HP Sorbonne Université, Hôpital Pitié-Salpêtrière, Institut de Cardiologie, ICAN, Paris, France
| | - Seth Sheldon
- The Department of Cardiovascular Medicine, University of Kansas Health System, Kansas City, KS 66160, USA
| | | | - Pamela K Mason
- Director, Electrophysiology Laboratory, University of Virginia, Charlottesville, VA, USA
| | - Stephanie Fichtner
- LMU Klinikum, Medizinische Klinik und Poliklinik I, Campus Großhadern, München, Germany
| | - Takashi Nitta
- Emeritus Professor, Nippon Medical School, Presiding Consultant of Cardiology, Hanyu General Hospital, Saitama, Japan
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29
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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30
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Levis M, Dusi V, Magnano M, Cerrato M, Gallio E, Depaoli A, Ferraris F, De Ferrari GM, Ricardi U, Anselmino M. A case report of long-term successful stereotactic arrhythmia radioablation in a cardiac contractility modulation device carrier with giant left atrium, including a detailed dosimetric analysis. Front Cardiovasc Med 2022; 9:934686. [PMID: 36072883 PMCID: PMC9441661 DOI: 10.3389/fcvm.2022.934686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/25/2022] [Indexed: 12/25/2022] Open
Abstract
Introduction Catheter ablation (CA) is the current standard of care for patients suffering drug-refractory monomorphic ventricular tachycardias (MMVTs). Yet, despite significant technological improvements, recurrences remain common, leading to increased morbidity and mortality. Stereotactic arrhythmia radioablation (STAR) is increasingly being adopted to overcome the limitations of conventional CA, but its safety and efficacy are still under evaluation. Case presentation We hereby present the case of a 73-year-old patient implanted with a mitral valve prosthesis, a cardiac resynchronization therapy-defibrillator, and a cardiac contractility modulation device, who was successfully treated with STAR for recurrent drug and CA-resistant MMVT in the setting of advanced heart failure and a giant left atrium. We report a 2-year follow-up and a detailed dosimetric analysis. Conclusion Our case report supports the early as well as the long-term efficacy of 25 Gy single-session STAR. Despite the concomitant severe heart failure, with an overall heart minus planned target volume mean dosage below 5 Gy, no major detrimental cardiac side effects were detected. To the best of our knowledge, our dosimetric analysis is the most accurate reported so far in the setting of STAR, particularly for what concerns cardiac substructures and coronary arteries. A shared dosimetric planning among centers performing STAR will be crucial in the next future to fully disclose its safety profile.
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Affiliation(s)
- Mario Levis
- Department of Oncology, University of Turin, Turin, Italy
| | - Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Massimo Magnano
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Marzia Cerrato
- Department of Oncology, University of Turin, Turin, Italy
| | - Elena Gallio
- Medical Physics Unit, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Alessandro Depaoli
- Department of Radiology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Federico Ferraris
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
- *Correspondence: Gaetano Maria De Ferrari
| | | | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
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The impact of particle radiotherapy on the functioning of cardiac implantable electronic devices: a systematic review of in vitro and in vivo studies according to PICO criteria. Radiol Med 2022; 127:1046-1058. [PMID: 35871428 PMCID: PMC9508006 DOI: 10.1007/s11547-022-01520-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/20/2022] [Indexed: 12/24/2022]
Abstract
The number of oncological patients who may benefit from proton beam radiotherapy (PBT) or carbon ion radiotherapy (CIRT), overall referred to as particle radiotherapy (RT), is expected to strongly increase in the next future, as well as the number of cardiological patients requiring cardiac implantable electronic devices (CIEDs). The management of patients with a CIED requiring particle RT deserves peculiar attention compared to those undergoing conventional photon beam RT, mostly due to the potential generation of secondary neutrons by particle beams interactions. Current consensus documents recommend managing these patients as being at intermediate/high risk of RT-induced device malfunctioning regardless of the dose on the CIED and the beam delivery method used, despite the last one significantly affects secondary neutrons generation (very limited neutrons production with active scanning as opposed to the passive scattering technique). The key issues for the current review were expressed in four questions according to the Population, Intervention, Control, Outcome criteria. Three in vitro and five in vivo studies were included. Based on the available data, PBT and CIRT with active scanning have a limited potential to interfere with CIED that has only emerged from in vitro study so far, while a significant potential for neutron-related, not severe, CIED malfunctions (resets) was consistently reported in both clinical and in vitro studies with passive scattering.
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Bhimani F, Johnson K, Brodin NP, Tomé WA, Fox J, Mehta K, McEvoy M, Feldman S. Case Report: Can Targeted Intraoperative Radiotherapy in Patients With Breast Cancer and Pacemakers be the New Standard of Care? Front Oncol 2022; 12:927174. [PMID: 35903710 PMCID: PMC9315093 DOI: 10.3389/fonc.2022.927174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 06/20/2022] [Indexed: 11/17/2022] Open
Abstract
Background Partial breast irradiation with Intra-operative radiotherapy (IORT) has become a popular management option as opposed to whole breast radiation using external beam radiotherapy for breast cancer patients. While previous studies have highlighted the use of IORT in breast cancer patients, there is a scarcity of literature on the use of IORT in those who also have ipsilateral pacemakers. Thus, the aim of our case report is to highlight the applicability of IORT in breast cancer patients who also have a pacemaker. Case Reports Two female patients with an implanted dual-chamber pacemaker presented with a diagnosis of left-sided invasive ductal carcinoma on mammogram. Mammography of the left breast revealed a 10 mm and 7 mm spiculated mass, respectively, further confirmed with an ultrasound-guided core biopsy that was conclusive of clinical Stage I T1 N0 grade 2, ER +, PR + Her2 – invasive ductal carcinoma. They met our eligibility criteria for IORT, which is being performed as a registry trial. These patients underwent a wide excision lumpectomy along with IORT. Conclusion Our findings underscore the successful use of targeted IORT for breast-conserving surgery in a patient with invasive ductal carcinoma and pacemaker, hence eliminating the necessity for relocating pacemaker surgeries in these patients. Furthermore, no device failure or malfunction for the pacemaker was recorded before, during, or after the surgery, demonstrating the safety of using IORT in patients with preinstalled pacemaker despite a lack of evidence on safe radiation dosage or manufacturer guidelines. Nonetheless, the effects of IORT on pacemaker < 10 cm were not studied in our patients and further clinical studies are recommended to reinforce the applicability and safe distance of IORT in breast cancer patients with pacemaker.
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Affiliation(s)
- Fardeen Bhimani
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Kelly Johnson
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - N. Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Wolfgang A. Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Keyur Mehta
- Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, United States
| | - Maureen McEvoy
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
| | - Sheldon Feldman
- Breast Surgery Division, Department of Surgery, Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, United States
- *Correspondence: Sheldon Feldman,
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A publicly available dataset of out-of-field dose profiles of a 6 MV linear accelerator. Phys Eng Sci Med 2022; 45:613-621. [PMID: 35553016 DOI: 10.1007/s13246-022-01131-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
An increase in radiotherapy-induced secondary malignancies has led to recent developments in analytical modelling of out-of-field dose. These models must be validated against measurements, but currently available datasets are outdated or limited in scope. This study aimed to address these shortcomings by producing a large dataset of out-of-field dose profiles measured with modern equipment. A novel method was developed with the intention of allowing physicists in all clinics to perform these measurements themselves using commonly available dosimetry equipment. A standard 3D scanning water tank was used to collect 36 extended profiles. Each profile was measured in two sections, with the inner section measured with the beam directly incident on the tank, and the outer section with the beam incident on a water-equivalent phantom abutted next to the tank. The two sections were then stitched using a novel feature-matching approach. The profiles were compared against linac commissioning data and manually inspected for discontinuities in the overlap region. The dataset is presented as a publicly accessible comma separated variable file containing off-axis ratios at a range of off-axis distances. This dataset may be applied to the development and validation of analytical models of out-of-field dose. Additionally, it may be used to inform dose estimates to radiosensitive implants and anatomy. Physicists are encouraged to perform these out-of-field measurements in their own clinics and share their results with the community.
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Riegel AC, Polvorosa C, Sharma A, Baker J, Ge W, Lauritano J, Calugaru E, Chang J, Antone J, Oliveira A, Buckenberger W, Chen W, Cao Y, Kapur A, Potters L. Assessing initial plan check efficacy using TG 275 failure modes and incident reporting. J Appl Clin Med Phys 2022; 23:e13640. [PMID: 35536772 PMCID: PMC9194987 DOI: 10.1002/acm2.13640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/26/2022] [Accepted: 04/18/2022] [Indexed: 11/25/2022] Open
Abstract
Plan checks are important components of a robust quality assurance (QA) program. Recently, the American Association of Physicists in Medicine (AAPM) published two reports concerning plan and chart checking, Task Group (TG) 275 and Medical Physics Practice Guideline (MPPG) 11.A. The purpose of the current study was to crosswalk initial plan check failure modes revealed in TG 275 against our institutional QA program and local incident reporting data. Ten physicists reviewed 46 high‐risk failure modes reported in Table S1.A.i of the TG 275 report. The committee identified steps in our planning process which sufficiently checked each failure mode. Failure modes that were not covered were noted for follow‐up. A multidisciplinary committee reviewed the narratives of 1599 locally‐reported incidents in our Radiation Oncology Incident Learning System (ROILS) database and categorized each into the high‐risk TG 275 failure modes. We found that over half of the 46 high‐risk failure modes, six of which were top‐ten failure modes, were covered in part by daily contouring peer‐review rounds, upstream of the traditional initial plan check. Five failure modes were not adequately covered, three of which concerned pregnancy, pacemakers, and prior dose. Of the 1599 incidents analyzed, 710 were germane to the initial plan check, 23.4% of which concerned missing pregnancy attestations. Most, however, were caught prior to CT simulation (98.8%). Physics review and initial plan check were the least efficacious checks, with error detection rates of 31.8% and 31.3%, respectively, for some failure modes. Our QA process that includes daily contouring rounds resulted in increased upstream error detection. This work has led to several initiatives in the department, including increased automation and enhancement of several policies and procedures. With TG 275 and MPPG 11.A as a guide, we strongly recommend that departments consider an internal chart checking policy and procedure review.
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Affiliation(s)
- Adam C. Riegel
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - Cynthia Polvorosa
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Anurag Sharma
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Jameson Baker
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - William Ge
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Joseph Lauritano
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Emel Calugaru
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Jenghwa Chang
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - Jeffrey Antone
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | - Angela Oliveira
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
| | | | - William Chen
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - Yijian Cao
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - Ajay Kapur
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
| | - Louis Potters
- Department of Radiation MedicineNorthwell HealthLake SuccessNew YorkUSA
- Donald and Barbara Zucker School of Medicine at Hofstra/NorthwellHempsteadNew YorkUSA
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First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device. ASAIO J 2022; 68:e84-e86. [PMID: 35503645 DOI: 10.1097/mat.0000000000001478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A 77 year old man previously implanted with a HeartMate II left ventricular assist device (LVAD) as destination therapy and an implantable cardioverter defibrillator presented with a left upper lobe squamous cell lung cancer. Oncology determined that proton beam therapy was indicated for treatment, and a multidisciplinary team of radiation physicists, radiation oncologists, and LVAD providers developed a protocol to proceed safely. He was successfully treated with combined proton beam radiation therapy and reduced dose chemotherapy. This case demonstrates feasibility and considerations of proton beam therapy for malignancy relevant to patients with implantable cardiac devices including LVADs.
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Gauter-Fleckenstein B, Tülümen E, Rudic B, Borggrefe M, Polednik M, Fleckenstein J. Local dose rate effects in implantable cardioverter-defibrillators with flattening filter free and flattened photon radiation. Strahlenther Onkol 2022; 198:566-572. [PMID: 35267050 PMCID: PMC9165256 DOI: 10.1007/s00066-022-01911-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 11/28/2022]
Abstract
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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Affiliation(s)
- Benjamin Gauter-Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Erol Tülümen
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Boris Rudic
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Martin Borggrefe
- I. Medizinische Klinik, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.,Partner Site Heidelberg/Mannheim, German Center for Cardiovascular Research (DZHK), Mannheim, Germany
| | - Martin Polednik
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Hayase J, Chin R, Cao M, Hu P, Shivkumar K, Bradfield JS. Non-invasive Stereotactic Body Radiation Therapy for Refractory Ventricular Arrhythmias: Venturing into the Unknown. J Innov Card Rhythm Manag 2022; 13:4894-4899. [PMID: 35251759 PMCID: PMC8887931 DOI: 10.19102/icrm.2022.130202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/02/2021] [Indexed: 11/12/2022] Open
Abstract
Stereotactic body radiation therapy (SBRT) is a promising new method for non-invasive management of life-threatening ventricular arrhythmias. Numerous case reports and case series have provided encouraging short-term results suggesting good efficacy and safety, but randomized data and long-term outcomes are not yet available. The primary hypothesis as to the mechanism of action for SBRT relates to the development of cardiac fibrosis in arrhythmogenic myocardial substrate; however, limited animal model data offer conflicting insights into this theory. The use of SBRT for patients with refractory ventricular arrhythmias is rapidly increasing, but ongoing translational science work and randomized clinical trials will be critical to address many outstanding questions regarding this novel therapy.
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Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Robert Chin
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Minsong Cao
- Radiation Oncology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Peng Hu
- Department of Radiological Services, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Daniela Falco M, Andreoli S, Delana A, Barbareschi A, De Filippo P, Leidi C, Marini M, Appignani M, Genovesi D, Di Girolamo E. In-vitro investigation of cardiac implantable electronic device malfunction during and after direct photon exposure: A three-centres experience. Phys Med 2022; 94:94-101. [PMID: 35007940 DOI: 10.1016/j.ejmp.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 11/26/2021] [Accepted: 12/28/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Radiotherapy may cause malfunction of implantable cardioverter-defibrillators (ICDs) and pacemakers (PMs). We carried-out a multicentre randomized in-vitro study on 65 ICDs and 145 PMs to evaluate malfunctions during and after direct irradiation to doses up to 10 Gy. METHODS Three centres equipped with different linear accelerator and treatment-planning systems participated in the study. Computed Tomography (CT) acquisitions were performed to build the treatment plans. All devices were exposed to dose of 2, 5, or 10 Gy (6 MV). All devices underwent a baseline examination and 64 wireless real-time telemetry-transmissions (47 ICDs and 17 PMs) were monitored during photon exposures. All devices were interrogated after exposure and once monthly for six subsequent months. RESULTS Fifty-four of the 64 wireless-enabled CIEDs (84.4%) recorded noise-related interferences during exposure. In detail, 40/47 ICDs (85.1%) reported interference, of which 16 ICDs (34%) reported potentially clinically relevant pacing inhibition and inappropriate detections. Following exposure, a soft reset occurred in 1/145 PM (0.7%) while 7/145 PMs (4.8%) reported battery issues. During the six-month follow-up, 1/145 PM (0.7%) reported a soft reset, while 12/145 more PMs (8.3%) and 1/64 ICD (1.5%) showed abnormal battery depletion. All reported issues occurred independently of exposure dose. Finally, irreversible effects on software and battery life occurred in only non-MRI-compatible devices. CONCLUSION ICDs mostly featured real-time transient sensing issues, while PMs mostly experienced long-term battery or software issues that were observed immediately following radiation exposure and during follow-up. Irreversible effects on battery life and software occurred in only non-MRI-compatible devices.
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Affiliation(s)
- Maria Daniela Falco
- Department of Radiation Oncology, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy.
| | - Stefano Andreoli
- Medical Physics Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Anna Delana
- Medical Physics Unit, "S. Chiara" Hospital, Trento, Italy
| | | | - Paolo De Filippo
- Electrophysiology Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | - Cristina Leidi
- Electrophysiology Unit, ASST "Papa Giovanni XXIII", Bergamo, Italy
| | | | | | - Domenico Genovesi
- Department of Radiation Oncology, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
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Tillery H, Moore M, Gallagher KJ, Taddei PJ, Leuro E, Argento DC, Moffitt GB, Kranz M, Carey M, Heymsfield S, Newhauser WD. Personalized 3D-printed anthropomorphic whole-body phantom irradiated by protons, photons, and neutrons. Biomed Phys Eng Express 2022; 8. [PMID: 35045408 DOI: 10.1088/2057-1976/ac4d04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/19/2022] [Indexed: 11/12/2022]
Abstract
The objective of this study was to confirm the feasibility of three-dimensionally-printed (3D-printed), personalized whole-body anthropomorphic phantoms for radiation dose measurements in a variety of charged and uncharged particle radiation fields. We 3D-printed a personalized whole-body phantom of an adult female with a height of 154.8 cm, mass of 90.7 kg, and body mass index of 37.8 kg/m2. The phantom comprised of a hollow plastic shell filled with water and included a watertight access conduit for positioning dosimeters. It is compatible with a wide variety of radiation dosimeters, including ionization chambers that are suitable for uncharged and charged particles. Its mass was 6.8 kg empty and 98 kg when filled with water. Watertightness and mechanical robustness were confirmed after multiple experiments and transportations between institutions. The phantom was irradiated to the cranium with therapeutic beams of 170-MeV protons, 6-MV photons, and fast neutrons. Radiation absorbed dose was measured from the cranium to the pelvis along the longitudinal central axis of the phantom. The dose measurements were made using established dosimetry protocols and well-characterized instruments. For the therapeutic environments considered in this study, stray radiation from intracranial treatment beams was the lowest for proton therapy, intermediate for photon therapy, and highest for neutron therapy. An illustrative example set of measurements at the location of the thyroid for a square field of 5.3 cm per side resulted in 0.09, 0.59, and 1.93 cGy/Gy from proton, photon, and neutron beams, respectively. In this study, we found that 3D-printed personalized phantoms are feasible, inherently reproducible, and well-suited for therapeutic radiation measurements. The measurement methodologies we developed enabled the direct comparison of radiation exposures from neutron, proton, and photon beam irradiations.
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Affiliation(s)
- Hunter Tillery
- Radiation Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, KPV4, Portland, Oregon, 97239-3098, UNITED STATES
| | - Meagan Moore
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Kyle Joseph Gallagher
- Radiation Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, KPV4, Portland, Oregon, 97239-3098, UNITED STATES
| | - Phillip J Taddei
- Department of Radiation Oncology, Mayo Clinic, 200 First St. SW, Rochester, Minnesota, 55905, UNITED STATES
| | - Eric Leuro
- Seattle Cancer Care Alliance, 1570 N 115th St, Seattle, Washington, 98133, UNITED STATES
| | - David C Argento
- Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Gregory B Moffitt
- Radiation Oncology, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Marissa Kranz
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, Washington, 98195, UNITED STATES
| | - Margaret Carey
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Steven Heymsfield
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
| | - Wayne David Newhauser
- Louisiana State University, 439-B Nicholson Hall, Tower Dr., Baton Rouge, Louisiana, 70803-4001, UNITED STATES
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Stick LB, Lægdsmand PMT, Bjerre HL, Høyer M, Jensen K, Jensen MF, Kronborg MB, Offersen BV, Kronborg CJS. Spot-scanning proton therapy for targets with adjacent cardiac implantable electronic devices – Strategies for breast and head & neck cancer. Phys Imaging Radiat Oncol 2022; 21:66-71. [PMID: 35243034 PMCID: PMC8861136 DOI: 10.1016/j.phro.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/11/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
Secondary neutron dose was calculated for pacemakers and implantable cardioverter defibrillators for patients with breast and head & neck cancer. Decision algorithms for selecting patients with targets adjacent to pacemakers and implantable cardioverter defibrillators for proton therapy were established. Eligibility for proton therapy depends on individual evaluation for some patients. The expected gain from proton therapy should outweigh the risk of device malfunction.
Background and purpose Cardiac implantable electronic device (CIED) malfunctions can be induced by secondary neutron dose from spot-scanning proton therapy. A recent in-vitro study investigating secondary neutron dose to CIEDs up to 7 mSv per fraction found that exposure of secondary neutrons in this range was clinically manageable. This study presents decision algorithms proposed by a national expert group for selection of patients with breast and head & neck (H&N) cancer with CIEDs adjacent to target for proton therapy based on the 7 mSv threshold. Methods and materials Ten patients with breast cancer and five with H&N cancer were included in the study. Five patients with breast cancer received photon therapy with CIED and proton plans were retrospectively created. The remaining patients received proton therapy without CIED and a worst-case position of a virtual CIED was retrospectively delineated. Secondary neutron dose was estimated as ambient dose equivalent H*(10) using Monte Carlo simulations. Results For patients with breast cancer and with contralateral CIED, the secondary neutron dose to the CIED was below 7 mSv per fraction for CTV < 1500 cm3 in 2 Gy fractions and CTV < 1000 cm3 in 2.67 Gy fractions. The secondary neutron dose to the CIED was below 7 mSv per fraction for all patients with H&N cancer. Conclusions Simulations of neutron exposure suggest that proton therapy is feasible for most patients with CIED adjacent to target. This forms the basis for decision algorithms for selection of patients with CIED for proton therapy.
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Affiliation(s)
- Line Bjerregaard Stick
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Corresponding author at: Danish Centre for Particle Therapy, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus, Denmark.
| | | | - Henrik Laurits Bjerre
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Høyer
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Kenneth Jensen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Birgitte Vrou Offersen
- Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
- Department of Experimental Clinical Oncology & Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
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Escande A, Frey P, Lacornerie T, Mervoyer E, Chargari C, Laurans M, Mornex F, Marijon É, Giraud P. Radiotherapy for patient with cardiac implantable electronic device, consensus from French radiation oncology society. Cancer Radiother 2021; 26:404-410. [PMID: 34969621 DOI: 10.1016/j.canrad.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Radiotherapy in patients with cardiac implantable electronic device such as pacemakers or defibrillators, is a clinical situation that is becoming increasingly common. There is a risk of interaction between the magnetic field induced by accelerators and the cardiac implantable electronic device, but also a risk of device dysfunction due to direct and/or indirect irradiation if the cardiac implantable electronic device is in the field of treatment. The risk can be dose-dependent, but it is most often independent of the total dose and occurs randomly in case of neutron production (stochastic effect). The presence of this type of device is therefore described as a contraindication for radiotherapy by the French national agency for the safety of medicines and health products (Agence nationale de sécurité du médicament et des produits de santé, ANSM). Nevertheless, since radiotherapy is often possible, it is advisable to respect the recommendations of good practice, in particular the eligibility criteria, the monitoring modalities before, during and after irradiation according to the type of treatment, the dose and the characteristics of the cardiac implantable electronic device. It is sometimes necessary to discuss repositioning the device and/or modifying the treatment plan to minimize the risk of cardiac implantable electronic device dysfunction. We present the update of the recommendations of the French society of oncological radiotherapy on in patients with cardiac implantable electronic device.
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Affiliation(s)
- A Escande
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Faculté de médecine Henri-Warembourg, université de Lille, 59000 Lille, France; UMR 9189, Centre de recherche en informatique, signal et automatique de Lille (Cristal), 59655 Villeneuve d'Ascq, France.
| | - P Frey
- Département de cardiologie, centre hospitalier Annecy Genevois, 74370 Épagny-Metz-Tessy, France
| | - T Lacornerie
- Département de physique médicale, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France
| | - E Mervoyer
- Département de cardiologie, Institut de cancérologie de l'Ouest, 44800 Saint-Herblain, France
| | - C Chargari
- Unité de curiethérapie, département de radiothérapie, Gustave-Roussy, 94805 Villejuif, France
| | - M Laurans
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, Université de Paris, 20, rue Leblanc, 75015 Paris, France
| | - F Mornex
- Département de radiothérapie, centre hospitalier Lyon Sud, 69310 Pierre-Bénite, France
| | - É Marijon
- Département de cardiologie, hôpital européen Georges-Pompidou, 20, rue Leblanc, 75015 Paris, France
| | - P Giraud
- Service d'oncologie radiothérapie, hôpital européen Georges-Pompidou, Université de Paris, 20, rue Leblanc, 75015 Paris, France
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42
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Su S, Atwal P, Lobo J, Duzenli C, Popescu IA. A new DOSXYZnrc method for Monte Carlo simulations of 4D dose distributions. Phys Med Biol 2021; 66. [PMID: 34787104 DOI: 10.1088/1361-6560/ac3a24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 11/16/2021] [Indexed: 11/12/2022]
Abstract
The purpose of this study is to present a novel method for generating Monte Carlo 4D dose distributions in a single DOSXYZnrc simulation. During a standard simulation, individual energy deposition events are summed up to generate a 3D dose distribution and their associated temporal information is discarded. This means that in order to determine dose distributions as a function of time, separate simulations would have to be run for each interval of interest. Consequently, it has not been clinically feasible until now to routinely perform Monte Carlo simulations of dose rate, time-resolved dose accumulation, or electronic portal imaging devices (EPID) cine-mode images for volumetric modulated arc therapy (VMAT) plans. To overcome this limitation, we modified DOSXYZnrc and defined new input and output variables that allow a time-like parameter associated with each particle history to be binned in a user-defined manner. Under the new code version, computation times are the same as for a standard simulation, and the time-integrated 4D dose is identical to the standard 3D dose. We present a comparison of scintillator measurements and Monte Carlo simulations for dose rate during a VMAT beam delivery, a study of dose rate in a VMAT total body irradiation plan, and simulations of transit (through-patient) EPID cine-mode images.
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Affiliation(s)
- S Su
- BC Cancer, Vancouver, Canada
| | - P Atwal
- BC Cancer, Abbotsford, Canada
| | - J Lobo
- University of British Columbia, Vancouver, Canada
| | - C Duzenli
- BC Cancer, Vancouver, Canada.,University of British Columbia, Vancouver, Canada
| | - I A Popescu
- BC Cancer, Vancouver, Canada.,University of British Columbia, Vancouver, Canada
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43
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Jurado-Bruggeman D, Muñoz-Montplet C, Hernandez V, Saez J, Fuentes-Raspall R. Impact of the dose quantity used in MV photon optimization on dose distribution, robustness, and complexity. Med Phys 2021; 49:648-665. [PMID: 34855988 DOI: 10.1002/mp.15389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 10/09/2021] [Accepted: 11/18/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Convolution/superposition algorithms used in megavoltage (MV) photon radiotherapy model radiation transport in water, yielding dose to water-in-water (Dw,w ). Advanced algorithms constitute a step forward, but their dose distributions in terms of dose to medium-in-medium (Dm,m ) or dose to water-in-medium (Dw,m ) can be problematic when used in plan optimization due to their different dose responses to some atomic composition heterogeneities. Failure to take this into account can lead to undesired overcorrections and thus to unnoticed suboptimal and unrobust plans. Dose to reference-like medium (Dref,m* ) was recently introduced to overcome these limitations while ensuring accurate transport. This work evaluates and compares the performance of these four dose quantities in planning target volume (PTV)-based optimization. METHODS We considered three cases with heterogeneities inside the PTV: virtual phantom with water surrounded by bone; head and neck; and lung. These cases were planned with volumetric modulated arc therapy (VMAT) technique, optimizing with the same setup and objectives for each dose quantity. We used different algorithms of the Varian Eclipse treatment planning system (TPS): Acuros XB (AXB) for Dm,m and Dw,m , and Analytical Anisotropic Algorithm (AAA) for Dw,w . Dref,m* was obtained from Dm,m distributions using an in-house software considering water as the reference medium (Dw,m* ). The optimization process consisted of: (1) common first optimization, (2) dose distribution computed for each quantity, (3) re-optimization, and (4) final calculation for each dose quantity. The dose distribution, robustness to patient setup errors, and complexity of the plans were analyzed and compared. RESULTS The quantities showed similar dose distributions after the optimization but differed in terms of plan robustness. The cases with soft tissue and high-density heterogeneities followed the same pattern. For AXB Dm,m , cold regions appeared in the heterogeneities after the first optimization. They were compensated in the second optimization through local fluence increases, but any positional mismatch impacted robustness, with clinical target volume (CTV) variations from the nominal scenario around +3% for bone and up to +7% for metal. For AXB Dw,m the pattern was inverse (hot regions compensated by fluence decreases) and more pronounced, with CTV dose variations around -7% for bone and up to -17% for metal. Neither AXB Dw,m* nor AAA Dw,w presented these dose inhomogeneities, which resulted in more robust plans. However, Dw,w differed markedly from the other quantities in the lung case because of its lower radiation transport accuracy. AXB Dm,m was the most complex of the four dose quantities and AXB Dw,m* the least complex, though we observed no major differences in this regard. CONCLUSIONS The dose quantity used in MV photon optimization can affect plan robustness. Dw,w distributions from convolution/superposition algorithms are robust but may not provide sufficient radiation transport accuracy in some cases. Dm,m and Dw,m from advanced algorithms can compromise robustness because their different responses to some composition heterogeneities introduce additional fluence compensations. Dref,m* offers advantages in plan optimization and evaluation, producing accurate and robust plans without increasing complexity. Dref,m* can be easily implemented as a built-in feature of the TPS and can facilitate and simplify the treatment planning process when using advanced algorithms. Final reporting can be kept in Dm,m or Dw,m for clinical correlations.
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Affiliation(s)
- Diego Jurado-Bruggeman
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Girona, Spain
| | - Carles Muñoz-Montplet
- Medical Physics and Radiation Protection Department, Institut Català d'Oncologia, Girona, Spain.,Department of Medical Sciences, University of Girona, Girona, Spain
| | - Victor Hernandez
- Department of Medical Physics, Hospital Universitari Sant Joan de Reus, IISPV, Tarragona, Spain.,Universitat Rovira i Virgili, Tarragona, Spain
| | - Jordi Saez
- Department of Radiation Oncology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Rafael Fuentes-Raspall
- Department of Medical Sciences, University of Girona, Girona, Spain.,Radiation Oncology Department, Institut Català d'Oncologia, Girona, Spain
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44
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Azraai M, D'Souza D, Nadurata V. Current Clinical Practice in Patients With Cardiac Implantable Electronic Devices (CIED) Undergoing Radiotherapy (RT). Heart Lung Circ 2021; 31:327-340. [PMID: 34844904 DOI: 10.1016/j.hlc.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/05/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
Patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy (RT) are more common due to ageing of the population. With newer CIEDs implementing the complementary metal-oxide semiconductor (CMOS) technology which allows the miniaturisation of CIED, it is also more susceptible to RT. Effects of RT on CIED ranges from device interference, device operational/memory errors of permanent damage. These malfunctions can cause life threatening clinical effects. Cumulative dose is not the only component of RT that causes CIED malfunction, as neutron use and dose rate effect also affects CIEDs. The management of this patient cohort in clinical practice is inconsistent due to lack of a consistent guideline from manufacturers and physician specialty societies. Our review will focus on the current clinical practice and the recent updated guidelines of managing patients with CIED undergoing RT. We aim to simplify the evidence and provide a simple and easy to use guide based on the recent guidelines.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, Bendigo, Vic, Australia.
| | - Daniel D'Souza
- Department of Cardiology, Bendigo Health, Bendigo, Vic, Australia
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45
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Hashimoto T, Demizu Y, Numajiri H, Isobe T, Fukuda S, Wakatsuki M, Yamashita H, Murayama S, Takamatsu S, Katoh H, Murata K, Kohno R, Arimura T, Matsuura T, Ito YM. Particle therapy using protons or carbon ions for cancer patients with cardiac implantable electronic devices (CIED): a retrospective multi-institutional study. Jpn J Radiol 2021; 40:525-533. [PMID: 34779984 PMCID: PMC9068656 DOI: 10.1007/s11604-021-01218-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/05/2021] [Indexed: 11/27/2022]
Abstract
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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Affiliation(s)
- Takayuki Hashimoto
- Department of Radiation Medical Science and Engineering, Faculty of Medicine, Hokkaido University, North 15 West 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan.
| | - Yusuke Demizu
- Department of Radiology, Hyogo Ion Beam Medical Center, 1-2-1 Kouto, Shingu-cho, Tatsuno, Hyogo, Japan
| | - Haruko Numajiri
- Department of Radiation Oncology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Tomonori Isobe
- Department of Radiation Oncology, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shigekazu Fukuda
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Masaru Wakatsuki
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Haruo Yamashita
- Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan
| | - Shigeyuki Murayama
- Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, Japan
| | - Shigeyuki Takamatsu
- Department of Radiation Therapy, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Katoh
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, Japan
- Department of Radiation Oncology, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, Kanagawa, Japan
| | - Kazutoshi Murata
- QST Hospital, National Institutes for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
- Department of Radiation Oncology, Gunma University Graduate School of Medicine, 3-39-22 Showa-machi, Maebashi, Gunma, Japan
| | - Ryosuke Kohno
- National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba, Japan
- Department of Accelerator and Medical Physics, National Institute for Quantum and Radiological Science and Technology, 4-9-1 Anagawa, Inage-ku, Chiba, Japan
| | - Takeshi Arimura
- Medipolis Proton Therapy and Research Center, 4423, Higashikata, Ibusuki, Kagoshima, Japan
| | - Taeko Matsuura
- Faculty of Engineering, Hokkaido University, Kita 13, Nishi 8, Kita-ku, Sapporo, Hokkaido, Japan
| | - Yoichi M Ito
- Biostatistics Division, Clinical Research and Medical Innovation Center, Hokkaido University Hospital, Kita14, Nishi5, Kita-Ku, Sapporo, Hokkaido, Japan
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46
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Kim M, Ford E, Smith W, Bowen SR, Geneser S, Meyer J. A system for equitable workload distribution in clinical medical physics. J Appl Clin Med Phys 2021; 22:186-193. [PMID: 34697863 PMCID: PMC8664136 DOI: 10.1002/acm2.13460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/21/2021] [Accepted: 10/11/2021] [Indexed: 11/07/2022] Open
Abstract
Background Clinical medical physics duties include routine tasks, special procedures, and development projects. It can be challenging to distribute the effort equitably across all team members, especially in large clinics or systems where physicists cover multiple sites. The purpose of this work is to study an equitable workload distribution system in radiotherapy physics that addresses the complex and dynamic nature of effort assignment. Methods We formed a working group that defined all relevant clinical tasks and estimated the total time spent per task. Estimates used data from the oncology information system, a survey of physicists, and group consensus. We introduced a quantitative workload unit, “equivalent workday” (eWD), as a common unit for effort. The sum of all eWD values adjusted for each physicist's clinical full‐time equivalent yields a “normalized total effort” (nTE) metric for each physicist, that is, the fraction of the total effort assigned to that physicist. We implemented this system in clinical operation. During a trial period of 9 months, we made adjustments to include tasks previously unaccounted for and refined the system. The workload distribution of eight physicists over 12 months was compared before and after implementation of the nTE system. Results Prior to implementation, differences in workload of up to 50% existed between individual physicists (nTE range of 10.0%–15.0%). During the trial period, additional categories were added to account for leave and clinical projects that had previously been assigned informally. In the 1‐year period after implementation, the individual workload differences were within 5% (nTE range of 12.3%–12.8%). Conclusion We developed a system to equitably distribute workload and demonstrated improvements in the equity of workload. A quantitative approach to workload distribution improves both transparency and accountability. While the system was motivated by the complexities within an academic medical center, it may be generally applicable for other clinics.
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Affiliation(s)
- Minsun Kim
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA
| | - Eric Ford
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA
| | - Wade Smith
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA
| | - Stephen R Bowen
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA
| | - Sarah Geneser
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA
| | - Juergen Meyer
- Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington, USA.,Department of Radiation Oncology, Seattle Cancer Care Alliance, Seattle, Washington, USA
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47
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Fradley MG, Lefebvre B, Carver J, Cheung JW, Feigenberg SJ, Lampert R, Liu J, Rajagopalan B, Lenihan DJ. How to Manage Patients With Cardiac Implantable Electronic Devices Undergoing Radiation Therapy. JACC: CARDIOONCOLOGY 2021; 3:447-451. [PMID: 34604807 PMCID: PMC8463726 DOI: 10.1016/j.jaccao.2021.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Michael G Fradley
- Cardio-Oncology Translational Center of Excellence, Division of Cardiology and Abramson Cancer Center, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Bénédicte Lefebvre
- Cardio-Oncology Translational Center of Excellence, Division of Cardiology and Abramson Cancer Center, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joseph Carver
- Cardio-Oncology Translational Center of Excellence, Division of Cardiology and Abramson Cancer Center, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jim W Cheung
- Weill Cornell Medicine, Department of Medicine, New York, New York, USA
| | - Steven J Feigenberg
- Department of Radiation Oncology, Perelman Center for Advanced Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Lampert
- Department of Medicine (Cardiovascular Disease/Electrophysiology), Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Liu
- Cardiology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | | | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, Missouri, USA
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48
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Matsubara H, Ezura T, Hashimoto Y, Karasawa K, Nishio T, Tsuneda M. Study of feasible and safe condition for total body irradiation using cardiac implantable electronic devices. JOURNAL OF RADIATION RESEARCH 2021:rrab088. [PMID: 34542633 DOI: 10.1093/jrr/rrab088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/09/2021] [Indexed: 06/13/2023]
Abstract
Cardiac implantable electronic devices (CIEDs) were believed to have a tolerance dose and that direct irradiation has to be avoided. Thus, no clinical guidelines have mentioned the feasibility of total body irradiation (TBI) with a CIED directly. The purpose of this work was to study a feasible and safe condition for TBI using a CIED. Eighteen CIEDs were directly irradiated by a 6-MV X-ray beam, where a non-neutron producible beam was employed for the removal of any neutron contribution to CIED malfunction. Irradiation up to 10 Gy in accumulated dose was conducted with a 100-cGy/min dose rate, followed by up to 20 Gy at 200 cGy/min. An irradiation test of whether inappropriate ventricular shock therapy was triggered or not was also performed by using a 6-MV beam of 5, 10, 20 and 40 cGy/min to two CIEDs. No malfunction was observed during irradiation up to 20 Gy at 100 and 200 cGy/min without activation of shock therapy. These results were compared with typical TBI, suggesting that a CIED in TBI will not encounter malfunction because the prescribed dose and the dose rate required for TBI are much safer than those used in this experiment. Several inappropriate shock therapies were, however, observed even at 10 cGy/min if activated. The present result suggested that TBI was feasible and safe if a non-neutron producible beam was employed at low dose-rate without activation of shock therapy, where it was not inconsistent with clinical and non-clinical data in the literature. The feasibility of TBI while using a CIED was discussed for the first time.
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Affiliation(s)
- Hiroaki Matsubara
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Takatomo Ezura
- Department of Radiology, Tokyo Women's Medical University Hospital, Tokyo 162-8666, Japan
| | - Yaichiro Hashimoto
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Kumiko Karasawa
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Teiji Nishio
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
| | - Masato Tsuneda
- Department of Radiation Oncology, Tokyo Women's Medical University, Tokyo 162-8666, Japan
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49
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Azraai M, D'Souza D, Lin YH, Nadurata V. Current clinical practice in patients with cardiac implantable electronic devices undergoing radiotherapy: a literature review. Europace 2021; 24:362-374. [PMID: 34516616 DOI: 10.1093/europace/euab241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/25/2021] [Indexed: 12/25/2022] Open
Abstract
Patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy (RT) are more common due to the ageing of the population. With newer CIEDs' implementing the complementary metal-oxide semiconductor (CMOS) technology which allows the miniaturization of CIED, it is also more susceptible to RT. Effects of RT on CIED ranges from device interference, device operational/memory errors of permanent damage. These malfunctions can cause life-threatening clinical effects. Cumulative dose is not the only component of RT that causes CIED malfunction, as neutron use and dose rate effect also affects CIEDs. The management of this patient cohort in clinical practice is inconsistent due to the lack of a consistent guideline from manufacturers and physician specialty societies. Our review will focus on the current clinical practice and the recently updated guidelines of managing patients with CIED undergoing RT. We aim to simplify the evidence and provide a simple and easy to use guide based on the recent guidelines.
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Affiliation(s)
- Meor Azraai
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Daniel D'Souza
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Yuan-Hong Lin
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
| | - Voltaire Nadurata
- Department of Cardiology, Bendigo Health, 100 Barnard Street, Bendigo, Victoria 3550, Australia
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50
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Yang B, Yuan J, Cheung KY, Huang CY, Poon DMC, Yu SK. Magnetic Resonance-Guided Radiation Therapy of Patients With Cardiovascular Implantable Electronic Device on a 1.5 T Magnetic Resonance-Linac. Pract Radiat Oncol 2021; 12:e56-e61. [PMID: 34520872 DOI: 10.1016/j.prro.2021.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/28/2021] [Accepted: 08/31/2021] [Indexed: 11/17/2022]
Abstract
Magnetic resonance-guided radiation therapy is reported for treating patients with an insertable cardiac monitor and implantable cardiac pacemakers. All treatments were delivered using a 1.5 T MR-Linac. Among the 4 patients, 2 were treated with stereotactic body radiation therapy at a dose of 40 Gy in 5 fractions. A clinical safety protocol was developed to address the decision-making and patient selection, as well as the clarified responsibilities of different parties for management of patients with cardiovascular implantable electronic devices. Dose estimation based on out-of-field dose data are necessary for cardiovascular implantable electronic devices located outside the treatment fields.
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Affiliation(s)
- Bin Yang
- Medical Physics and Research Department, Happy Valley, Hong Kong, China.
| | - Jing Yuan
- Medical Physics and Research Department, Happy Valley, Hong Kong, China
| | - Kin Yin Cheung
- Medical Physics and Research Department, Happy Valley, Hong Kong, China
| | - Chen-Yu Huang
- Medical Physics and Research Department, Happy Valley, Hong Kong, China
| | - Darren M C Poon
- Comprehensive Oncology Centre, Hong Kong Sanatorium & Hospital, Happy Valley, Hong Kong, China
| | - Siu Ki Yu
- Medical Physics and Research Department, Happy Valley, Hong Kong, China
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