Pacemaker and radiotherapy

I had an uncomfortable experience yesterday of receiving what should have been 8 Gy of radiotherapy ( DXT) for lymphoma, resulting in a tachycardia ( fast heart beat) of 120/min, paced, when my resting rate is 60 /min. My cancer is mid chest, at the back, and is cutaneous ( skin). The radiation ( X rays) directly affected my pacemaker causing me to paced at 120/min.

There is a study of 96 patients with a similar problem
(http://www.ro-journal.com/content/7/1/198)

I managed 60 seconds of a 5 minute planned therapy- the procedure as abandoned due to the increased heart rate. I plan to have a pacemaker check up in 49 hours, and otherwise feel well. Normally, I am very fit swimming 1 mile daily etc..

Does anyone have any further advice as to how to manage this problem ?

Thanks,
Selwyn

5 Comments

Hi Selwyn

by IAN MC - 2015-10-04 10:10:32

Good to hear from you again.

Just an observation :-

I am surprised that this topic has not been raised before because pacemaker patients needing radiotherapy must be a relatively common occurrence. I am sure that radiotherapy departments work to guidelines with PM patients but as PM technology changes, I wonder how regularly guidelines are reviewed ? I see that some literature says that radiotherapy should be limited to 2 Gy on the pacemaker.

As you know , specialised centres around the world are now now doing MRI's on PM patients even if their PMs are not described as being MRI - compatible .

My understanding is that the PM is first put into some sort of safe mode with a magnet and then the settings are restored to normal after the scan. Close liaison is needed during the procedure between the radiologists and the PM gurus.Pulse and ECG are monitored throughout the procedure.

All pacemaker abnormalities have been found to be transient and reversible.

I guess the more dependent on the PM , then the more tricky it is ?

Could it not be a similar scenario with radiotherapy as both involve electro magnetic radiation , although I realise that the wavelength and intensity may be different ?

I know that I would be happier having someone from cardiology on hand if I were to have radiotherapy, but I do hope someone responds who has been through it themselves.

Best Wishes

Ian

Rad Therapy for Prostate Cancer

by donr - 2015-10-08 02:10:15

I went through 28 sessions of IMRT in 2004 for Prostate cancer at a major radiation center at Emory Hospital Winship Cancer Center in Atlanta, Georgia, USA. I had only had my PM for a year when this occurred.

The first question I asked my oncologist was about the safety of my PM. I have no idea how much radiation I received, but it was a whopping dose at the prostate gland.

As we went through the pas de deux leading up to the protocol, he pulled out the notebook on my particular case w/ the beam shaping & iso exposure contours in it & we began discussing the resolution of the shaped beam. He told me it was 1/4 inch (6mm).

I figured at that point that my PM was far enough away from my prostate that it was perfectly safe!

However, I coordinated w/ my Cardio & Oncologist & we came up w/ a simple protocol for verifying that it was safe for my PM.

The Cardio did a download the day prior to my first session & one immediately following it by a few hours.

I felt nothing unusual during the session & the PM download showed nothing. During the 48 sessions, lasting from late Jan to Good Friday on 9 April, I never felt anything untoward occur & several downloads showed nothing unusual.

I looked up a Google ref on the type radiation you were to experience (DXT). I got the impression that DXT is just a hose spray of radiation, w/ no shaping or exposure along multiple axes around the body. It also implies that the intensity is such that the penetration into the body is not very great.

If that is truly the case, it makes me wonder why the Titanium case did not shield the electronics sufficiently to prevent that reaction.

Which leads me to the next question - can they not place a lead slab directly above your PM to shield it?

Followed, of course, by another question or two - Did a download show pacing spikes for the accelerated HR? Was the PM really the source of the acceleration?

120 BPM is no great shakes for a fast HR. You probably do better than that when you swim a mile.

Last, but not least - I remember the first time I wandered into the Radiation chamber. The door was steel & a foot thick. The walls were reinforced high density ferro-concrete & also a foot thick. The machine, a varian Brothers "Device" w/ a linear accelerator hummed threateningly in the back of the room & I clambered up onto a carbon fiber mesh "Bed " at the center of the device, which rotated around me, stopping at 7 angles for 15 seconds each to nuke my worthless butt.

It clanked, clicked, whirred, ground like a meat mincer, & came w/i a few inches of my torso as it did its job. To say the least, the device was intimidating. They strapped me onto the "Bed" & then raised it some unknown distance above the floor. Can you say "Trapped & claustrophobic"? I sure could!

The room was very dimly lit & believe it or not, the walls were painted charcoal. Straight out of an Edgar Allen Poe horror story. I called the device "Enola Gay." (I'll let the curious among gentle readers Google her name for the significance.)

Considering the relatively low HR (120 BPM) I would consider part of it to be caused by anxiety & rule that out as a cause.

Donr

Radiation and Pacemakers.

by Selwyn - 2015-10-08 12:10:33

Thanks for the above information.
St Jude ( the makers of my PM) have guidance ( I have found) at https://professional-intl.sjm.com/.../fl-therapeutic-radiation-042011.ashx?...
I have been to the pacing clinic today and had my PM changed from DDDR to DDD

I am due to start radiotherapy again tomorrow. The beam is focused directly against the skin ( where the lymphoma cancer is). There is then a shield of lead around the area for about 1 inch ( 2.4cm) width.

There was no print out at the time of the fast heart rate by the medical staff. It felt like I was being paced at 120/min.

The consultant radiologist says the 60 secs. of radiation I received was insignificant, and that it is likely to be an electromagnet effect. The electrophysiologist thinks that the PM would not give a HR of 120 if subjected to electromagnetism ( and I am of that opinion).

I will mention further screening, thanks Don. The radiotherapist says the radiation drops 50% for every 3cm of body tissue depth- hence I think her theory of electromagnetism evolved.

I did have a head/neck/torso mask made for me ( as I have to have radiotherapy to the neck) which pins me down when it is bolted to the table. Luckily, I used to scuba dive on wrecks, have been cave diving, and used to wear a hood in cold water- all good training, which I would recommend, if anyone is contemplating head/neck radiotherapy. I even now think Anthony Gormley's statues -see Crosby, 'Another Place'- that are almost outside my home, have added meaning. Did he really do that?!!

Selwyn



Because...

by donr - 2015-10-09 04:10:28

...of diving I don't think you would be one to freak out in the therapy room!

Is it an IMRT device? Sounds like it from your description of the head/neck/torso mask gear. the Emory facility had a wall of those things hanging available for the patients who needed them. No claustrophobia for you!

As to the EM effect - I think that one is a stretch. Were there significant stray EM fields involved in the production of the X-rays, they would have gotten to MY PM, also.

If I recall the device correctly, it uses a linear accelerator to boost electrons to a very high velocity; it is driven by a large electron tube (a valve to youse guys) called a Klystron that involves magnetic fields, but that gizmo is off in a corner somewhere & the fields are not THAT strong. The electrons are delivered to the head of the device right above your body through a long tube called a wave guide - no magnetism there. The stream of electrons in the wave guide constitutes an electric current, w/an associated magnetic field, but that is all contained w/in the guide, itself. That passes right past your body to get to the target in the radiation head. If that were the source of the problem for a PM, that would have affected me, also, but nothing!

From your description, the cancer is localized - at least near your PM; the beam is very closely controlled as to shape, so it should not be getting to your PM. Plus the shield you mentioned.

I found a very good Google article on IMRT. I've been looking for one for several years. If you are interested it is at:

https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=3&cad=rja&uact=8&ved=0CDEQFjACahUKEwiE_KDth7TIAhUEdD4KHckJDbA&url=http%3A%2F%2Fhpschapters.org%2Fflorida%2F13PPT.pdf&usg=AFQjCNGSMPk6scloTUeRD08u14eDn9TtLw&bvm=bv.104615367,d.cWw

Good luck today w/ your next session.

Donr

Radiotherapy and Pacemakers

by Selwyn - 2015-10-16 04:10:53

Thanks for your good wishes.

Turning off the rate adaption ( DDDR to DDD) worked a treat. No problems at all with arrhythmias.

The radiation used is photons ( X Rays) - it was not possible to shield the PM as radiation was to the back. The neck radiation (at a separate site) is ongoing (12 sessions) and has not produced any problems.

The head/neck and upper torso mask seems to provide a way of relaxing without letting your head flop to one side. So far, no snoring!

The pacemaker clinic ( University Hospital Aintree, Liverpool, UK) have been wonderful at fitting me in with checks and turning on and off the rate adaption without going through appointments. They just slot me into their busy day.

I must say the radiotherapy department at Clatterbridge, UK, have been very kind. I have a 9am appointment every day, and I am out by 9.10am. So far no side effects whatsoever. Well done the NHS!

Selwyn

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