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LETTER TO THE EDITOR
Year : 2016  |  Volume : 53  |  Issue : 4  |  Page : 482
 

Palliative hypofractionated radiation therapy in a patient of locally advanced nasopharyngeal cancer with cardiac implantable electronic device (CIED): Management of a challenging case


1 Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
2 All Institute of Medical Sciences, New Delhi, India

Date of Web Publication21-Apr-2017

Correspondence Address:
SJ Bharti
Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.204768

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How to cite this article:
Varughese S, Bharti S, Biswas A, Verma S. Palliative hypofractionated radiation therapy in a patient of locally advanced nasopharyngeal cancer with cardiac implantable electronic device (CIED): Management of a challenging case. Indian J Cancer 2016;53:482

How to cite this URL:
Varughese S, Bharti S, Biswas A, Verma S. Palliative hypofractionated radiation therapy in a patient of locally advanced nasopharyngeal cancer with cardiac implantable electronic device (CIED): Management of a challenging case. Indian J Cancer [serial online] 2016 [cited 2019 Dec 9];53:482. Available from: http://www.indianjcancer.com/text.asp?2016/53/4/482/204768


Sir,

The current evidence on the effects of radiotherapy on CIED gives no clear 'cut off' value for device malfunctioning.[1],[2] A 45 years old male patient of poorly differentiated nasopharyngeal carcinoma T4N3aM0 with pacemaker (St Jude's Medical, DDDR mode (Dual chamber Rate adjusted), Heart rate 60, Sensitivity 0.5-2mV) for complete heart block was deemed unsuitable for concurrent radio-chemotherapy in view of locally advanced disease, poor general condition (PS-ECOG3) and cardiac comorbidities and planned for palliative radiotherapy to a dose of 20 Gray in 5 fractions over 1 week in the multidisciplinary head and neck cancer clinic. Palliative radiotherapy was planned by bilateral parallel opposed face and neck fields (16x13 cm) with 6 MV X-rays on Varian CL2300 C/D linear accelerator with dose prescribed at a depth of 7 cm. The lower part of radiation field included the pacemaker site. Temporary transvenous pacing was done through right femoral vein prior to radiotherapy. During radiotherapy, patient was monitored by the oncologist and anesthesiologist using cardiac monitor (E.C.G, pulse oximeter) and defibrillator and transcutaneous pacer (with leads attached) were kept standby. The pacemaker function was checked before and after each fraction and the mode changed from DDDR to DOO (Dual chamber asynchronous mode) before each fraction. The patient tolerated the planned treatment well without any serious adverse event and had modest symptom palliation 3 months after completion of radiotherapy.

Megavoltage radiation can lead to electromagnetic interference and subsequent pacemaker malfunction in the form of runaway pacemaker, decrease in battery life, resetting to factory settings and coil failure.[3] Based on the radiation dose, location of the pacemaker and pacing dependency, patients are categorized into low, medium and high risk.[3] The illustrative patient had high risk of pacemaker malfunction due 4% pacer dependency and the location of the CIED within the radiation portal (estimated dose to pacemaker >10Gray).[3] In such scenario, Hurkmans et al., recommends reconsideration of radiotherapy or relocation of CIED (temporary pacing).[4] Interestingly a study by Ferrara et al., showed no evidence of pacemaker dysfunction in spite of mean pacemaker Dmax of 2.5 Gray in patients with head and neck cancer.[5] To sum up, safe clinical practice in high risk patients includes reconsideration of radiotherapy or relocation of CIED, intensive cardiac monitoring and preparedness for resuscitation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hurkmans CW, Scheepers E, Springorum BG, Uiterwaal H. Influence of radiotherapy on the latest generation of pacemakers. Radiother Oncol 2005;76:93-8.  Back to cited text no. 1
    
2.
Rodriguez F, Filimonov A, Henning A, Coughlin C, Greenberg M. Radiation-induced effects in multiprogrammable pacemakers and implantable defi brillators. Pacing Clin Electrophysiol 1991;14:2143-53.  Back to cited text no. 2
    
3.
Sundar S, Symons RP, Deehan C. Radiotherapy to patients with artificial cardiac pacemakers. Cancer Treat Rev 2005;31:474-86.  Back to cited text no. 3
    
4.
Hurkmans CW, Knegjens JL, Oei BS, Maas AJ, Uiterwaal GJ, van der Borden AJ, et al. Management of radiation oncology patients with a pacemaker or ICD: A new comprehensive practical guideline in the Netherlands. Dutch Society of Radiotherapy and Oncology (NVRO). Radiat Oncol 2012;7:198.  Back to cited text no. 4
    
5.
Ferrara T, Baiotto B, Malinverni G, Caria N, Garibaldi E, Barboni G, et al. Irradiation of pacemakers and cardio-defi brillators in patients submitted to radiotherapy: A clinical experience. Tumori 2010;96:76-83.  Back to cited text no. 5
    




 

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