If a patient with a pacemaker were to present in our clinic for SBRT treatment of a left

upper lobe lung lesion, there would be several things that would be important to consider.
For example, according to Prisciandaro et al1, the pacemaker device should not be irradiated
with the primary beam, dose should be kept below 2 Gy when possible, and low energy
beams should be used to prevent secondary neutrons. This is true of the practice we follow
in our clinic for patients with pacemakers as well. In the past, our physicians have even
requested that patients, who have a tumor volume in the vicinity of a pacemaker, have the
pacemaker moved to an area outside of the treatment field because the dose to the device
would have been too great. According to AAPM report number 45,2 when a pacemaker is
exposed to a sufficient dose of ionizing radiation it can cause individual chip components to
fail causing various malfunctions of the device, which is why it is so important to ensure the
dose stays below the recommended 2 Gy.
Prior to planning, the patient’s pacemaker should be carefully contoured, so the device can
be constrained on in order to keep the dose as low as possible. Blamek et al3 suggests
contouring the pacemaker’s more radioresistant parts (casing and battery) separately to
allow more dose to these parts and improve dose distribution throughout the target. Rings
can be used to achieve a steep dose fall-off, helping to further limit dose to the pacemaker.
Using the contoured pacemaker as an organ at risk (OAR), a maximum dose can be
assigned, to help achieve the desired low dose to this area. At my clinical site, the patient’s
pacemaker is interrogated on the first day prior to the treatment being delivered and then
again following the first treatment. Patients who are pacemaker dependent also have their
vitals assessed daily during treatments to ensure their safety in case the pacemaker were to
be affected. While no amount of radiation is proven to be 100% safe for pacemakers,
following the recommendations above decreases the risk of pacemaker malfunction and
improves the safety of our patients.

1. Prisciandaro JI, Makker A, Fox CJ, et al. Dosimetric review of cardiac implantable
electronic device patients receiving radiotherapy. J Appl Clin Med Phys. 2015;16(1):254-
263. http://dx.doi.org/10.1120/jacmp.v16i1.5189
2. AAPM Report No. 45. Management of Radiation Oncology Patients with Implanted
Cardiac Pacemakers: Report of Task Group No. 34. Med Phys. 1994;21(1):85-90.
http://dx.doi.org/10.1118/1.597259
3. Blamek S, Gabrys D, Kulik R, Kruczek A, Miszczyk L. Stereotactic body radiosurgery,
robotic radiosurgery and tomotherapy in patients with pacemakers and implantable
cardioverters – defibrillators. Exp Clin Cardiol. 2014;20(7):757-763.