Radiotherapy for Dupuytren's Disease
Radiatiotherapy is a non-surgical treatment that can slow down the progression of Dupuytren's disease in its early stages.
Only the hand is treated daily for 5 days ( Monday – Friday ) then there is a delay of 6 – 8 weeks and the treatment is repeated. Ie 10 treatments in all.
Each treatment is 3 Gy of radiation = total 30Gy. Radiotherapy is thought to decrease the tendency to progression of the disease and subsequent finger deformity. Some patients comment that the nodules feel softer but many patients notice NO immediate difference.
Radiotherapy is used to treat many cancers and the doses may involve 20 – 80 Gy of WHOLE BODY radiation.
Radiotherapy is also used to treat other benign conditions including:- The treatment of Keloid scars and to prevent calcification ( Heterotopic Ossification) around revision hip replacements.
Keloid scar Heterotopic Bone
Radiotherapy has been used in Germany for over 14 years.
Radiation therapy - how does it work?
In early Dupuytren's disease the palmar fascia goes through a very active phase where the cells are multiplying rapidly. This “proliferative" phase results in the development of nodules & cords in the palm.
Over time the cords contract & the fingers develop contractures. The initial active stage is most suitable for radiotherapy. The radiation causes damage to the DNA in rapidly dividing cells.
Normal tendon Scar tissue Dupuytren’s cord Dupuytren’s nodule
Note the large number of cells in the Dupuytren’s nodule above.
Treatment
At Prince of Wales Hospital in Sydney there is a long term research project on the outcomes following Radiotherapy for Dupuytren’s. You will be assessed by a Hand Therapist and the Professor of Radiation Oncology ( Prof Michael Jackson). It is on the basis of this assessment that your treatment will be planned.
This treatment is also available in other centres around Australia.
You will be followed up initially, at 3, 6,12,18 months and then annually for several years to assess your outcome and hand function. This will involve a 10-15 minute assessment and review of your hands with some photos being taken, and 2 patient questionnaires.
Prior to the radiotherapy the area to be irradiated has to be defined. Because Radiotherapy is usually not repeated it is very important that all sites of Dupuytren's in the hand are identified and included within the irradiated area.
The red and green lines seen on the skin above are used to confirm exact margins for the irradiated area. They are Not Lasers!!
At the same time non diseased areas are usually not irradiated to minimize the theoretical risk of secondary cancer. This area is shielded but a lead guard individually made for each patient.
An experienced clinician will be able to palpate even tiny nodules and cords.
The irradiated area is marked on the hand. The hand is ready for treatment.
Benefits of radiotherapy
Radiotherapy is capable of slowing the progression of Dupuytren’s disease. Some small nodules may even shrink or disappear. Some patients mention that the hand “feels softer”.
Radiotherapy is much less effective on established cords and cannot make an already bent hand straight again.
Note there is NO cure for Dupuytren's disease.
Research
Long-term results from Betz et al. ("Radiotherapy in Early Stage Dupuytren's Contracture - Long Term results after 13 Years" 2010) clearly demonstrate the advantage of early treatment. It is most effective to treat the Dupuytren's nodule within the first year it is noticed, The problem is that few people consult their doctor in the very early stages of the disease.
Seegenschmeidt study:
Phase III clinical study between 1997 and 2009. 624 patients (489 with 5 years follow up). Patients divided into 3 Groups:
- No treatment
- 21Gy radiotherapy
-30 Gy radiotherapy
Radiotherapy reduces the progression of patients requiring surgery from 31% to 7% over a 5 year period.
More Research information.
Who should be treated?
There is no clear understanding of the natural history of Dupuytren’s disease in Australia. Not every patient with Dupuytren's nodules will experience contracture. See risk factors for predicting aggressive forms of the disease.
While pain is not a common complaint in Dupuytren’s disease some patients notice tenderness in the early phases of the disease and this may be improved with radiotherapy.
Indications for Radiotherapy:
1. Stage 0 Disease – ie No deformity
2. Disease present for only a short period of time
3. Dupuytrens in the proliferative phase – Sometimes nodules tender
- Hand may be “itchy"
4. Older age – No clear cut off BUT ideally > 50 – 60 yrs.
Side effects of treatment:
- Dry skin (25%) – has not been a major problem – well controlled with regular application of skin moisturiser.
- Theoretical risk of cancer (risk unknown) but has not been reported to date.
- The mere mention of radiotherapy evokes mental images such as:
The sophistication of radiotherapy is far greater than in the past. Prince of Wales Hospital uses electrons instead of high energy x-rays. One could argue that it is less dangerous than a career in orthopaedics where the WHOLE BODY exposure is up to 500 mGy annually. Ie a 40 year career = 20 Gy
The Key question is “Would you recommend it for your family” . My answer is that “I would have no hesitation in having Radiotherapy for Dupuytrens disease if I was over 60”. Many of my patients have had radiotherapy at age 50. They are fully aware of the “unknowns” in this treatment but are very keen to avoid surgery.
- Delayed wound healing post fasciectomy (0-5%) – To date has not been a problem.
- Skin atrophy and telegenctasia (7%)
- Persistent erythema or redness(2%)
- Altered sensation (<5%)
These possible side effects are being monitored for at the regular follow-up appointments.
See separate section on Complications.