Dr Kline here. I am a big proponent for radiating dupuytrens and have been doing so for the past four years. I have a radiation oncologist here in Boise who has had experience with e-beam radiation and dupuytrens disease during her residency and handles my local cases. Over the years, I have built up an extensive network of radiation oncologists throughout the western USA because a large portion of my patients live outside of Idaho and want to have this done in their hometown.
I have found the radiation oncologists informed and receptive to performing radiation for dupuytrens disease, they all seem to know about it! Initially, I was recommending this only on early active disease (node based), but as I developed more experience with NA, I found that the female patients were having a faster rate of recurrence then males. My local radiation oncologist and I decided to start radiating dupuytrens after NA release in women only if they had stage II or less, and had a perfect release status post NA (flat palm and good extension in all fingers). We do not have 5 year data on this yet but so far, so good - only one failure so far (recurrence). Over the last 2 years we've started adding men to the protocol. We try to radiate the hand within 72 hours after release (NA), and follow the standard German protocol. Plans are to get a paper out on this in 2 years after more data and patient follow up. The goal here is to stop progression of the disease, or at least slow it down.
As a side note, I have had my own hands treated exactly this way, with an early release of both little fingers followed by radiation. I found the side effects very tolerable, one day of redness and some dryness of the palm. It has been 2 years post-radiation for me with no progression of my dupuytrens. If your age is greater than 40 the risk of cancer is virtually zero.
Here are the results of a recent long term evaluation of radiation therapy, indicating 70% of patients experience no progression of disease after radiation and also supporting the fact that cancer risk from this is virtually nil.
Strahlenther Onkol. 2010 Feb;186(2):82-90. Epub 2010 Jan 28. Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years.
Betz N, Ott OJ, Adamietz B, Sauer R, Fietkau R, Keilholz L. Department of Radiation Oncology, University Hospital Erlangen, Universitätsstrasse 27, Erlangen, Germany.
BACKGROUND AND PURPOSE: In early-stage Dupuytren's contracture, radiotherapy is applied to prevent disease progression. Long-term outcome and late toxicity of the treatment were evaluated in a retrospective analysis.
PATIENTS AND METHODS: Between 12/1982 and 02/2006, 135 patients (208 hands) were irradiated with orthovoltage (120 kV; 20 mA; 4-mm Al filter), in two courses with five daily fractions of 3.0 Gy to a total dose of 30 Gy; separated by a 6- to 8-week interval. The extent of disease was described according to a modified classification of Tubiana et al. Long-term outcome was analyzed at last follow-up between 02/2008 and 05/2008 with a median follow-up of 13 years (range, 2-25 years). Late treatment toxicity and objective reduction of symptoms as change in stage and numbers of nodules and cords were evaluated and used as evidence to assess treatment response.
RESULTS: According to the individual stages, 123 cases (59%) remained stable, 20 (10%) improved, and 65 (31%) progressed. In stage N 87% and in stage N/I 70% remained stable or even regressed. In more advanced stages, the rate of disease progression increased to 62% (stage I) or 86% (stage II). 66% of the patients showed a long-term relief of symptoms (i.e., burning sensations, itching and scratching, pressure and tension). Radiotherapy did not increase the complication rate after surgery in case of disease progression and only minor late toxicity (skin atrophy, dry desquamation) could be observed in 32% of the patients. There was no evidence for a second malignancy induced by radiotherapy.
CONCLUSION: After a mean follow-up of 13 years radiotherapy is effective in prevention of disease progression and improves patients' symptoms in early-stage Dupuytren's contracture (stage N, N/I). In case of disease progression after radiotherapy, a "salvage" operation is still feasible.
Let me first emphasize that I am not an opponent to RT. I had 5 RTs myself (in different areas), with good results and so far with no side effects except a somewhat more dry skin in the radiated areas. Our views differ in whether RT after NA is eliminating recurrence or not.
In order to evaluate the outcome of RT after NA we need to compare long-term outcomes of a group of patients who had NA+RT with another group that had NA only. Results might also depend on whether the original extension deficit was severe or not, i.e. whether the NA was on a stage 1 or a stage 2 patient, so both patient groups would ideally have started with a similar extension deficit. Before we have those data available it is difficult to assess the value of RT after NA, isn't it? Wouldn't it be better to say that there might possibly be a chance to delay recurrence with RT but we are not yet sure about it?
The paper of Betz et al. that you posted here (thank you for posting it!) seems to support my concern: According to their data RT is efficient in stage N (prior to any contracture). There positive results (= disease stable or improved) are at 87 %, falling down to 14 % at stage 2. That is a dramatic difference and to me a clear indication that RT is not efficient on cords but good on proliferating fibroblasts. The target for RT are fibroblasts, not the collagen of cords.
I think we both agree that a patient who had NA at stage 2 is - from a material point of view - still a stage 2 patient, even if the finger is now straight again, because the cords remain in the hand. Now what would be the target for RT with such a patient? The remaining cord? The gap where the cord was broken?
I have had the same discussions with my radiation oncologist. When consulting with my patients I echo the results of the Betz paper and let them make up their own minds. All patients must undergo evaluation by the radiation oncologist who also thoroughly reviews the pros and cons of radiation therapy with them.
What happens when you cut cords via NA and return hands to stage N? If the disease returns, does this indicate activation of the proliferation fibroblasts? My radiation oncologist says yes and believes that radiation is beneficial. I personally do not believe that by returning a stage I or II to stage N that the benefits from radiation will be as effective as radiation of pristine 0, N or N/1. That being said, so far the women that I have radiated post-NA have done very well. I will be getting a paper out on this once I have sufficient data out to at least the 5 years point, which is soon.
So far I have had 2 patients needing redo after their NA-plus-radiation, and in both cases the cords that reformed seem so weak that I felt that forced mechanical extension of the joint would have been as effective as NA for this secondary release.
I posted Betz paper to show the low cancer risk and benefits for early disease. There is also a paper out there (I can not find it for the life of me---European study) where they performed radiation after z-plasty. The recurrence rate was decreased by approximately 17-18%. This may not sound significant, but if there was a slight decrease in recurrence after the active tissue was removed, think of the benefits to tissue that is actually sensitive to radiation. Studies are needed to verify, and that's what I am trying to do.
Thanks to Wolfgang and Dr. Kline for this discussion about RT. As it is with everything else about this disease, every hand is different with regards to effectiveness of RT. We need the long term research. Thanks, Dr. Kline for keeping records and posting other studies.
Even for myself with initial results being very successful in stopping or slowing the progression, I am still in a wait and see mode. All I know for sure is that I had nodules continually developing and progressing in all 4 quadrants of my palm. After RT last July, many nodules reduced or went away, some got softer and no new nodules have formed in the radiated area. I am hopeful that it will last. We'll see.
Just wanted to say thank you to Dr. Kline for taking time out of his schedule to call me today even though he has never seen me. I sent him pics of my hand and explained the dilemma of having the nodule in my pinkie that is contracting it and no apparent cord. He called me the next day and we spoke for quite a while and I believe I will be going to see him and hopefully get radiation treatment. He is so nice I felt like I was speaking to a long time friend! Maybe, because he has Dupuytrens himself, he is able to empathize with us.