This is my left hand that has not had RT. It's developing more nodules on the forefinger and cords between the forefinger and thumb.

I met with Dr. Keterelos today. He is very thorough. He measured, palpated, took pics, and asked questions. He specifically asked about my symptoms, how Dupuytren's has affected my life, and recorded my answers on a survey sheet. I think it's time for RT on my left hand and he agrees.

He ordered an MRI that will show specific things - different types of tissue, location and depth of Dupuytren's. He says that the MRI gives more information than a CT scan or ultrasound. He considers the MRI key in determining the field of radiation. He showed me MRI images of a hand and what the MRI will/can show and that's what he wants to see. He told me what he was looking for, but I didn't grasp it all. He wasn't rushing, but I don't know enough about MRIs to know what questions to ask. My MRI is scheduled for April 24th. Maybe I'll better understand the terminology.

Insurance billing working on that the codes and whether Medicare will pay. They called me already. I'm getting the codes that Scripps Clinic used for the radiologist's services that Medicare did not pay and the codes that Scripps Green Hospital used for the actual electron radiation that Medicare did pay for. LLUMC is being proactive in billing this right.

On the back of this hand, my left hand, I had a squamous cell skin cancer removed about 2 months ago. Another suspicious spot popped up last week. Dr. K wants a biopsy on that before proceeding with RT. It is on the back of my hand almost at the web of my thumb. I have an appointment with my dermatologist Wednesday. This hand has never been radiated, but I have very fair skin and am checked every 3 months. I usually have a 2 or 3 spots a year that are suspicious enough for a biopsy and about one a year that is early stage cancer - only basal cell or squamous cell so far.

I feel very confident with Dr. K. He is ensuring that he knows exactly what to radiate and wants to include all that is needed with a margin but not healthy tissue. He is well informed, methodical, observant, and thorough. He has copies of research and relative information in my file and uses it. I'm impressed.

I'll post the next steps.

Hi Flora,
Sorry to hear that your DD acted up again, but glad to see you are being proactive and considering RT for your left hand, before it gets worst. I assume Dr. K. is with Loma Linda (is that what LLUMC stands for?) because you talked about going there next time you need RT.

I am watching closely my small finger of the left hand, as it has started to show signs of progression, (don't want it to get to the point where I'll need NA or to start contracting like my "messed up small finger of the right hand). I had planned to drive up to see Dr. Denkler this winter, but different things kept me from doing that and now we are in the middle of moving to another house, so hopefully this summer I will do something...maybe even RT at LLUMC like you. I am really interested to find out from you if LLMUC will process the billing properly so that Medicare picks up the tab.

Good luck to you with the RT on the left hand, and please keep us posted, both about the procedure and the billing coverage.
best to you
Luba

Edited 04/17/12 09:40

In my first consultation with Dr. Keterelos we discussed the protocol. He uses 2Gy x 7 days out of 14. He showed me the research that he finds valid. I'm fine with that and actually to me less radiation is better if it works and research shows it works. On my left hand, I had even less radiation. At Scripps, I had 2Gy x 5 days, and the following week 2Gy x 5 days. It stopped the progression. Dr. Keterelos was very thorough with palpation. I was confident from the palpation and his comments about what he was feeling that he knows what he is doing.

Luba, yes, LLUMC is Loma Linda University Medical Center. I think it is worth getting a consultation with him. I know Medicare pays for consultations. He's good.

Are you moving to another town or just another house?

updated overviews on RT can be found here:

http://www.springer.com/medicine/orthope...8-3-642-22696-0
http://www.springerlink.com/content/m25w532366371juh/?MUD=MP

Abstract

http://www.springerlink.com/content/m25w532366371juh/

Purpose: Several retrospective studies have shown that radiotherapy (RT) can prevent progression of Dupuytren’s disease (DD), but so far no dose-response relationship has been established. This chapter presents long-term results of our previously published prospective randomized trial comparing two different RT doses with a control group without RT. Methods: From January 1997 to December 2009 over 600 patients with DD were referred to our clinic for RT to prevent further disease progression. As of January 2011, 489 pts (291 males; 198 females) with at least five (range 5–13; mean 8.5) years follow-up (FU) were included in the analysis. Due to bilateral affliction, a total of 718 hands (sites) were evaluated. Overall 73% of all hands were affected, 230 (47%) on both hands; according to Tubiana’s classification, 470 (65.5%) hands had stage N (nodules/cords, no extension deficit), 124 (17%) had stage N/I (&#8804; 10° deficit), 106 (15%) had stage I (11–45° deficit), and 18 (2.5%) had stage II (46–90° deficit) or more. After clinical assessment and informed consent, patients could choose between observation only (83 patients with 122 affected hands) and RT (406 patients with 596 affected hands); all patients in the RT group were randomized into two different RT concepts: One group (207 patients with 303 affected hands) received 10 × 3 Gy (total 30 Gy) in 2 series of each 5 × 3 Gy separated by a break of 12 weeks; the other group (199 patients with 297 affected hands) received 7 × 3 Gy (total 21 Gy) in one series within 2 weeks. Orthovoltage RT (120 kV) was applied using standard cones and individual shielding of uninvolved areas of the palm. The relevant patient and disease parameters were equally distributed between control and both RT groups. The clinical evaluation (side effects, efficacy) was performed at 3 and 12 months after RT and at last follow-up (FU) in December 2010. Subjective (patient’s satisfaction) and objective parameters (palpation, measurements, and comparative photographs) were applied to assess the response. The primary endpoints were objective clinical progression and necessity of salvage surgery. Secondary endpoints were treatment of side effects and specific objective disease parameters (number and size of nodules, cords) and patient’s subjective satisfaction. Results: The acute radiogenic toxicity was low with 26.5% CTC grade 1 and 2.5% CTC grade 2; late effects, such as dry skin, were acceptable low with 14% LENT grade 1; no secondary cancer was observed in the long-term follow-up. After a minimum FU of >5 and a mean FU of 8.5 years, a total of 119 (16.5%) sites showed remission of nodules, cords or stage; 383 (53%) remained stable and 206 (29%) progressed and of those 97 (13.5%) required surgery. The progression rate in the control group (any progression 62%, surgery 30%) as compared to RT groups (21 Gy: 24%/surgery 12%; 30 Gy: 19.5%/surgery 8%) was significantly higher (p < 0.0001). Similarly, the overall and mean number of nodules, cords, and other changes decreased in the RT groups as compared to the progression in the control group (p < 0.01). Tubiana’s classification at last FU revealed a stage progression in the control group in 63 (52%) sites as compared to 64 (22%) and 49 (16%) in the 21 and 30 Gy RT group. There were 50 (8%) relapses inside and 114 (19%) outside the RT field in the RT group as compared to 52% and 28% potential relapses in the control group. Salvage surgery was possible without healing problems. Symptomatic relief was achieved in 4 (8%) sites of the control group as compared to 24 (21%) and 32 (26%) sites in the 21 and 30 Gy group, respectively. Uni- and multivariate prognostic factors for disease progression were smoking habit (trend), symptom duration prior to RT over 24 months, Dupuytren stage, extension deficit, and digital involvement (all p < 0.05). The most important independent factor was the implementation of RT as compared to the control without RT. Conclusions: RT is effective to prevent progression of Dupuytren’s disease; it reduces the necessity of hand surgery which is required due to disease progression at a minimum FU of 5 years. In addition, RT can reduce disease-related symptoms or helps to avoid their progression. Both RT protocols have been found to be effective and well tolerated, with slight advantage for the 30 Gy group as compared to 21 Gy group. Both acute and chronic side effects were well accepted and tolerated by the patients; so far no secondary malignancy was observed. From the radiobiologic background and rationale of radiotherapy, it appears possible not only to implement radiotherapy in the beginning of the disease process but also during active disease periods, for early relapses after surgery