Radiation Oncology/Benign/Dupuytrens

Dupuytren's Contracture Overview Proliferative disorder of connective tissue involving palmar fascia of the hand Highest prevalence in regions of Scotland, Ireland, and France Usually starts in 4th decade, and peaks in 5th - 6th decade Male: female = 3:1, with 2/3 developing bilateral disease Etiology and pathogenesis still poorly understood Clinical progression: Early stage: subcutaneous nodules, may be fixed to skin Intermediate stage: tough cords Late stage: cords attach to periosteum of hand bones, leading to characteristic contracture of the palm, medial phalangeal (MP) and proximal interphalangeal joints (PIP) Typically no invasion of muscles (unlike desmoid) Clinical progression in early stage disease ~50% Role of RT based on retrospective studies. Based on mechanism of disease, RT appears best when used early in the disease process. Randomized evidence suggests 3 Gy x 7 fractions sufficient Staging Tubiana's Classification (1966) Stage Description Contracture degree N Symptoms only (nodules, skin retraction, fixation) None N/I Symptoms + deformity 1-10 I Symptoms + deformity 11-45 II Symptoms + deformity 46-90 III Symptoms + deformity 91-135 IV Symptoms + deformity >135 Evidence Essen, Germany (1997-1998) -- RT 30/10 (15/5 + 15/5) vs RT 21/7 Randomized. 129 patients, 198 involved hands. Early stage progressive disease, no surgery. Stage N (37%), Stage N/I (31%), Stage I (30%), Stage II (3%). Prophylactic RT orthovoltage, margin 1-2 cm proximal/distal and 0.5-1 cm radial. Arm 1) RT 15/5, 8 week break, 15/5 vs. Arm 2) RT 21/7. Minimum F/U 1 year 2001 11172962 -- "Radiotherapy optimization in early-stage Dupuytren's contracture: first results of a randomized clinical study." (Seegenschmiedt MH, Int J Radiat Oncol Biol Phys. 2001 Mar 1;49(3):785-98.) Outcome: 1-year regression 56% vs 53% (NS), stable 37% vs. 38% (NS), progression 7% vs 9% (NS). Treatment "failure" 8%, but only 2% required hand surgery for progression Toxicity: Acute minimal, chronic Grade 1 in 5% sites, no difference between groups Conclusion: Both dose schedules equally effective to prevent disease progression. Long term F/U needed