Wednesday, 14 March 2012

Radiation Treatment for Ledderhose and Dupytren’s Disease

Radiation Treatment for Ledderhose and Dupytren’s Disease:

Ok so for those who are thinking I have already covered this but the best that I have done before was my review of one of the papers that came out: here -
Today I am going to try to review some the data that I can find on radiotherapy for DD and LD for this I am using a couple of sources which include my book (chapter 50) which I mentioned here: book and also another paper that I have found which is entitled Radiation Therapy for Early Stages of Morbus Ledderhose which may also have some useful data in it. See here for an interview I have done with one of the top UK specialists to use this treatment for these diseases.

For starters I am being a bit selfish with this post as part of the reason for me doing this research is to see whether going to Germany and getting radiation treatment done is the best option for me to take next. I am going to try and set this up a bit like my previous posts on treatments which are here for Steroid injections and here for Orthotics and here for Surgery

Radiation for the treatment of Plantar Fibromas / Plantar Fibromatosis / Ledderhose Disease(LD) (and Dupuytren’s disease) (DD):



So radiation treatment means hitting the cells with a dose of something nasty that is going to kill the bad cells but leave the good cells and therefore leave the individual healthy.  



How and why does radiation help Ledderhose disease?:



As always seems to be stated LD is a hyper-proliferative disease and this means that the cells that cause the disease grow at a rate that is faster than they should and this is why you end up with excess cells and therefore a lump.  Although nowhere I can find states exactly how radiation helps with Ledderhose disease I am going to assume that it is on the same principle as with cancer cells and that the cells that are growing faster are more susceptible to death when treated with radiation as they have less time to fix the damage created and so the cells reach a state where they cannot survive. This would also be backed up by many sources I have seen saying that the treatment of Ledderhose is best done early on when the lump(s) are increasing in size rather than later on when the lumps maybe bigger and more painful but are in a less proliferative state. Actually on further inspection the paper on the use in early stages actually says:




"The radiobiological mechanism of RT in ML is suggested to be based predominantly on an inhibition of the fibroblast and myofibroblast proliferation known to be responsible for the symptoms and progression of the disease. Therefore, the optimal time for prescription of RT is given in patients with progressive disease. The radiosensitivity of these cell lines is known from the treatment of other benign mesenchymal disorders [31]. In addition, MD specimens show an increase of growth factors produced by macrophages and platelets, including the fibroblast growth factor, transforming growth factor-β, epidermal growth factor, platelet-derived growth factor, and also connective tissue growth factor (CTGF), which play key roles in the pathogenesis of ML and MD [31]. The impact of  low RT doses on cytokine expression has been demonstrated for analgetic RT of degenerative disorders [27–29], but as by now, it remains unclear whether it also plays a role for RT of proliferative disorders. Hence, this should be one of the targets of future basic research.”


Results?



So I will try to compare paper by paper and then give some sort of conclusion based on what I have seen. So first of all I am going to look at the:


1) Radiation Therapy for Early Stages of Morbus Ledderhose

At a follow up time point of 6-76 months (average 22.5) none of the patients had experience a worsening of symptoms and surgical intervention was avoided in all patients. In 33.3% of patients there was complete remission of the lumps and in 54.5% of patients there was partial remission where there was a noted decrease in the size of the nodules and any remaining patients stayed the same.



2) Dupuytren’s Disease and related hyperproliferative disorders, chapter 50 – Long-Term Outcome of Radiotherapy for Primary and Recurrent Ledderhose Disease:


So for this I have the whole of an entire chapter to look through and try to see what useful information they have but I shall start with their conclusions which is:
“RT (radiation therapy) is the MOST effective treatment for primary and recurrent Ledderhose Disease due to very low progression or relapse rates. RT permits the avoidance of primary and secondary surgical interventions due to high remission rates in various aspects of LD disease.”

I think that is quite an impressive conclusion to come to and I actually read this before seeing all the results in detail. Interestingly for me one of the key things is looking at the statistics for mean time of first symptoms before use of RT and average was actually 30 months, that is 2 ½ years and is actually about exactly the same length of time I have had this since I first started to have any trouble. Another reason that I see a positive for me is that 87% of the treated feet had pain and 84% had walking difficulties which suggest unlike other studies that this can be used as a treatment option once the disease has progressed beyond the initial proliferative phase.
Overall they saw that in the patients that had RT 44% had a reduced number and or size in nodules however 90% of patients that had RT reported that they had an improvement with regards to symptoms and only 7% showed progression. 83% of people who had pain on walking and 68% of those who had pain at rest said they had an improvement. Both before and after radiation patients were asked to assess their pain and symptoms on a scale of 1-10 and on average patients said that they improved by 3.2 points in 89%.
Side Effects:

1) Radiation Therapy for Early Stages of Morbus Ledderhose

There were six patients who developed slight erythema (redness of the skin) or hyper-pigmentation and a few patients had increased dryness of skin. Note that although there is an increased risk of cancer it is absolutely minimal.

2) Dupuytren’s Disease and related hyperproliferative disorders, chapter 50 – Long-Term Outcome of Radiotherapy for Primary and Recurrent Ledderhose Disease:

There are some side effects that they associated with the use of RT for treatment of LD. Again this was mainly restricted to redness of drying of the skin and they note that no radiogenic toxicity was found.

I was searching around for more information on this and came across the following link. Here they discuss the odds of getting cancer as a result of the radiation therapy and handily they include a 25 year old as one of their model calculation and say that the increased risk is around 0.1% increase and that this means that my chances of getting cancer with the treatment would be 24.1% rather than 24%...
My Feelings:

I think that this is an exciting area of research and it is clear that it does seem to help a lot of patients and in a lot of cases the pain has gone away. Note that although this is the case the NHS in the UK has still not approved this for use with Ledderhose and this means that if you want to get the treatment here it would cost £2000 whilst you could go to Germany and get it done for £1000 (plus travel costs). I decided to go with getting it done in the UK and have found the treatment I have received by Dr Shaffer and the team at the Royal Surrey County Hospital to be fantastic. 

Video of how Radiotherapy works: 


Also if you go to this Forum http://www.dupuytren-online.info/Forum_English/index.php - Most of the feedback I am seeing for radiation treatment is very positive and most of the information about surgery - my only option left on the NHS - is quite negative. So this is why I went for radiotherapy rather than surgery though if you are not as lucky as me to have some relatives to pay for it then you will struggle to afford the procedure. 


References:

Radiation Therapy for Early Stages of Morbus Ledderhose

Dupuytren’s Disease and related hyperproliferative disorders, chapter 50 – Long-Term Outcome of Radiotherapy for Primary and Recurrent Ledderhose Disease:

Updated: 17/06/2012