RADIOTHERAPY FOR BENIGN DISEASE XStrahl Users conference Moscow 2014
SUMMARY • The use of radiotherapy for benign disease • Dupuytren’s disease • Ledderhose disease • Plantar Fasciitis • Keloid scarring
USE OF RADIOTHERAPY FOR BENIGN DISEASE • Germany – 20, 000 patients per year treated with RT for benign disease • UK – many fewer • Often • Benign tumours e. g. acoustic neuroma, pituitary adenoma • Benign conditions • Heterotopic ossification • Keloid scarring • Thyroid eye disease • Dupuytren’s disease
HYPERPROLIFERATIVE DISORDERS • • Hand - Dupuytren’s disease Foot – Ledderhose disease (plantar fibroma) Penis – Peyronie’s disease Frozen shoulder • Often occur in combination
CAUSES • Genetic • Northern European • Males • Environmental • Manual labour (vibration), prior hand trauma • Alcohol (xs), Smoking • Diabetes mellitus
WHAT IS DUPUYTREN’S DISEASE? • Common benign thickening and shortening of the palmar fascia leading to finger contractures • Average of onset 50 - 60 years
Nodule Cords Skin retraction
LOSS OF HYPEREXTENSION
DEVELOPMENT OF CONTRACTURE
TREATMENT FOR DUPUYTREN’S DEPENDS ON STAGE Early Dupuytren’s (Stage N, N/I) • Nodules, cords, skin retraction • Contracture: 0 – 10 degrees • Treatment eligibility • If progressing in last 12 months • Treatment • Radiotherapy Advanced Dupuytren’s (Stage I - IV) • Nodules, cords, skin retraction • Contracture: > 10 degrees • Treatment eligibility • Generally > 20 -30 degrees + functional impairment • Treatment • Surgical Release
TREATMENT VS STAGE Stage RT Surgical release N N/I I II IV
SURGICAL RELEASE OF CONTRACTURE 1. Fasciectomy – surgery to release contracture & remove disease. 2. Collagenase – injection that dissolves collagen to release contracture 3. Needle aponeurotomy – mechanical release of contracture
RADIOTHERAPY DETAILS • GTV = Nodules & cords • PTV margin = 1. 5 cm Superficial X-rays: • 80 k. V (2 mm Al) to 140 k. V (8 mm Al) Electrons • 6 Me. V + 5 mm bolus
RADIOTHERAPY: DOSE AND TIMING 15 Gy/5#/1 wk 8 – 12 week break 15 Gy/5#/1 wk = Total 30 Gy in 10 fractions
EVIDENCE: SEEGENSCHMIEDT TRIAL • 30 Gy/10# vs. 21 Gy/7# • n = 489 patients with at least 5 years of follow-up • 47% = bilateral RT so 718 hands treated • All had clinically evident progressive disease • Counselled about RT and watch and wait • Mean follow-up = 8. 5 years
RESULTS AT 8. 5 YEARS FOLLOW-UP Dose Control (n=122) 30 Gy (n=245) Regression/ Progression Surgery (%) stable (%) 38 62 30 80 20 8
RADIOTHERAPY SIDE-EFFECTS • Acute – red/dry skin • Grade 1 = 25%, Grade 2 = 2% • Chronic skin changes in 5% at 12 months • Risk of radiation-induced malignancy • 0. 1% lifetime risk
RADIOTHERAPY FOR DUPUYTREN’S: CONCLUSIONS • Radiotherapy is effective in the early stage of Dupuytren’s • It stops the disease progressing, and reduces the need for surgery • It causes minor side-effects, and has a very small risk of causing malignancy
LEDDERHOSE DISEASE (PLANTAR FIBROMATOSIS) Histologically identical to Dupuytren’s disease Coexists with Dupuytren’s disease in 25%
CLINICAL • Firm nodules - medial & central plantar fascia • Generally non-tender on palpation, but cause pain on standing/walking • Overlying skin mobile • Disease course: • Variable • Typically rapid growth over 1 -2 months, then dormant or slow growth over years.
MANAGEMENT • General care: • Avoid direct pressure • Stretching • Soft inner soles, custom orthotics, padding • Surgery • Excision of nodule – 85% recurrence rate • Radical plantar fasciectomy with skin grafts – morbid, variable results, last resort – 25% recurrence • High risk of severe side-effects e. g. painful scars, numbness, haematoma, infection, delayed wound healing • RADIOTHERAPY
STUDY OF RADIOTHERAPY FOR LEDDERHOSE DISEASE • • n = 158 Patient chose which treatment 97 patients (61. 5%) chose RT 61 (38. 5%) formed a control group • Field = Palpable & imaged lesions + 2 cm margin • Shielded uninvolved areas with lead • Median FU = 5. 5 years
RADIOTHERAPY: DOSE AND TIMING 15 Gray in 5 fractions over 1 week 8 – 12 week break 15 Gray in 5 fractions over 1 week = Total 30 Gray in 10 fractions
RESULTS • ↓risk of progression from 38% to 8% • ↓ need for surgery from 21% to 5% • ↓ symptoms in 79% vs 19% • Minor side-effects in most patients • Conclusion: • Radiotherapy is a very effective and safe treatment for Ledderhose disease
PLANTAR FASCIITIS • Inflammation and/or degeneration of the plantar fascia → heel pain • In 10% of the population • Especially: • 40 - 60 years, • Men: Women = 2: 1 • Cause = mechanical overload: • Obesity, prolonged standing, intense exercise • 80% → complete resolution in 12 months • Some do not resolve, can be disabling
GENERAL MANAGEMENT SIMPLE MEASURES • Resting • Weight loss • Painkillers • Icing • Stretching exercises • Footwear changes and orthotics.
OTHER TREATMENTS • Steroid injections • Extracorporeal shock-wave treatment (ESWT): • Non-invasive treatment, uses acoustic shockwaves. Painful. • Results inconclusive • Surgery: • Only if fail conservative treatment. • Plantar fascia division or gastrocnemius release. • No randomised evidence
RADIOTHERAPY FOR PLANTAR FASCIITIS • Randomised trial: • 6 Gy in 6 fractions over 3 weeks vs. 0. 6 Gy in 6 fractions over 3 weeks • Modality: • 4 – 6 MV • • Parallel pair of MV photons 250 -200 k. V • • Direct plantar field, bolus laterally & dorsally Prescribe to 5 mm depth Response rate: 82% vs. 36%
KELOID SCARRING • Common benign skin growths • Abnormal healing response to minor injury e. g. ear piercing, chickenpox, BCG • Particularly occur on the upper chest, shoulders and earlobes. • Especially in dark-skinned patients and between the ages of 10 – 30 years
KELOID SCARRING • Result in raised scars that may be red or hyperpigmented. • Often cosmetically disfiguring, but can also cause itching and pain. • Extend outside the confines of the original wound and do not spontaneously regress.
KELOID SCARRING
TREATMENT • Steroid injections • Surgery alone = 70% recurrence rate • Surgery + Radiotherapy • Case series only • 15% recurrence at 5 years, 27% at 10 years • Radiotherapy dose & modality • 60 – 120 k. V photons • Single dose within 24 -72 hours = 5 - 10 Gy • Fractionated: 12 Gy in 3 fractions over 3 - 5 days
CONCLUSIONS • Radiotherapy can be used successfully for the treatment of benign conditions • It is probably underused due to lack of resources and referral patterns • The risk of inducing a malignancy must always be borne in mind
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