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)

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 PMID 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