Absolutely yes. You should definitely discuss any comorbidities with your doctor and radiation oncologist before going ahead with the treatment.
Radiation damages DNA. This damage is likely to be fatal to proliferating cells, while non-proliferating cells, given time, can repair the damage. Early in the development of Dupuytren's and Ledderhose's disease, cells called fibroblasts proliferate and develop the capacity to contract. Radiotherapy uses enough radiation to kill proliferating cells while not permanently damaging normal, non-proliferating cells. It achieves this by ensuring that normal cells have the time they need to recover while proliferating cells do not.
This has an important implication. There's no point in irradiating a hand or foot if the disease isn't active and the fibroblasts aren't replicating. If the disease isn't active, the fibroblasts are no more vulnerable than any other cells. For the radiation to be effective we must time the therapy in relation to the disease's cycle, not as a function of our convenience or that of the clinic. How do you know if the disease is active? For many people, active disease makes the palms itch and tingle. Active disease also manifests as hardening of nodules (Prof Seegenschmiedt compares the hardness of a new nodule to that of a tomato, while as it gets older it is like an orange, then a tennis ball and finally a coconut), the appearance of new nodules, and the appearance or tightening of cords over the previous month or so.
In the protocol developed by Prof Seegenschmiedt and his team, rather than irradiating the hand or foot with, say, 30Gy in a single dose, half the dose is fractionated over 5 days at the rate of 3Gy a day, followed by a gap of 12 to 16 weeks, and then the treatment is completed with another half dose of 15Gy spread over 5 days.
Why not deliver all the 15Gy in a single dose instead of splitting it over 5 days? Spreading (half of) the total dose over 5 days gives the healthy cells a bit of breathing space each day to repair their damaged DNA, while the proliferating fibroblasts are increasingly damaged and less and less capable of survival as the treatment is repeated day after day. Interrupting the sequence by a weekend almost certainly makes no difference to the effectiveness of the treatment. The two-day break from treatment might help the normal cells recover a bit more, which would perhaps help to reduce any likelihood of acute side effects. The point is to give the first 15Gy in a reasonably short space of time (less than a couple of weeks) to make sure that the proliferating fibroblasts get as damaged as possible without the chance to repair themselves, but over time long enough to give normal cells that chance.
The interval between the two half-treatments, or series of radiation, is probably more important than we yet realise. The purpose of the gap is to allow the normal cells time to recover completely, but more importantly, to allow any fibroblasts that were quiescent at the time of the first radiation to begin their replication. In an ideal world, the second set of treatments wouldn't be necessary - and that's the premise of the single 7-day treatment. But the biological world doesn't behave for our convenience. So, we can be sure that the first set will miss some quiescent fibroblasts.
How to make sure that they are active during the second set? The current regime for Dupuytren's and Ledderhose disease is based on what oncologists have found to be effective against certain cancers. The art is to destroy as much of the proliferating tissue as possible in the first of the two half-sessions, without damaging the healthy tissue beyond repair, and then wait an appropriate time to ambush the newly proliferating cells a few weeks later. My guess is that Prof Seegenschmiedt has enough experience to have it down - the longer the better, up to about 4 months. A shorter time doesn't catch them waking up, and a long time allows them to get out of phase so some will be quiescent again. About 12 to 16 weeks seems to be the optimum.
Many oncologists use a shorter break, often of 4 to 6 weeks.
To the best of my belief, our present state of understanding of the histological effect of radiation on Dupuytren's and Ledderhose disease is not great enough to know whether other fractionation regimes are as good as, or better than, the one used by Prof Seegenschmiedt. A very large clinical trial would be needed to give statistical validity to the most effective protocol for most people (everyone is different), but Prof Seegenschmiedt’s protocol seems to give satisfactory results in most cases.
I told Prof Seegenschmiedt that I had heard that some radiation oncologists treating Dupuytren's disease were using his 30Gy fractionated protocol (5 days, a gap of several weeks, 5 days) but making the second series of 5 optional so that it would only be delivered “if needed”. He looked dismayed and said, “not enough time! Not enough time! You cannot possibly make a diagnosis on the progress in such a short time after the first series. This is not fair to the patient! We know that to stop the progress of the disease we must deliver the highest possible dose compatible with avoiding side effects, and we know that the dose we need is around 30Gy. The gap between the two series of 5 isn’t to give the doctor the opportunity to decide whether to continue. It is to give time for the healthy tissue to recover and for Dupuytren's fibroblasts that were not proliferating at the first treatment the time to start proliferating and become vulnerable to the radiation.”
He was, I think, quite appalled that anyone would regard the second series as anything but part of a coherent single treatment of hyper fractionated radiation. For him, it simply doesn't make sense to stop half-way through, and his data suggest that 15Gy will probably be better than nothing at all, but nothing like as effective as 21Gy, which in turn is not as effective as 30Gy.
I also asked Prof Seegenschmiedt about the “7 vs 10” protocols – that is, the protocol in which 21Gy are delivered in 7 doses, relative to the protocol in which 31Gy are delivered in the “5-gap-5” sequence.
He said, first, that he would always recommend the 5-gap-5 protocol since it gives rise to better results (he now has better statistics to show this but has not yet written them up) and fewer side-effects.
Secondly, he said that it was important that the 7-dose protocol should take place over more than 7 days. The most effective schedule is one that takes place over 15 days, with radiation every other day, with a break at the weekends (M-W-F, M-W-F, M). The reason for this is that 21Gy is a lot of radiation for the body to absorb and deal with. If the series is compacted in time, it greatly increases the risk of acute side effects, because the dose is too concentrated. Even when it is delivered over 2+ weeks, acute side effects occur more frequently than they do with the 5-gap-5 protocol.
The treatment of Dupuytren's or Ledderhose disorders with radiation is rather different from cancer treatment.
Your radiation oncologist will probably have many years experience with cancer, but you might want to consider asking them about the extent of their experience of treating Dupuytren's or Ledderhose disorders.
Some possible things you might want to know:
(1) Where and with whom did your oncologist train to treat Dupuytren's or Ledderhose Disease, Peyronie's or other fibromatosis?
(2) How long ago did they first use radiation to treat patients for these disorders?
(3) How many patients, or hands and feet, have they treated?
(4) What kind of after-care and follow-up do they offer for their patients after the end of the radiation therapy? What intervals are there between the follow-ups, and for how long do they follow patients?
(5) What protocol of radiation treatment do they use - how much radiation in a single dose, what kind of fractionation, and how long between the first dose and the last?
(6) In the event that in years to come you have to go back to a radiation oncologist for whatever reason, and need to tell them about previous treatments, you might want to ask your oncologist what kind of radiation technique they use - orthovoltage, electrons, photons, and with what energy?
(7) Do they teach or publish educational material?
(8) Have they ever published their clinical results in the medical literature?
You might also consider asking them whether they would be in favour of the establishment of an international professional body, dedicated to identifying and spreading best practices in the use of radiation for treating DD, LD and other fibromatoses, with a membership of practicing oncologists and medical institutions around the world.
Some radiation oncologists would not even consider it. Others, who would consider it, would treat each case individually, but the prevailing attitude is one of caution.
In 2020, UK-based radiation oncologist Dr. Richard Shaffer published a blog post on the subject. He provided his own opinion, and discussed variables that other practitioners might take into consideration: “Repeating Radiotherapy For Early Dupuytren’s & Ledderhose Disease.
Dr. M. Heinrich Seegenschmiedt commented in 2019. He discussed his experience in which radiotherapy retreatment after previous radiotherapy was a "rare, but possible, solution under certain conditions." For details, navigate to item #24 in a collection of writings that he has shared.
Yes, you can.
Radiation oncologists deal with this issue routinely. A common example is when a patient being treated for prostate cancer has a metal hip replacement.
If you have a metal pin in your wrist or hand, tell your oncologist. They may decide to schedule a CT scan to help plan the therapy. Many practices use this information as input for planning software that tailor-makes the radiation sequence for you.
Copyright © 2018 www.dupuytrens.club - All Rights Reserved.
Contact information provided below for radiation oncologists who have treated for Dupuytren's Contracture or Ledderhose . Comments or opinions expressed here or on DART are not intended to diagnose or prevent disease. Advice or comments should not be relied upon unless confirmed by your treating physician. No doctor-patient relationship is intended and members are advised to consult their doctors for medical advice. No representation is made about the quality or professional competency of the listed doctors. This listing is compiled from referrals of DART members and is provided as a place for you to begin your own research. If you find the contact info outdated or in error, please comment on DART where it can be corrected. You might also google the doctor or clinic to find updated contact information. Many of these doctors also practice at secondary locations that may be closer to you. Check their website. In addition to their clinical practice, many of these radoncs are also on the faculty of local medical schools where they teach radiation oncology. If you have doctor or clinic information not listed below, please share with DART so it can be made available to others looking for treatment in that location. some photos from dupuytrens.org Thank you.
Powered by GoDaddy