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Not a single cancer has ever been attributed to radiotherapy for Dupuytren’s or Ledderhose disease.
Not one.
All ionising radiation can damage the DNA of a cell in such a way that the cell, having repaired the damage incorrectly, becomes cancerous. But this risk of radiotherapy for Dupuytren's and Ledderhose disease is entirely theoretical so far.
The theoretical increase in risk is about 0.02% if you are 60 when you get the radiation treatment, and it doubles for every decade younger, so if you are 50 it's about 0.04%, 40 0.08%, and 30, 0.2%.
Now this means that instead of running a risk of say 35%, you're up to 35.2% if you are 30 when you get the treatment. In other words, the increase in risk is not zero but it is negligible.
In fact, there is some evidence that having Dupuytren's or Ledderhose disease may be linked to a higher risk of cancer – and the radiotherapy has nothing to do with it.
About a quarter of all deaths in the industrialised countries are from cancer - that is, about 25%. A small number of studies suggest that people who have had surgery for Dupuytren’s or Ledderhose disease are more likely to die of cancer than people without the disease - about a third, say 35%.
So there's a possible link between these diseases and cancer but we don't understand it.
If you’ve ever had an X-ray you know exactly how much it hurts – not at all.
But there may be some pain after the treatment – See FAQ52 for more information.
Most people have few or no side-effects, but the relative risk of side-effects seems to be linked to the protocol used.
The body can deal with a certain amount of radiation in a certain time, but the higher the dose and the shorter the time over which it is absorbed, the more likely it is that the body will react badly – that is, display side-effects. If you receive 30Gy in two series, perhaps split over 8 weeks, your body has time to recover from the first 15Gy pulse before facing the second one sometime later. If you receive 21Gy in a single series lasting 7 days, although your body has to deal with 3Gy a day as before, the assault on your tissues is sustained for longer in that single series. This tends to increase the risk of unwanted side-effects.
The use of the word “risk” acknowledges that there is no hard and fast rule and that everyone reacts differently.
The most widely-shared side-effect is tiredness. This, almost certainly, has little to do with the radiation itself, since only a very small area of your hands or feet is being radiated, but it is much more likely that it is related to the circumstances around the treatment. Your routine is changed, you have to be at a certain place at a certain time each day, you have to travel to get to the appointment, you may have had to travel to, and be in an unfamiliar city, and you may have to live in a hotel or stay with friends during the treatment. To add to that you may quite naturally feel anxious about the treatment and concerned about whether it will work for you. Tiredness is natural.
Many people notice a sensation of heat in the radiated area, rather like that of sunburn, after a few days of treatment. Your skin may turn red and feel dry and tender, again as if you had a mild sunburn. This set of symptoms may last for a couple of weeks after the therapy, and it may even intensify for a while in the days after the end of the treatment. This reaction is exactly analogous to that of sunburn. Sunburn is caused by overexposure to ultraviolet light, which is highly energetic, and damages tissues in and under the skin. The machine used to provide your radiation therapy does not use ultraviolet, but much more energetic radiation, and works by damaging the fibroblasts that are running out of control. It also, inevitably, damages normal cells. The “sunburn” symptoms are those of tissues reacting to high doses of extremely energetic radiation. The symptoms may continue after treatment because the tissues will not fully recover for several weeks.
Other symptoms that are commonly encountered by people undergoing radiation therapy for cancer include hair loss, nausea, frequent urination, and diarrhea. None of these side effects has been reported for people receiving therapy for Dupuytren's or Ledderhose disease.
Your treatment is designed to give as few side-effects as possible. For this reason, it is unlikely (though not impossible) that you will experience some long-term, or even permanent, changes.
You may notice that the skin in the treated area seems to have a permanent suntan, or creases in the palm may take on a deeper colouring, veering towards magenta. The skin may feel harsher and less elastic than it was. In some unfortunate people, radiotherapy may cause radiation fibrosis, where the tissues become less stretchy. This is problematic for patients who have had radiation therapy involving organs such as the heart, liver or lungs, but much less likely to be problematic for patients treated for Dupuytren's and Ledderhose disease, whose tissues of the radiated area are in any case less stretchy than they should be.
You may also notice that the nodules and cords become better defined, and perhaps more tender to the touch, after radiation therapy. Before the therapy, the areas around the activity of the disease are inflamed and puffy. This swollen tissue masks the outline of the nodules and cords. After the radiation, the inflammation disappears, and the nodules become more easily felt beneath the skin.
Some people experience a period of increased pain in the irradiated areas, sometimes lasting several weeks. It’s not very clear why this happens, but one suggestion is that nerves that had become surrounded by and embedded in the collagen laid down by the disease are triggering as the inflammation around them decreases.
There is not a huge amount of evidence in the medical literature on side effects of radiation therapy for Dupuytren's disease, and as far as I know nothing at all on Ledderhose or Peyronie's disease. The following excerpts are typical.
[Erythema = reddening of the skin
Desquamation = peeling
Atrophy = shrinking and thinning (wasting away)
Teleangiectasia = reddish clusters or spidery marks caused by dilatation of the capillaries
Sarcoma = malignant cancer of the soft tissues]
Erythema of the treated area was reported in 42 patients (20.4%) and no data were available for 27 patients (13.1%). Dryness of the treated skin was present in 82 patients (39.8%) and no data were available for 15 patients (7.3%). Desquamation was reported in eight patients (3.8%).
Chronic side-effects that persisted for more than 4 weeks after the end of the treatment were dryness of the skin (41 patients, 20%), skin atrophy (seven patients, 3%), lack of sweating (eight patients, 4%), teleangiectasia (six patients, 3%), desquamation (five patients, 2%) and sensory affection (four patients, 2%).
Zirbs, M., Anzeneder, T., Bruckbauer, H., Hofmann, H., Brockow, K., Ring, J., and Eberlein, B. (2015). Radiotherapy with soft X-rays in Dupuytren’s disease - successful, well-tolerated and satisfying. Journal of the European Academy of Dermatology and Venereology 29, 904–911.
An estimate of the statistical risk of lethal skin cancer caused by RT at age 45 for Dupuytren's disease is provided by the International Dupuytren Society in collaboration with the German Centre for Environmental and Health Research. In patients exposed to RT for Dupuytren's disease (30 Gy low energy fractionated X-rays) the risk is estimated to be about 0.02% higher than the probability of dying from cancer without RT (estimated to be -24 ± 0.26%). Since the excess risk is very small compared to the background risk it is impossible to evaluate this accurately in a clinical study.
It should be noted that the risk is subject to a number of assumptions. In particular it is calculated for one hand, so the risk doubles if both hands are treated. The calculations are based on an irradiated area of 60 cm2, which is fairly large, so the risk is reduced if the irradiated area is smaller, and it assumes that the remaining hand and body are sufficiently protected during treatment. The risk estimate is also affected by the age of exposure to RT treatment. For a patient of 25 years the risk is approximately double that of a 45-year-old and it is about half for an individual receiving treatment at age 60. Although rare, Dupuytren's disease can occur in children and young adults. Clearly their risk of radiation-induced cancer (RIC) will be increased further so RT should only be used alongside careful counselling of the patient.
The above estimate applies to the risk of a fatal radiation-induced skin cancer. There may also be a risk of sarcoma; this is difficult to assess but is likely to be less than the risk for skin cancer. One factor which may affect the risk in an unknown manner is the reported higher risk of dying of cancer in individuals with Dupuytren's disease. As discussed in the section on the risk of a radiation-induced malignancy following low to moderate dose radiotherapy, a recent study has modelled the risk of a range of cancers arising from radiation exposure for benign disease using male and female anthropomorphic phantoms. Although not exactly comparable, the calculated risk was similar to the above estimate. To the authors' knowledge, not a single case of cancer caused by radiation therapy for Dupuytren's disease has been reported in the literature.
It should be noted that there are other more immediate effects that, although less serious than cancer, have a greater probability of occurring. For example, in a long-term follow-up of 176 radiated hands, 25% exhibited anhidrosis, 8.5% skin atrophy and >1% reduced wound healing.
Anon (2015). A review of the use of radiotherapy in the UK for the treatment of benign clinical conditions and benign tumours (UK Royal College of Radiologists).
[The following text relates mainly to radiation used in the treatment of cancer.]
Treatment reactions reach their peak approximately ten to 14 days after treatment completion. After this time the skin reaction will gradually reduce as the basal cell layer recovers and normal equilibrium between cell death and cell reproduction returns to the epidermis.
While most skin reactions heal over time, some patients may experience long-term skin changes that appear months or years after treatment. These include:
■ Changes in pigmentation due to the effect of radiation on melanocytes.
■ Decreased tissue flexibility affecting range of motion and tissue strength caused by the effect of radiation on the supporting structures in the dermis.
■ The appearance of spidery red lines, called telangiectasia, caused by damage and stretching of the capillary blood vessels during treatment.
■ Impaired wound healing in the treated area.
Factors influencing the severity of skin reactions
While skin reactions are one of the most common side effects of external beam radiotherapy, the severity varies between patients due to a wide range of factors. This means that it is not always possible to predict in advance the severity of skin reactions that an individual may experience. However, knowledge of the risk factors can help staff develop appropriate individualised evidence-based care.
Influences on radiotherapy skin reactions can be divided into extrinsic and intrinsic factors. Extrinsic factors are those related to the treatment process, while intrinsic factors are those related to the patient.
Treatment dose and volume: Severity of skin reactions are affected by the cumulative treatment dose. Skin reactions tend to appear in the second and third week of treatment and their incidence increases as treatment continues. Patients having palliative radiotherapy at doses less than a total of 2000cGy are at reduced risk of skin reactions.
Size and location of the treatment field: Reactions are greater in larger and/or irregular shaped treatment areas where it is more difficult to achieve an even dose across the field.
This can be seen in radiotherapy to the breast, where women with larger cup sizes of D or above tend to have more severe skin reactions than women with smaller breasts. Skin folds and treatment sites with increased potential for friction and/or moistness are also associated with more severe skin reactions. This includes the axilla, under the breast, head and neck, perineum and groin.
Fractionation schedules: Fractionation Radiotherapy is often delivered in small doses each day over a period of time; this is called fractionation. Delivering treatment this way increases the chances of killing cancer cells when they are more sensitive to the effects of radiotherapy in the mitosis phase. These smaller daily doses also allow normal cells to recover and repair from sub-lethal damage, therefore reducing toxicity. Different fractionation schedules influence the incidence, timing and severity of skin reactions.
Treatment technique: Different techniques are used to plan and deliver radiotherapy and the technology used is continually evolving to improve treatment accuracy. The use of intensity-modulated radiotherapy (IMRT) has been shown to reduce the incidence of long-term effects and plans are in place for its use to be increased in the UK.
Warnock, C., and Lee, N. (2014). Skin reactions from radiotherapy. Cancer Nursing Practice 13, 16–22.
You may see some changes during and for some time after the radiation.
The skin is constantly renewing itself. Dead cells slough off the top of the skin, and new cells form at the base of the epidermis. Between the epidermis and the top of the skin lies the dermis, which contains blood vessels, glands, nerves and hair follicles, and provides the structure that allows the epidermis to renew itself, a process that normally takes about 4 weeks, or a bit less when the skin is healing.
Because cells in the basal layer of the epidermis proliferate rapidly, this layer is particularly sensitive to radiotherapy. It also lies very close to the target cells for radiotherapy of Dupuytren's and Ledderhose disease, so the radiation that is designed to kill proliferating fibroblasts in diseased tissue also causes considerable collateral damage in the basal layers of the skin.
If enough proliferating epidermal cells that were destined to repopulate the skin are killed off, a skin reaction may develop and the epidermis may become broken. Basal cell loss is noticeable with doses of about 20–25 Gy, rising beyond that to about 50 Gy. The reaction tends to peak at the end of the week, or up to a week after the end of the treatment. This means that skin reactions are unlikely to be seen with the 2-series, 30 Gy protocol, but may be seen with the 21Gy, ten-day protocol.
The most common skin reaction is a slight superficial, often patchy, reddening of the skin (erythema). Occasionally the skin becomes dry, flaky or scaly. Rarely, the skin may blister, peel and slough off. Combinations of these three reactions are sometimes seen, and the skin may also become itchy, uncomfortable or even painful.
Most skin reactions disappear within 4 weeks of treatment, though reformed skin may be strongly coloured for some time, as a consequence of radiation damage to the cells that produce melanin. This 4-week recovery period sets a lower limit of the gap between two sequences of treatment in the 30 Gy protocol. Clearly, a longer gap gives more time for the skin to regenerate.
The skin may never completely recover its earlier elasticity or thickness. Furthermore, because the disease is no longer active, previously inflamed areas are likely to become less puffy, making it easier to detect and outline the structures below the skin. Thus, the nodules and cords may become more pronounced both visually and to the touch.
There is no evidence that washing makes skin reactions worse, but there is some evidence that not washing may lead to problems. If your skin is intact, you may swim during and after radiotherapy, but you must rinse your skin well afterwards and moisten it with aqueous cream.
There is no good evidence that aqueous cream is less effective than topical ascorbic acid, creams containing starch, or creams with active ingredients like sucralfate, hyaluronic acid, and aloe vera gel.
The only side effects I have experienced was a slight ache in my palms that felt a little like sunburn, starting about 4 days into the therapy, and then slight redness in the creases in my hands for a few weeks. I think most people probably have a similar minimal reaction, though certainly, some people find that they react much more to the radiation.
Resources:
Warnock, Claire and Lee, Nicola (2014). Skin reactions from radiotherapy. Cancer Nursing Practice. 13, 9, 16-22. doi: 10.7748/cnp.13.9.16.e1146.
Wells, M., and MacBride, S. (2003). Radiation skin reactions. In Supportive Care in Radiotherapy, S. Faithfull, and M. Wells, eds. (Edinburgh : Churchill Livingstone)
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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 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.
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