Paige Solie, Bryan Stump, Cortney Cashner

Working Title
A case study of radiotherapy treatment for Dupuytren’s Contracture and Ledderhose disease.
Problem Statement
The problem is that there is a paucity of literature regarding radiation therapy treatment planning
for Dupuytren’s and Ledderhose patients.
Purpose Statement
The purpose of this case study is to demonstrate treatment planning considerations of 6 and 9
MeV for Dupuytren’s and Ledderhose cases in radiotherapy.
Goals/Objectives
1: Special considerations for patient set-up
2: Use of Imaging (CT)
3: Treatment Planning Techniques
4: Use of hand MU calculations
Summary
Dupuytren’s contracture (DC) is a benign condition affecting the fascia underneath the
skin of the palm and fingers which causes them to thicken and tighten. This leads to the fingers
pulling inwards, towards the palm, resulting in contracture. Progression of the contracture is
typically slow and happens over the course of multiple years, with some patients exhibiting very
few symptoms for many years. As this disease progresses, patients may have increased difficulty
with fine motor skills, making it challenging for them to perform daily activities. The disease
course of DC is variable and there is still more research being done on the intrinsic and extrinsic
factors thought to play a role such as gender, age, genetic predisposition, manual labor, hand
trauma, and other co-morbidities.1 Current studies have found that DC is inheritable and most
prevalent among males over the age of 50. Recently, a survey demonstrated that up to 7% of the
US population is diagnosed with DC or experiences symptoms of the disease. Of this 7%, one-
third of the patients’ daily function is negatively impacted by the disease.2 According to the
International Dupuytren Society, early disease is commonly classified as a contraction of digits
0-45 degrees, or nodules and cords present without contracture.3
 Similarly, there is a plantar equivalent of DC called Ledderhose disease (LD), which
affects the plantar fascia of the foot. There may be one or more subcutaneous nodules that are
painless and slowly growing. As the nodules increase in size, the foot may become painful
during standing and/or walking and may become disabling.3 The prevalence of Ledderhose
disease is unknown.5

Several treatment options have been researched for these diseases, including surgery,
steroids, vitamin E and other similar compounds, physical therapy, and radiation therapy (RT).
However, the only treatments with clinically significant outcomes are surgery, intralesional
steroid injections, and RT.4,6 Determining which treatment option to select depends on the degree
to which the affected digits are contracted. Additionally, invasive treatments for Ledderhose
disease are not recommended therefore, RT is a suitable option.5 RT alone is not recommended
for disease beyond its early stages because of a greater chance of worsening the disease.4 An
institutional study found that 80% of their patients found radiation treatments to provide stable or
improved symptoms.6 Side effects of RT treatment included short-term erythema and long-term
hand atrophy. There have been no reports of secondary malignancy in patients receiving this
treatment, but one limitation of the current literature is a lack of long-term follow-up and
reporting.4,5,6

With the uncertainties surrounding why DC has a variable progression and how different
genetic and lifestyle factors affect this progression, future DC treatment and management must
focus on individualized medicine. Focusing on an individual patient’s clinical features,
environmental factors, and genetic predisposition can allow clinicians to differentiate patients
with slow progression and favorable prognoses from those suffering an aggressive course of the
disease to optimize treatment for each patient and choose the right course of treatment.
Identifying patients with minimal disease progression would help clinicians identify these
patients may be good candidates for radiotherapy to prevent further progression. As such,
radiation therapy for patients with DC and LD may become increasingly common and lead to an
increased need for further protocols on how to treat these patients.

Current literature has little published information on DC and LD treatment in the Medical
Dosimetry Journal due to the rarity of these cases. While DC is rare, radiotherapy has been
shown to successfully treat approximately two-thirds of early-stage patients, giving it great
clinical utility as a viable treatment option.3 The lack of experience and the lack of journal
information regarding the treatment of these diseases poses an issue for dosimetrists creating a
plan for these diseases for the first time. Therefore, this case study could contribute useful
information to the dosimetry field for future reference on DC and LD radiation treatment
planning. Given the limited amount of literature on this topic, the purpose of this case study is to
provide further examples and guidelines for how to treat Dupuytren’s based on the observation
of multiple patient cases. There will be additional information on treatment planning of
Ledderhose disease and observation of patients who received treatments on sites in both the
hands and feet. Further information on this topic may serve as a valuable resource to physicians
and dosimetrists with little experience treating these diseases.

References
1. Molenkamp S, van Straalen RJM, Werker PMN, Broekstra DC. Imaging for Dupuytren
disease: a systematic review of the literature. BMC Musculoskelet Disord. 2019;
20(1):224. https://dx.doi.org/10.1186/s12891-019-2606-0.
2. Boe C, Blazar P, Iannuzzi N. Dupuytren contractures: An update of recent literature. The
J Hand Surg. 2021; 46(10):896-906. http://dx.doi.org/10.1016/j.jhsa.2021.07.005.
3. Dupuytren Contracture and Ledderhose Disease. International Dupuytren Society.
Dupuytren online website. https://www.dupuytren-online.info. Accessed March 27, 2022.
Updated January 7, 2022.
4. Eng TY, Abugideiri M, Chen TW, et al. Radiation therapy for benign disease:
Arteriovenous malformations, desmoid tumor, Dupuytren contracture, graves
ophthalmopathy, gynecomastia, heterotopic ossification, histiocytosis. Hematol Oncol
Clin North Am. 2019; 34(1): 205–227. https://doi.org/10.1016/j.hoc.2019.09.005.
5. Steenbakkers R. SP-0764: (Re-)Irradiation in morbus Dupuytren and Ledderhose.
Radiother Oncol. 2020; 152(1):S421. https://doi.org/10.1016/S0167-8140(21)00786-6.
6. Lloyd SA, Braunstein SE, Gottschalk AR. Radiotherapy is an effective treatment in
early-stage Dupuytren’s disease and Ledderhose disease: A single institution
retrospective review. Int J Radiat Oncol Biol Phys. 2017; 99(2):E513.
https://doi.org/10.1016/j.ijrobp.2017.06.1830.