Radiation therapy for early Dupuytren's disease

NICE interventional procedures guidance [IPG368] Published date:

2 The procedure

2.1 Indications and current treatments

  1. Dupuytren's disease is a benign, slowly progressive condition of unknown origin, characterised by connective tissue thickening in the palm of the hand, forming nodules and cords, which leads to difficulty in extending the fingers. Symptoms include reduced range of motion, reduced hand function and pain. Most patients are affected in both hands.

  2. Treatments aim to restore hand function and/or prevent progression. These include needle fasciotomy in earlier stages and open surgical correction in later stages when secondary changes to tendons and joints have developed.

2.2 Outline of the procedure

  1. The aim of this procedure is to prevent or postpone the need for surgical intervention. The mechanism of action of radiation therapy is unclear, but it is thought to affect the development and growth rate of fibroblasts within the palmar fascia.

  2. Radiation therapy is delivered to the nodules and cords that have formed in the hands and is given over several consecutive days, until the planned radiation dose (usually about 15 Gy in 5 fractions) has been delivered. In severe disease, particularly if there is contracture of the proximal interphalangeal joint, more than 1 course of treatment may be used, with each course being separated by a few weeks.

Sections 2.3 and 2.4 describe efficacy and safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview.

2.3 Efficacy

  1. A randomised controlled trial (RCT) of 129 patients (198 hands) treated by 30 Gy or 21 Gy of radiation reported that objective symptom assessment (number and consistency of cords and nodules, and degree of extension deficit) showed regression in 56% (53/95) and 53% (55/103) of hands respectively at 1-year follow-up (no significant difference reported between groups). The same trial reported that subjective symptom assessment (not otherwise defined) showed regression of Dupuytren's disease in 65% (41/63) and 53% (35/66) of patients respectively at 1-year follow-up (significance between groups not stated).

  2. A case series of 135 patients (208 hands) reported complete symptom relief in 16% (14/87) of patients; good symptom relief in 18% (16/87); minor symptom relief in 32% (28/87); no change in 14% (12/87); and worsening symptoms in 20% (17/87) of patients at median 13-year follow-up.

  3. This case series of 135 patients (208 hands) reported stable disease in 59% (123/208) of hands and progression in 31% (65/208) of hands at median 13year follow-up.

  4. A case series of 25 patients reported full functional recovery in 32% (8/25) of patients, with maximum benefit achieved at 6 months. At final follow-up (range 2 to 10 years) 75% of patients had symptom improvement (not otherwise defined).

  5. The Specialist Advisers listed key efficacy outcomes as correction of contracture, restoration of hand function and avoidance of recurrence requiring surgery. They expressed uncertainty about the procedure's efficacy for nodular disease, which is commonly asymptomatic and may not progress.

2.4 Safety

  1. The RCT of 129 patients (198 hands) treated by 30 Gy or 21 Gy of radiation reported chronic toxicity events in 16% (15/95) and 11% (11/103) of hands respectively at 3-month follow-up (significance not stated). These included skin dryness, increased desquamation, mild skin atrophy and slight subcutaneous fibrosis requiring ointments. Alteration of temperature and pain sensation was reported in 4% (8/198) of hands, although it is unclear to which treatment group this applied (minimum follow-up 1 year).

  2. In a subset of 110 patients (168 hands) from the RCT of 129 patients, no significant difference was reported in the rate of acute skin changes between patients treated by 30 Gy (13% [10/78]) and 21 Gy (18% [16/90]) (significance and follow-up not stated).

  3. The case series of 135 patients (208 hands) reported mild skin atrophy with occasional telangiectasia in 7% (14/208) of hands, and minor skin dryness and increased desquamation in 23% (47/208) of hands at median 13-year follow-up.

  4. The Specialist Advisers considered the long-term potential for developing radiation-induced cancer to be a theoretical adverse event.

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