Dupuytren’s: The Whole Truth?
I had the honour of being asked to be on a panel discussion at the Autumn meeting of the British Society of Surgery of the Hand. The session was entitled “Dupuytren’s: The Whole Truth?” and was chaired by Prof Tim Davis. Other panel members were all hand surgeons: Christine Leclerq from Paris, Riccardo Giunta from Munich, and James Leaney from Yorkshire.
I have sometimes found that surgeons can be somewhat hostile to the idea of radiotherapy for Dupuytren’s, but it turned out to be a very positive and interesting session. There were about 500 surgeons in the audience, a split of ¾ hand surgeons and ¼ plastic surgeons.
About half of the slides had a radiotherapy component, and I was asked to comment on various cases. I won’t reproduce the discussion word for word, but the most interesting points were:
- The first appearance of nodules is not an indication for radiotherapy. I only consider irradiation if there is progressive disease. The best indicators, in my opinion, are distal cord formation, especially if associated with loss of hyperextension, which I assess in every patient.
- Symptoms such as painful or prominent palmar nodules may need treatment to reduce symptoms. In my series looking at radiotherapy for Ledderhose disease (nodules in the foot), there was a 70-80% response rate, and in my experience, this is similar to the response seen in palmar nodules. I also find that this is effective on Garrod’s pads (knuckle pads on the PIP joints), and have irradiated patients for this reason, although almost always in combination with irradiation of palmar disease.
- The current evidence supporting radiotherapy has limitations, and I expressed my regret that the German trial did not have a randomized control arm. However, I pointed out the stark difference in outcome between the treated and non-treated groups, and also noted the currently recruiting Australian study, which ultimately will answer this question one way or the other.
- Radiotherapy after contracture release: I’m finding this question increasingly asked by patients, although I’m hardly ever referred patients by surgeons for this indication. In my mind, this refers to patients who are at high risk of recurrence of contracture, for instance, those who have failed prior release, have a strong diathesis, or are having a minimally invasive technique. The fact that there is no evidence in the literature for this approach reminds me that I need to look at the outcome of patients, albeit not many, that I have treated for this indication.
- Radiotherapy after needle aponeurotomy (NA) or after Xiapex: There have been three trials showing that NA and Xiapex have a 50% contracture recurrence rate at 3 years and that there is no significant difference between them. For this reason, many surgeons are moving away from Xiapex and towards NA. 50% recurrence rate seems like a very poor outcome for a patient who has many years of work and/or leisure ahead of them, and there is clearly a rationale for post-release irradiation. The Australian group (as above) are looking at this question, but they are irradiating the day after release and lumping in the post-fasciectomy group, and I worry about irradiating too early for this group of patients, with the risk of interfering with wound healing. I’m very keen to get a case series together of post-release RT patients, in order to get a good readout of recurrence rate at 3 years. If it is very different from 50% then this will be a great signal that it is worth pursuing. Again, this question is being addressed by the Australian randomized trial, but the results will take quite a number of years, and meanwhile we need at least some data to drive our decision-making. Several surgeons expressed an interest in this approach, and intuitively I would go for this if it was my hand being treated.
- We talked about side effects. I was not surprised that the hand surgeons did not know that radiotherapy given at an intermediate dose tends not to have serious side-effects in the vast majority of cases. I was particularly pleased to be able to reassure them that:
a. There is no evidence that radiotherapy impairs future surgical outcomes.
b. The risk of radiation-induced cancer is extremely low. I noted that the rates quoted are largely derived from cancer-associated mortality from nuclear disasters and that it is difficult to extrapolate to incidence of BCC, which are surgically treatable. However, it was difficult to argue with an incidence of 0.04% lifetime risk. Of note, I quote between 0.01% and 0.1% to my patients, with some dependence on age.
After the talk, I had about 15 individual surgeons come up to me. Their comments were very positive. A number of them said that they knew very little about radiotherapy before, and would not have considered referral, but that they now understood more and would certainly consider referral in future.
So a very positive outcome. Clearly, a single talk is not going to change all hearts and minds, but it felt very encouraging that the surgeons wanted to discuss collaboration and further discussion.