Adventures in Dupuytrens

[TheWallnerus]

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60yo healthy female with pretty respectable case of Dupuytrens goes to a rad onc at outside institution for treatment. The Rx was 21Gy in 7 fraction qd. There was essentially no response. Treatment completed Nov 2025.

She wants retreatment now at our institution.

What dose and fractionation will you use.

 

[Gfunk6]

Dupuytren RT is not primarily a shrinkage treatment. It is intended to prevent progression in early active disease. If she has not progressed since Nov 2025, I would not offer retreatment now. If she has objective progression, I’d first confirm whether progression is in-field versus new out-of-field disease and whether she has contracture requiring hand-directed intervention. For untreated active disease, my preferred regimen is 3 Gy x 5, break 6–8 weeks, then 3 Gy x 5, total 30 Gy. 21 Gy in 7 fractions is an accepted alternative, but I would not call lack of visible regression a failure.

 

[TheWallnerus]

Dupuytren RT is not primarily a shrinkage treatment. It is intended to prevent progression in early active disease. If she has not progressed since Nov 2025, I would not offer retreatment now. If she has objective progression, I’d first confirm whether progression is in-field versus new out-of-field disease and whether she has contracture requiring hand-directed intervention. For untreated active disease, my preferred regimen is 3 Gy x 5, break 6–8 weeks, then 3 Gy x 5, total 30 Gy. 21 Gy in 7 fractions is an accepted alternative, but I would not call lack of visible regression a failure.

No progression, btw I would call her disease early stage as well

Agree RT is mostly an anti progression treatment but in my experience many do get a regression of some sort, LedRAD trial showed the same disease process can improve eg



But I guess you’re saying you wouldn’t (re)treat here

 

[drowsy12]

Dupuytren RT is not primarily a shrinkage treatment. It is intended to prevent progression in early active disease. If she has not progressed since Nov 2025, I would not offer retreatment now. If she has objective progression, I’d first confirm whether progression is in-field versus new out-of-field disease and whether she has contracture requiring hand-directed intervention. For untreated active disease, my preferred regimen is 3 Gy x 5, break 6–8 weeks, then 3 Gy x 5, total 30 Gy. 21 Gy in 7 fractions is an accepted alternative, but I would not call lack of visible regression a failure.

agree

 

[Ray D. Ayshun]

0.5 Gy x 18 to get her up to 30 Gy total. Use AMM with imrt and daily imaging given direct overlap.

 

[evilbooyaa]

No progression, btw I would call her disease early stage as well

Agree RT is mostly an anti progression treatment but in my experience many do get a regression of some sort, LedRAD trial showed the same disease process can improve eg



But I guess you’re saying you wouldn’t (re)treat here

What do yo umean by 'There was essentially no response'? What 'response' were you expecting to see?

LedRAD (link: Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial - PubMed) showed a subjective improvement in pain in 74% of patients receiving RT, because plantar fibromatosis is generally painful.

When you say no response, do you mean she had pain pre-RT and it is unchanged? If so, she would fall into the 26% of patients, not *that* rare.

Generally contractures in the hand are less about pain and more about loss of function, so I think you might be comparing apples/oranges in terms fo the 'response' you're expecting.

I don't see a great reason to re-treat unless she's truly worsening. Stable is good.

 

[TheWallnerus]

What do yo umean by 'There was essentially no response'? What 'response' were you expecting to see?

Better mobility, less contracture tightness, some fibrotic resolution/nodule shrinkage... anything.

LedRAD (link: Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial - PubMed) showed a subjective improvement in pain in 74% of patients receiving RT, because plantar fibromatosis is generally painful.

Almost always associated with walking/putting pressure ("rock in my shoe"), not so much at rest; Dupuytrens patients would maybe report some pain with walking on hands, handstands (maybe I would too)

 

[Palex80]

I would not retreat if treatment was completed just 6 months ago and the patient did not respond.

 

[evilbooyaa]

Better mobility, less contracture tightness, some fibrotic resolution/nodule shrinkage... anything.

Almost always associated with walking/putting pressure ("rock in my shoe"), not so much at rest; Dupuytrens patients would maybe report some pain with walking on hands, handstands (maybe I would too)

1st point - LEDRad did not analyze that in any manner in their trial. They evaluated pain.

2nd point - sure. Ask the patient if she did a handstand before and after the treatment and if the pain was different. Then you can see if she falls into the 74% or not.

Citing a trial that evaluated a specific symptom as an endpoint and then 'expecting' a response for an endpoint that is NOT that specific symptom that was evaluated in that trial does not compute.

I'm not saying some fraction of Dupuytren's patients don't have a clinical 'response' in the way you're hoping for, but that we don't seem to know what fraction of patients actually have that sort of response in a randomized fashion. Maybe there's retrospective data for the endpoints you're interested in but nothing I'm aware of.

I agree with others that the bulk of Dupuytren's treatments are to prevent further progression. She does not have further progression, thus does not have 'failure' of the treatment.

 

[TheWallnerus]

1st point - LEDRad did not analyze that in any manner in their trial. They evaluated pain.

2nd point - sure. Ask the patient if she did a handstand before and after the treatment and if the pain was different. Then you can see if she falls into the 74% or not.

Citing a trial that evaluated a specific symptom as an endpoint and then 'expecting' a response for an endpoint that is NOT that specific symptom that was evaluated in that trial does not compute.

I'm not saying some fraction of Dupuytren's patients don't have a clinical 'response' in the way you're hoping for, but that we don't seem to know what fraction of patients actually have that sort of response in a randomized fashion. Maybe there's retrospective data for the endpoints you're interested in but nothing I'm aware of.

I agree with others that the bulk of Dupuytren's treatments are to prevent further progression. She does not have further progression, thus does not have 'failure' of the treatment.

When you treat a lot of Dupuy or Ledderhose you find one of the best markers for predicting pain reduction is nodule reduction. Nodule reduction does happen in a lot of people, and a lot of the pain with Leddehose is mechanical from the nodule itself and weight bearing. Clearly the most satisfied patients are the ones with actual changes in the physical exam. Of course when consulting with patients the treatment goal is preventing progression, but counseling for actual possible clinical improvements is reasonable. My goal on the post was not so much this however it was the 21/7 vs 30/10 schedules and see if anyone had any anecdotes about that. There is data.

 

[Palex80]

2nd point - sure. Ask the patient if she did a handstand before and after the treatment and if the pain was different. Then you can see if she falls into the 74% or not.
'failure' of the treatment.

I think >99% of my Dupuytren's patients can't do a handstand.
Likely, >95% of all my patients (regardless of condition) can't do a handstand.

Neither can I.

 

[evilbooyaa]

I think >99% of my Dupuytren's patients can't do a handstand.
Likely, >95% of all my patients (regardless of condition) can't do a handstand.

Neither can I.

When you treat a lot of Dupuy or Ledderhose you find one of the best markers for predicting pain reduction is nodule reduction. Nodule reduction does happen in a lot of people, and a lot of the pain with Leddehose is mechanical from the nodule itself and weight bearing. Clearly the most satisfied patients are the ones with actual changes in the physical exam. Of course when consulting with patients the treatment goal is preventing progression, but counseling for actual possible clinical improvements is reasonable. My goal on the post was not so much this however it was the 21/7 vs 30/10 schedules and see if anyone had any anecdotes about that. There is data.

Again, I don't doubt that SOME fraction of patients have a clinical response in the way that you're looking for. But what percentage of patients is it? It's one thing for you to have feelings and counsel patients on it, but has there ever been published data on the outcomes that you are looking for, as you (seemingly) try to justify re-irradiation for someone who hasn't met the definition of failure?

What data is there comparing 21Gy/7 fx qD vs the 30/10 split course?

 

[TheWallnerus]

Again, I don't doubt that SOME fraction of patients have a clinical response in the way that you're looking for. But what percentage of patients is it?

I feel like a plurality of patients have some nodular response based on my experiences and published results. I treat a lot of these patients; 20-40 Dupuy/Lederhose a year. I do long term f/u's; nodules are late responding tissues. TBH the published literature could be much better being more scientific about the metrics of the nodules' response.

What data is there comparing 21Gy/7 fx qD vs the 30/10 split course?

Here's that. It's why I prefer 30/10. I wanted to know if people have done much 21 Gy. I have never... in theory, since this patient got 21 instead of 30 Gy, there could be more chance for less response.

 

[taserlaser]

I feel like a plurality of patients have some nodular response based on my experiences and published results. I treat a lot of these patients; 20-40 Dupuy/Lederhose a year. I do long term f/u's; nodules are late responding tissues. TBH the published literature could be much better being more scientific about the metrics of the nodules' response.



Here's that. It's why I prefer 30/10. I wanted to know if people have done much 21 Gy. I have never... in theory, since this patient got 21 instead of 30 Gy, there could be more chance for less response.

I was trained on the split course by my current practice partner and also used it at another institution. Since COVID (and reduced orthovoltage access) she has adopted the 21 Gy course for her patients. Haven’t heard any concerns on efficacy but haven’t really inquired. If there were though she would continue with split I think. She does several Dups a month I think, usually at least a consult a week.

 

[evilbooyaa]

I feel like a plurality of patients have some nodular response based on my experiences and published results. I treat a lot of these patients; 20-40 Dupuy/Lederhose a year. I do long term f/u's; nodules are late responding tissues. TBH the published literature could be much better being more scientific about the metrics of the nodules' response.



Here's that. It's why I prefer 30/10. I wanted to know if people have done much 21 Gy. I have never... in theory, since this patient got 21 instead of 30 Gy, there could be more chance for less response.

If nodules are late responding tissues then perhaps 6m onths isn't long enough to see a response

Fair enough, I was unaware of the 2011 trial in regards to 21Gy/7Fx. But even the trial you linked showed 16.5% remission of nodules/cords/stage, 53% stability, and 29% progression at a minimum of 5-year f/u

 

[TheWallnerus]

If nodules are late responding tissues then perhaps 6m onths isn't long enough to see a response

Fair enough, I was unaware of the 2011 trial in regards to 21Gy/7Fx. But even the trial you linked showed 16.5% remission of nodules/cords/stage, 53% stability, and 29% progression at a minimum of 5-year f/u

One report I linked showed 50+% nodule change incidence. But I agree 6 months can be too soon to gauge anything. But if I see some change at 6 months I tend to see change at 9 and 12 months. But if no change at 6 months I see less chance for change beyond that. And change is not a goal per se, but it’s on the table.

Anyways. I’m holding off on doing anything. Re assess in a few months.