The Long-Term Effects of Radiotherapy for Ledderhose Disease

Contents

Based on an article titled “Radiotherapy for patients with Ledderhose disease: Long-term effects, side effects and patient-rated outcome”

Originally written by: Haan et al., 2022

https://www.sciencedirect.com/science/article/pii/S0167814022000354

By: Murielle Nsiela 

Ledderhose disease was named after George Ledderhose, who first described it in 1894. Scientifically named plantar fibromatosis, it is a disease that affects people assigned male at birth (AMAB) ten times more than people assigned female at birth (AFAB) and is characterised by the growth of a hard, round or flattened lump (nodule) on the soles of the feet. The disease affects both feet and has a slow progression rate; it is primarily seen in middle-aged and elderly individuals.1, 3 

These lumps are not as painful initially; however, they gradually become painful as they start to grow.2 This pain can appear while performing activities and while at rest. The intensity can vary from tenderness on the soles of the feet to severe pain. As the disease progresses, it can lead to functional disabilities. In addition, it may negatively impact the quality of life of an individual.3 

Ledderhose disease can be diagnosed using specific imaging techniques such as X-rays or MRI. In some instances, doctors can identify the type of nodules the patient has. The disease symptoms include joint pains, a feeling of pins and needles, tightening of the skin around the foot, itching, and stinging sensation around the foot.4 

It is suggested that individuals with this disease are likely to have other conditions associated with the excess fibrous tissue being formed on the soles of the feet. These related conditions include Peyronie disease, Dupuytren contracture, knuckle pads, repeated trauma, diabetes, chronic liver disease, long-term alcohol consumption and epilepsy. The exact cause of the disease is not well known; however, heredity factors do play a role in developing ledderhose disease.4 

Several treatment options are available for the disease, including radiotherapy, surgery, cortisone injections, modification of shoes and extracorporeal shock wave therapy, although the level of scientific data on the efficacy of each treatment differs.5 In addition, surgery has been suggested to be an effective option for the most severe cases. However, this does not entirely guarantee the recurrence of the disease. Furthermore, this treatment option often leaves scars and other complications.6 

There have been only three clinical studies of ledderhose treatment with radiotherapy; these studies have only shown short term follow-ups after treatment. In the first two studies, follow-ups occurred at 23 and 38 months; there was no disease progression in patients and pain reduction was observed in more than 60% of patients. Furthermore, there were minimal side effects, such as skin dryness and redness.3 

The third study investigated the effect of electron radiotherapy; the follow-ups occurred after 31 months, and ~80% of patients had a decrease in complaints, and 94% of them reported that radiotherapy does work. However, very little is known about the long-term outcomes of radiotherapy. Therefore, Haan et al. conducted a study to determine the long-term effects of using radiotherapy in treating ledderhose disease in a group of patients.3 

Radiotherapy was conducted using orthovoltage at 150 kV or electrons at 8 or 10 MeV, with a ten-week interval between the two courses of treatment. The follow-ups were after 49 months which was longer compared to the other studies. Out of the 82 patients eligible to participate in the study, the results of only 67 patients were obtained.3  

Before the treatment, the overall pain score for patients was 5.7; however, this decreased to 1.7 for all feet calculated. In addition, there were no instances whereby the pain gradually increased. The most statistically significant higher and lower pain scores were in people AFAB  compared to those AMAB. Furthermore, 69% of patients had expressed that radiotherapy had a permanent positive effect on pain. A further 78% of the patients involved were satisfied with the effects of the treatment provided.3 

A total of 57% of patients found that the treatment was not burdensome to them; however, there was a significant difference in treatment intensity between people AMAB versus those AFAB . People AFAB had found this treatment more burdensome in comparison to those AMAB. However, this difference between the sexes was not reported in the previous studies.7 Previous literature showed that sex played an essential role in response to pain.8 

Overall, there was no difference in results between the feet treated with orthovoltage and those treated with electrons. In addition, regarding side effects, only two long-term side effects were found, including dryness of the skin and redness of the skin. However, nine patients reported skin dryness more than four years after complete treatment.3 

The results from Haan et al. coincide with the previous three short-term studies conducted on the effects of radiotherapy on ledderhose disease. Concerns of developing radiation-induced cancer after undergoing radiotherapy treatment around the sole of the foot were very low: even with high and low dose radiation, it was suggested to be around 0.02%.9 Nevertheless, despite the low incidence rate, it is suggested to discuss this risk with patients as early as possible. 

In conclusion, the study showed that using radiotherapy to treat ledderhose disease is an effective treatment method with very high patient satisfaction rates and long-term pain relief. In addition, the treatment is well tolerated with minimal side effects. However, although this study is the longest one yet,  it is still considered too short when considering the life expectancy of patients. Therefore, further elongated studies, possibly life-lasting follow up, would be necessary. 

References

  1. G. Ledderhose Zur pathology des Aponeuroses des Fusses und Hand Arch Klin Chir, 55 (1897), pp. 694-712.
  2. M. Espert, M.R. Anderson, J.F. Baumhauer Current concepts review: plantar fibromatosis Foot Ankle Int, 39 (2018), pp. 751-757.
  3. De Haan A, van Nes J, Werker P, Langendijk J, Steenbakkers R. Radiotherapy for patients with Ledderhose disease: Long-term effects, side effects and patient-rated outcome. Radiotherapy and Oncology. 2022;168:83-88. 
  4. Ledderhose disease | Genetic and Rare Diseases Information Center (GARD) – an NCATS Program [Internet]. Rarediseases.info.nih.gov. 2022 [cited 3 April 2022]. Available from: https://rarediseases.info.nih.gov/diseases/6873/ledderhose-disease
  5. M. Fuiano, M. Mosca, S. Caravelli, S. Massimi, M.G. Benedetti, F. Di Caprio, et al.Current concepts about treatment options of plantar fibromatosis: a systematic review of the literature Foot Ankle Surg, 25 (2019), pp. 559-564.
  6. J.R. Young, S. Sternbach, M. Willinger, I.D. Hutchinson, A.J. Rosenbaum The etiology, evaluation, and management of plantar fibromatosis Orthop Res Rev, 11 (2019), pp. 1-7.
  7. J. Schuster, S. Saraiya, N. Tennyson, M. Nedelka, N. Mukhopadhyay, E. Weiss Patient-reported outcomes after electron radiation treatment for early-stage palmar and plantar fibromatosis Pract Radiat Oncol (2015).
  8. S. Pieretti, A. Di Giannuario, R. Di Giovannandrea, et al. Gender differences in pain and its reliefAnn Ist Super Sanita, 52 (2016), pp. 184-189.
  9. S.R. McKeown, P. Hatfield, R.J.D. Prestwich, R.E. Shaffer, R.E. Taylor Radiotherapy for benign disease; assessing the risk of radiation-induced cancer following exposure to intermediate-dose radiation Br J Radiol, 88 (2015), p. 20150405.

Hyperlinks

  1. Peyronie’s disease: symptoms, diagnosis & treatment - urology care foundation [Internet]. [cited 2022 Jun 3]. Available from: https://www.urologyhealth.org/urology-a-z/p/peyronies-disease
  2. Dupuytren's contracture [Internet]. nhs.uk. 2022 [cited 3 April 2022]. Available from: https://www.nhs.uk/conditions/dupuytrens-contracture/
  3. Extracorporeal Shockwave Therapy (ESWT) [Internet]. Physiopedia. 2022 [cited 3 April 2022]. Available from: https://www.physio-pedia.com/Extracorporeal_Shockwave_Therapy_(ESWT)
  4. Debowski M. Electron therapy | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia.org. 2022 [cited 3 April 2022]. Available from: https://radiopaedia.org/articles/electron-therapy
  5. Orthovoltage [Internet]. ucsfhealth.org. 2022 [cited 3 April 2022]. Available from: https://www.ucsfhealth.org/treatments/orthovoltage

Author: Murielle Nsiela

MSc Graduate in Medical Engineering - Bachelor's degree, Pharmaceutical Science, Keele University, Staffordshire UK

MSc in Medical Engineering Design, Keele University Modules included: Advanced engineering applications, Engineering for medical applications report, Bioreactors and Growth environment, Creative engineering design, Experimental research methodology and research projects



BSc (Hons) Pharmaceutical Science, Technology and Business, Keele University Modules included: Core topics in pharmaceutical science, Laboratory studies - tabletting and liposomes report, applied Pharmaceutical Science 2, Pharmaceutical research project

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