Benign Hyperproliferative Diseases
Benign Hyperproliferative Diseases include conditions such as Dupuytren’s disease of the hand, Ledderhose disease (plantar fibromatosis) and Keloid Scars. Many clinicians associate radiation with the treatment of cancer, but it superficial and orthovoltage radiation also have a place in the treatment of other types of benign disease.
Treatment options available for Dupuytren’s disease of the hand include:
1. Radiation therapy is indicated for early progressive disease, where there is no contracture or minimal contracture (less than 10 degrees), in order to prevent disease progression and prevent the need for surgery to release a contracture. The alternative treatment in the early stages is watching and waiting. Side effects tend to be mild and include skin redness, soreness, dryness, change in texture, skin atrophy, minimal risk of radiation-induced carcinoma (age-dependent).
2. Steroid injections are sometimes used to reduce pain, but pain tends not to be a major issue with this disease, and there is no evidence for their use in preventing progression.
3. In the later stages, where there is contracture of more than 20-30 degrees, radiation therapy is not indicated and various release procedures can be used, which include:
a. Fasciectomy – This surgical procedure involves correcting the contracture and removing diseased tissue. Disadvantages include long recovery time and complications including infection, bleeding, wound rupture, tendon and nerve damage.
b. Needle aponeurotomy (percutaneous needle fasciectomy) – A needle is used to puncture the fibrous cord in order to weaken it until it can be broken by mechanical force. This is minimally invasive but is associated with a reasonably high chance of recurrence.
c. Collagenase is the injection of an enzyme that dissolves the collagen in the Dupuytren’s cord, which can then be mechanically broken. In those fingers that are successfully straightened, there is a low contracture recurrence rate. Risks include swelling, bruising, bleeding, and pain.
Treatment options depend on the severity of the disease and may include:
1. Conservative treatments including orthotics and changing footwear – these can relieve the pressure on the lumps and so reduce pain, but they do not affect the underlying disease process.
2. Steroid injections – these tend to be painful, can lead to skin thinning and plantar fascial rupture, and do not have a proven symptomatic benefit.
a. Lumpectomy is associated with a very chance of disease recurrence, and often the recurrent disease and associated scarring can cause more pain post-operatively than pre-operatively.
b. Radical plantar fasciectomy is associated with a lower recurrence rate, but is associated with significant post-operative complications such as wound healing problems, chronic pain and poor functional outcome
4. Radiation therapy can have significant symptomatic benefit in majority of patients, including reduction in pain and size of lumps and increase in mobility. Side effects tend to be mild and include skin redness, soreness, dryness, change in texture, skin atrophy, minimal risk of radiation-induced carcinoma (age-dependent).
They may occur in response to relatively minor trauma, such as ear piercing, and particularly occur on the upper chest, shoulders and earlobes. They are more common in dark-skinned patients, but also occur at a lower rate in patients with light skin. They are most common between the ages of 10 – 30 years, but also occur at a lower rate outside of this age range.
Treatment options for keloid scars include:
1. Intra-lesional steroid injection: Corticosteroids are often used as a primary and secondary treatment (i.e. after surgery) for keloids and have been shown to inhibit the formation of collagen by fibroblasts.
2. Surgical excision: While other treatments can reduce the height of the scar, surgery is the only treatment that can reduce the width of the lesion. When surgery is used as the sole modality, the recurrence rate is high. Also, surgery can result in a keloid scar that is larger than the original lesion. It is therefore generally used only as part of multi-modal therapy, for instance with post-excision intra-lesional steroid injections.
3. Silicone gel sheet application
4. Intra-lesional 5-fluorouracil
5. Other treatments include intralesional interferon, cryotherapy, bleomycin, ultraviolet irradiation, topical imiquimod, photodynamic therapy, electrical stimulation, and laser therapy.
6. Surgery with post-operative radiation therapy – The radiation is generally delivered within 24 hours of surgery. Relatively low doses of radiotherapy tend to be used and side effects tend to be mild, but can include skin redness and dryness, and a small risk of radiation-induced carcinoma, dependent on age and site of irradiation. Low reoccurrence rate.
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