Strahlentherapie beim Morbus Ledderhose—Indikation und klinische Ergebnisse

Soleful solutions: Advancements in treatment strategies for ledderhose disease

INTRODUCTION

Ledderhose disease (plantar fibromatosis) is a benign and progressive proliferative disorder of the plantar fascia that forms fixed and painful nodules within the fascia, causing functional disability and decreased quality of life.

METHODS

we conducted a narrative review using Pubmed (https://pubmed.ncbi.nlm.nih.gov/) and searched for the terms "Ledderhose disease" "plantar fibromatosis" "Ledderhose disease treatment" "plantar fibromatosis treatment" with further focused searches in Pubmed to supplement information regarding each intervention.

RESULTS

many non-surgical therapeutic strategies are used in managing symptoms. These include pharmacological and non-pharmacological treatment options. Surgical treatment is employed when these therapies are not able to control the symptoms.

CONCLUSION

understanding and exploring effective treatment modalities for Ledderhose disease (LD) is important in improving the functional disability and quality of life. This review aims to showcase a general outline of the condition and illustrate the present treatments used to manage the disease.

LEVELS OF EVIDENCE

Therapeutic study, Level V.

Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial

BACKGROUND AND PURPOSE

Radiotherapy is considered a treatment option for Ledderhose disease. However, its benefits have never been confirmed in a randomised controlled trial. Therefore, the LedRad-study was conducted.

MATERIALS AND METHODS

The LedRad-study is a prospective multicentre randomised double-blind phase three trial. Patients were randomised to sham-radiotherapy (placebo) or radiotherapy. The primary endpoint was pain reduction at 12 months after treatment, measured with the Numeric Rating Scale (NRS). Secondary endpoints were pain reduction at 6 and 18 months after treatment, quality of life (QoL), walking abilities and toxicity.

RESULTS

A total of 84 patients were enrolled. At 12 and 18 months, patients in the radiotherapy group had a lower mean pain score compared to patients in the sham-radiotherapy group (2.5 versus 3.6 (p = 0.03) and 2.1 versus 3.4 (p = 0.008), respectively). Pain relief at 12 months was 74% in the radiotherapy group and 56% in the sham-radiotherapy group (p = 0.002). Multilevel testing for QoL scores showed higher QoL scores in the radiotherapy group compared to the sham-radiotherapy group (p < 0.001). Moreover, patients in the radiotherapy group had a higher mean walking speed and step rate with barefoot speed walking (p = 0.02). Erythema, skin dryness, burning sensations and increased pain were the most frequently reported side effects. These side effects were generally graded as mild (95%) and the majority (87%) were resolved at 18 months follow-up.

CONCLUSION

Radiotherapy for symptomatic Ledderhose disease is an effective treatment resulting in a significant pain reduction, improvement of QoL scores and bare feet walking abilities, in comparison to sham-radiotherapy.

Plantar Fibromatosis: Pathophysiology, Surgical and Nonsurgical Therapies: An Evidence-Based Review

Plantar fibromatosis (morbus Ledderhose), an extra-abdominal desmoid tumor of the plantar foot, is a rare benign hyperproliferative disorder of the plantar fascia with an unknown etiology. The main clinical characteristics include slow growing nodules on the medial and central bands of the plantar fascia, which may become painful and negatively affect ambulation. Most established conservative therapies today target symptomatic relief. As symptoms progress, therapies such as injections, shockwave ablation, radiation, and/or surgery may be required. This review aims to provide insight into the pathophysiology of this condition in addition to detailing current and investigational therapies for this disorder. Many therapies have been proven in similar conditions, which could lead to promising treatment options for plantar fibromatosis.

LEVELS OF EVIDENCE

Level V: Expert opinion.

Partial fasciectomy is a useful treatment option for symptomatic plantar fibromatosis

Plantar fibromatosis is a rare, benign fibroproliferative disorder of the plantar fascia. It is considered as a low-grade tumour and it can be locally aggressive. It can present as painful swelling with impairment of local function. Upon failure of non-operative management, surgical treatment options include total fasciectomy or partial fasciectomy. Although surgical excision is the mainstay of treatment, recurrence rate can be up to 60%. The aim of this study was to determine the recurrence and complication rates of surgically treated plantar fibromatosis. A retrospective study was conducted involving patients who had a confirmed diagnosis and excision of plantar fibromatosis treated in our institution between 2011 and 2016. Demographic data, follow-up duration, recurrence and complications were reviewed. Eighteen patients underwent 19 operations. Mean age was 41.3 years (20-57). There were 12 male patients. The main presenting features were pain, swelling and impairment of function. They were investigated by ultrasound scan (12 feet, 63%) and/or magnetic resonance imaging (8 feet, 42%). Two patients (11%) had prior surgery at other institutions whilst 3 patients (17%) had multiple nodules at presentation. All patients underwent partial fasciectomy of the plantar fibromatosis. At up to 5 years follow-up, one patient (6%) had a recurrence in our series whilst 3 patients (17%) had scar related problems (2 patients with scar pain and one patient had hypersensitive scar that resolved after 12 months). Symptomatic plantar fibromatosis can be effectively treated with partial plantar fasciectomy.

Patient-reported outcomes after electron radiation treatment for early-stage palmar and plantar fibromatosis

PURPOSE

Palmar and plantar fibromatosis (PPF) is a progressive connective tissue disorder of the hand/foot that often leads to debilitating functional impairment. In Europe, orthovoltage radiation therapy (RT) has been demonstrated to prevent local disease progression for up to 80% of patients with early-stage PPF. There are limited data reporting outcomes for populations outside of Europe or using electron RT.

METHODS AND MATERIALS

Between 2008 and 2013, 44 early-stage PPF cases received RT. RT fields involved clinically defined targets encompassing involved areas (skin changes, cords, nodules) with at least 1.5-cm margins. En face electrons (6-12 MeV) and bolus (0.5-1 cm) were selected individually. Outcomes are reported for patients who participated in an institutional review board-approved standardized questionnaire and chart review.

RESULTS

Thirty-three patients received 66 treatments (45 hands/15 feet and 6 reirradiations). Most frequent dose schemes were 21 Gy (3 Gy in 7 fractions) and 30 Gy (3 Gy in 10 fractions with 6- to 8-week breaks after 15 Gy). Median time to follow-up survey was 31 months. Disease progression at any location within or outside the RT treatment field occurred in 20 of 33 patients (61%). Fourteen of 60 sites (23%) developed in-field progression, but 4 sites were successfully reirradiated with final local control in 50 of 60 sites (83%). RT improved pretreatment symptoms of pain with strain at 30 of 37 sites (81%) and itch/burn sensations at 17 of 21 sites (81%). There were no reported grade ≥2 late toxicities even with reirradiation. Patient reported overall success with treatment was 31 of 33 patients (94%).

CONCLUSION

PPF is a progressive disease. En face electron RT is an effective therapy that stabilizes or improves symptoms in the majority of patients. Reirradiation can be considered as a treatment option for in-field progression. Patients report minimal toxicity and a high rate of satisfaction with treatment.

Plantar fibromatosis--topical review

Morbus Ledderhose is a rare hyperproliferative disease of the plantar fascia, leading to the formation of nodules. Its origin is unknown. No causal therapy is available, and treatment remains symptomatic. Various therapeutic strategies to alleviate symptoms are available and are adapted to the severity of the disease. In early stages, conservative therapy including nonpharmacological, physical, and pharmacological treatments is applied. If the disease progresses, irradiation of the plantar surface, injections of steroids, shock wave therapy, and partial or complete fasciectomy as an ultimate therapy may be indicated. Novel experimental treatment options including application of fibrinolytic agents are currently being tested, but no controlled, randomized long-term studies are available. This review aims to provide a systematic overview of current established procedures and outlines novel experimental strategies for the treatment of morbus Ledderhose, including future avenues to treat this rare disease.

High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis (Ledderhose's disease)

Background

Plantar fibromatosis is a benign disease creating nodules on the medial plantar side of affected patients. While surgical removal is regarded as the therapeutic mainstay, recurrence rates and impairment of daily activities remains substantial. High-energy focussed extracorporeal shockwave therapy has been suggested to be potentially effective in plantar fibromatosis in terms of pain reduction.

Hypothesis

High-energy focussed extracorporeal shockwave therapy reduces pain in plantar fibromatosis.

Findings

A total number of six patients (5 males, 58±4 years) were included with plantar fibromatosis (Ledderhose’s disease) associated with pain. Three patients were operated on previously, one had concomitant Dupuytren’s contracture. High-energy focussed ESWT was applied using a Storz Duolith SD1 (2000 impulses, 3 Hz, 1.24 mJ/mm2) in two sessions with 7 days between. Pain was 6±2 at baseline, 2±1 after 14 days and 1±1 after 3 months. Softening of the nodules was noted by all patients. No adverse effects were noted.

Conclusions

High-energy focussed extracorporeal shockwave energy reduces pain in painful plantar fibromatosis (Morbus Ledderhose). Further large-scale prospective trials are warranted to elucidate the value of high-energy focussed extracorporeal shockwave therapy (ESWT) in plantar fibromatosis in terms of recurrence and efficacy.

Recurrence of plantar fibromatosis after plantar fasciectomy: single-center long-term results

BACKGROUND

Plantar fibromatosis is a rare, hyperproliferative, benign lesion of the plantar aponeurosis with an unknown cause. Surgical treatment is associated with a high recurrence rate and risk of complications. The goal of this study was to determine the recurrence rate of plantar fibromatosis after plantar fasciectomy at the authors' institute during the past three decades and the factors associated with an increased risk for recurrence.

METHODS

The study group contained 27 patients with plantar fibromatosis, who underwent 40 operations on 33 feet, including 13 right (39 percent) and 20 left (61 percent) feet.

RESULTS

The overall recurrence rate was 60 percent. Treating a primary lesion with total plantar fasciectomy was associated with the lowest (25 percent) and local resection of the lesion was associated with the highest recurrence rate (100 percent). There seemed to be a relation between the existence of multiple nodules in one foot and a higher recurrence rate. The recurrence of a primary lesion treated with fasciectomy combined with postoperative radiotherapy seemed to be lower in comparison with the recurrence rate after surgery only.

CONCLUSIONS

Surgical treatment of plantar fibromatosis is associated with a high recurrence rate and indicated only when the lesions are highly symptomatic and conservative measures fail. Total plantar fasciectomy is the most successful treatment in this study, particularly for primary lesions. The role of postoperative radiotherapy should be evaluated further. A prospective multicenter study comparing different surgical procedures will be needed to determine the type of operation that most effectively eliminates plantar fibromatosis.

Radiotherapy in early-stage Dupuytren's contracture. Long-term results after 13 years

BACKGROUND AND PURPOSE

In early-stage Dupuytren's contracture, radiotherapy is applied to prevent disease progression. Long-term outcome and late toxicity of the treatment were evaluated in a retrospective analysis.

PATIENTS AND METHODS

Between 12/1982 and 02/2006, 135 patients (208 hands) were irradiated with orthovoltage (120 kV; 20 mA; 4-mm Al filter), in two courses with five daily fractions of 3.0 Gy to a total dose of 30 Gy; separated by a 6- to 8-week interval. The extent of disease was described according to a modified classification of Tubiana et al. Long-term outcome was analyzed at last follow-up between 02/2008 and 05/2008 with a median follow-up of 13 years (range, 2-25 years). Late treatment toxicity and objective reduction of symptoms as change in stage and numbers of nodules and cords were evaluated and used as evidence to assess treatment response.

RESULTS

According to the individual stages, 123 cases (59%) remained stable, 20 (10%) improved, and 65 (31%) progressed. In stage N 87% and in stage N/I 70% remained stable or even regressed. In more advanced stages, the rate of disease progression increased to 62% (stage I) or 86% (stage II). 66% of the patients showed a long-term relief of symptoms (i.e., burning sensations, itching and scratching, pressure and tension). Radiotherapy did not increase the complication rate after surgery in case of disease progression and only minor late toxicity (skin atrophy, dry desquamation) could be observed in 32% of the patients. There was no evidence for a second malignancy induced by radiotherapy.

CONCLUSION

After a mean follow-up of 13 years radiotherapy is effective in prevention of disease progression and improves patients' symptoms in early-stage Dupuytren's contracture (stage N, N/I). In case of disease progression after radiotherapy, a "salvage" operation is still feasible.

Radiation therapy for early stages of morbus Ledderhose

PURPOSE

To evaluate the efficacy of radiation therapy (RT) in the treatment of early stages of benign plantar fibromatosis (Morbus Ledderhose [ML]).

PATIENTS AND METHODS

From 2003 to 2008, 24 patients (33 sites) with a mean age of 52 years received RT for symptomatic ML. Prior to RT, 19 patients complained of pain and 15 had walking difficulties. 21 patients (28 sites) were irradiated with orthovoltage X-rays and three (five sites) received electron-beam irradiation. The RT protocol consisted of five weekly fractions of 3.0 Gy (15 Gy), repeated after 6 weeks to a total dose of 30 Gy in 20 patients (28 sites). In four patients (five sites), two single fractions of 4.0 Gy were applied, repeated at intervals of 4 weeks to total doses of 24-32 Gy. Primary study endpoints were the prevention of disease progression and the avoidance of a surgical intervention. Secondary endpoints were pain relief, improvement of gait, and patients' subjective satisfaction measured with a linear analog scale (LAS).

RESULTS

After a median follow-up of 22.5 months, none of the patients experienced a progression of number and size of the lesions or the clinical symptoms. In eleven sites (33.3%) complete remission of cords or nodules occurred, in 18 (54.5%) a reduced number or size was noted, and four sites (12.1%) were unchanged. Pain relief was achieved in 13/19 patients (68.4%), and an improvement of gait abnormalities was noted in 11/15 patients (73.3%). The patients' subjective satisfaction measured by means of the LAS revealed a median improvement of 3.5 points in 22/24 patients (91.6%). Skin or soft tissues toxicities RTOG grade > 2 were not noted.

CONCLUSION

RT is effective for treatment of the early stages of ML and may obviate the need for a surgical intervention. Long-term follow-up studies including a larger number of patients are required to define the role of RT in the management of this disorder.

Radiation therapy for the treatment of benign vascular, skeletal and soft tissue diseases

The concept of radiation therapy for the treatment of benign diseases refers to the use of moderate to high-energy ionising radiation as part of the treatment of non-malignant, but not necessarily harmless, diseases. The usefulness of radiation therapy, based on the anti-inflammatory properties of ionising radiation, has long been known. Apart from the treatment of intracranial benign tumours, such as meningiomas and neurinomas, the prevention of cardiovascular restenosis or treatment of skeletal degenerative diseases are, without doubt, the main fields of action for radiation therapy in benign conditions. Nonetheless, many other non-cancer entities may benefit from ionising radiation therapy treatment. The purpose of this review is to highlight and update indications for treatment with radiation therapy in benign conditions, focusing on skeletal degenerative processes, vascular conditions and soft tissue diseases.

Pathologic and MR Imaging Features of Benign Fibrous Soft-Tissue Tumors in Adults

Benign fibrous (fibroblastic or myofibroblastic) soft-tissue tumors are a heterogeneous group of fibrous lesions with widely varied anatomic locations, biologic behavior, and pathologic features. The four broad categories of fibrous proliferation are benign fibrous proliferations, fibromatoses, fibrosarcomas, and fibrous proliferations of infancy and childhood. The first two categories include nonaggressive fibroblastic lesions such as nodular fasciitis, as well as fibromatoses that demonstrate more aggressive biologic behavior (eg, desmoid tumors). In adults, fibrous tumors are among the most common soft-tissue lesions encountered in clinical practice. MR imaging can be useful for defining the intrinsic signal characteristics, size, and compartmental extension of these lesions. Histologic features of the tumor also may be depicted on T2-weighted MR images. Hypocellular fibrous tumors with dense collagenous components tend to have lower signal intensity on T2-weighted images than do lesions that are more cellular or that contain greater amounts of extracellular myxoid matrix. When interpreting MR images of soft-tissue masses in adults, radiologists should be aware of the clinical behavior, common sites of occurrence, and histopathologic and imaging features of the common benign fibrous soft-tissue tumors.