Radiotherapy in painful heel spurs (plantar fasciitis)—results of a national patterns of care study

The analgesic effect of low-dose radiotherapy in treating benign musculoskeletal painful disorders using different energies: A retrospective cohort study

Introduction:

This retrospective cohort study tries to determine if there is a correlation between the effectiveness of low-dose radiotherapy (LDRT) in treating painful inflammatory or degenerative musculoskeletal disorders (MSDs) and the applied radiotherapy energy.

Patients and Methods:

Between September 2019 and January 2020, a total of 91 patients with either painful inflammatory or degenerative MSDs were treated with LDRT. The inclusion criteria were patients older than 40 years with either painful inflammatory disorders such as epicondylitis humeri, plantar fasciitis or degenerative osteoarticular disorders of the wrist or ankle joints. All patients were treated with a single dose of 0·5 Gy and a total dose of 6·0 Gy (2 to 3 fractions weekly). Patients were divided into two groups. Orthovolt group was treated with 200 Kv, 15 mA and 1 mm copper filtration with different tubes according to the site to treatment using direct fields. The second group included patients treated with Linac machines with opposing fields using energies between 6 and 18 MV. The pain was evaluated before and on the last day of treatment and 4–6 months later using the Numerical Rating Scale.

Results:

91 patients compatible with the inclusion criteria were identified with a median of 60 years. The median duration of symptoms was 6 months. 46% of patients were males, and 54% were females. The Orthovolt group included 49% of the patients and the Megavoltage group 51%. Most of the patients (98%) were previously treated with other methods such as local corticosteroid injection, painkillers or physiotherapy. At the end of the treatment, 60% of the patient’s showed subjective pain relief and only 6% had a complete response. The follow-up conducted 4 to 6 months after the treatment showed that 65% of patients had a complete response and 8% had an improvement. The comparison between both studied groups shows that the used energy does not affect the response either at the end of the treatment or at the second control. The relationship between the aetiology and the early and late responses shows no difference in the early response but a better late response in patients suffering from inflammatory diseases with a p-value of 0·015. The response according to the treated location shows that patients with osteoarthritis of the ankle joint have a worse response in comparison to other examined joints and plantar fasciitis.

Conclusion:

LDRT is an effective analgesic treatment option for both inflammatory and degenerative MSDs. There is no difference in response according to the used energy, and most of the patients show late responses 4 to 6 months after the treatment.

Low-dose radiation treatment for painful plantar enthesophyte: a highly effective therapy with little side effects

AIM

Plantar enthesophyte is a common degenerative disorder. Surgical and medical treatment options are associated with either poor outcome or high percentage of relapse. Observations have indicated a beneficial effect of radiation therapy. We therefore wanted to evaluate pain reduction using orthovolt or cobalt-based radiation treatment for painful plantar enthesophyte and determine long-term response as well as prognostic parameters in this condition.

METHODS

We identified a total of 102 consecutive patients treated for a total of 117 symptomatic heel spurs. 59 patients were treated with cobalt radiation, 31 patients with orthovolt therapy and 12 patients with both radiation systems. Primary outcome measure was pain reduction being scored using the modified Rowe Score prior therapy, at the end of each treatment series as well as after 6 weeks. Secondary outcome measure was long-term outcome, evaluated in patients with a follow-up period of longer than 3 years.

RESULTS

Before radiation therapy, 61 patients (60.4%) had a score of 0, significant strong pain. At the time of completion of radiation treatment, 3 patients (2.7%) were pain-free (score of 30), whereas 8 patients (7.9%) had still severe pain (score 0). 6 weeks after radiation therapy, 33 patients (32.7%) were pain-free and 8 patients (7.9%) had severe pain (score 0), while at the time data of collection, 74 patients (73%) were free of pain and 1 patient (1%) had strong pain (score 0). Duration of pain before the start of radiation treatment was a significant prognostic factor (p = 0.012) for response to treatment.

CONCLUSION

Radiotherapy of painful plantar enthesophyte is a highly effective therapy with little side effects providing long-term therapeutic response. The only significant prognostic parameter for response to treatment is the duration of pre-radiation therapy pain. Early integration of radiation therapy in the treatment seems to result in superior pain reduction.

Radiotherapy CT-based contouring atlas for non-malignant skeletal and soft tissue disorders: a practical proposal from Spanish experience

OBJECTIVE

Interest in low-dose radiotherapy (LD-RT) for the symptomatic treatment of nonmalignant conditions, including inflammatory and degenerative disorders of the joints and para-articular soft tissues, has increased substantially in recent years. In the present document, we provide a CT-based contouring atlas to help identify and delineate the most common osteoarticular regions susceptible to LD-RT.

METHODS

The clinical efficacy of LD-RT is supported by a large body of evidence. However, there is no consensus on the parameters for contouring the planning target volume (PTV). Moreover, 3D simulation and planning should be the standard of care even for nonmalignant disorders. For this reason, the present guidelines were prepared to help guide PTV contouring based on CT images, with the same quality criteria for patient immobilization, treatment simulation, planning and delivery as those routinely applied for cancer radiotherapy.

RESULTS

PTV for radiotherapy requires precise identification of the target areas based on CT and other imaging techniques. Using a series of cases treated at our institution, we have defined the PTVs for each location on the simulation CT to establish the relationship between the image and the anatomical structures to be treated. We also specify the immobilization systems used to ensure treatment accuracy and reproducibility.

CONCLUSIONS

This comprehensive atlas based on CT images may be of value to radiation oncologists who wish to use LD-RT for the symptomatic treatment of degenerative or inflammatory osteoarticular diseases.

ADVANCES IN KNOWLEDGE

The recommendations and contouring atlas described in this article provide an eminently practical tool for LD-RT in non-malignant conditions, based on the same quality criteria recommended for all modern radiotherapy treatments in Spain.

Low-Dose Radiation Therapy: A New Treatment Strategy for Alzheimer's Disease?

Alzheimer's disease (AD) is a neurodegenerative disease characterized by extracellular amyloid-β (Aβ) peptide aggregates, forming amyloid plaques, and intracellular deposits of phosphorylated tau. Neuroinflammation is now considered as the third hallmark of AD. The majority of clinical trials tested pharmacological strategies targeting amyloid, tau, and neuroinflammation, with disappointing results overall. In parallel, innovative strategies exploring other pathways and approaches are being tested. In this article, we focus on the rationale and preliminary preclinical evidence for a novel application to AD of a widely used therapeutic strategy for oncological and benign conditions: low-dose radiation therapy (LD-RT). LD-RT has shown to be effective against systemic amyloid deposits, as well as against chronic inflammatory diseases, and could thus be able to modulate amyloid load and neuroinflammation in AD. The anti-amyloid effect could be possibly mediated by the LD-RT action on the β-sheet structure of amyloid fibrils, by breaking H-bonds, and depolymerize glucoaminoglycans which are highly radiation-sensitive molecules associated with amyloid fibrils. The anti-inflammatory effect could be linked to the decrease of leukocytes-endothelial cells interactions and to the stimulation of the release of anti-inflammatory molecules. One preclinical study has observed a dramatic reduction of amyloid plaques 4 weeks post-RT, more important with fractionated protocols at low doses than hypofractionated single dose treatments, associated with modulation of inflammatory and anti-inflammatory cytokines and cognitive improvement. Ongoing Phase I clinical trials will test the ability of LD-RT to hold these promises.

Long-term effect and prognostic factors of a low-dose radiotherapy of painful plantar calcaneal spurs : A retrospective unicenter study

PURPOSE

To estimate the long-term effect of low-dose radiotherapy of painful plantar calcaneal spurs, and to verify possible prognostic factors.

PATIENTS AND METHODS

In this retrospective unicenter study, electronic patient files of patients with painful plantar calcaneal spurs treated with low-dose radiotherapy between July 2009 and February 2020 were reviewed. The low-dose radiotherapy consisted of a total dose of 3.0 Gy given with a fraction dose of 0.5 Gy three times a week. The pain reduction was estimated using a patient questionnaire with a visual analogue scale. Kaplan-Meier statistics and Cox regression analysis were used for the statistical analysis.

RESULTS

Altogether, 864 heels of 666 patients were reviewed. The probability of an insufficient pain control 10 years after low-dose radiotherapy was 45.9% (95% confidence interval 39.4-52.4%) in the subset of patients with a minimum follow-up of 3 months (582 heels of 467 patients). Patients with an unsatisfactory pain reduction 3 months after low-dose radiotherapy were offered a re-irradiation. Forty percent of the patients who received a re-irradiation developed good pain reduction. Occurrence of an initial aggravation of pain during or within 3 months after low-dose radiotherapy (p = 0.005), and treatment of bilateral painful plantar calcaneal spurs (p = 0.008) were identified as significant unfavorable prognostic factors on univariate analysis. On multivariate analysis, the initial aggravation of pain remained as independent significant prognostic factor (p = 0.01). No clear radiation toxicity was observed.

CONCLUSIONS

Low-dose radiotherapy is a safe and effective treatment option for patients with painful plantar calcaneal spurs. An initial aggravation of pain during or within 3 months after radiotherapy was identified as unfavorable prognostic factor for the treatment outcome. Re-irradiation of patients with an unsatisfactory pain reduction after low-dose radiotherapy is effective and should be offered to patients.

RESULTS OF CZECH NATIONAL STUDY OF RADIATION EXPOSURE FROM RADIOTHERAPY OF NON-MALIGNANT DISEASES, IN PARTICULAR OF HEEL SPURS

About 26 000 patients are treated per year with radiotherapy for non-malignant diseases in the Czech Republic. Approximately 75% of them are treated on X-ray therapy units and most of these patients undergo radiotherapy of heel spurs. The evaluation of radiation exposure of these patients was based on measured organ doses and on data from clinical practice. Collective effective doses for particular diagnoses were calculated in order to compare doses resulting from different diagnoses treated on X-ray therapy units. The collective effective dose from radiotherapy of heel spurs in the Czech Republic in 2013 was evaluated to 77 manSv. It represents 25.6% of the total collective effective dose for all diagnoses of radiotherapy for non-malignant diseases treated on X-ray therapy units.

First Insights into the Effect of Low-Dose X-Ray Irradiation in Adipose-Derived Stem Cells

(1) Background: Emerging interest of physicians to use adipose-derived stem cells (ADSCs) for regenerative therapies and the fact that low-dose irradiation (LD-IR ≤ 0.1 Gy) has been reported to enhance the proliferation of several human normal and bone-marrow stem cells, but not that of tumor cells, lead to the idea of improving stem cell therapies via low-dose radiation. Therefore, the aim of this study was to investigate unwanted side effects, as well as proliferation-stimulating mechanisms of LD-IR on ADSCs. (2) Methods: To avoid donor specific effects, ADSCs isolated from mamma reductions of 10 donors were pooled and used for the radiobiological analysis. The clonogenic survival assay was used to classify the long-term effects of low-dose radiation in ADSCs. Afterwards, cytotoxicity and genotoxicity, as well as the effect of irradiation on proliferation of ADSCs were investigated. (3) Results: LD (≤ 0.1 Gy) of ionizing radiation promoted the proliferation and survival of ADSCs. Within this dose range neither geno- nor cytotoxic effects were detectable. In contrast, greater doses within the dose range of >0.1–2.0 Gy induced residual double-strand breaks and reduced the long-term survival, as well as the proliferation rate of ADSCs. (4) Conclusions: Our data suggest that ADSCs are resistant to LD-IR. Furthermore, LD-IR could be a possible mediator to improve approaches of stem cells in the field of regenerative medicine.

Updated strategies in the treatment of benign diseases-a patterns of care study of the german cooperative group on benign diseases

Purpose

Radiation therapy (RT) is a common treatment for benign diseases in Germany. Because the treatment concepts are inconsistent, we conducted this pattern-of-care study on behalf of the German Cooperative Group on Benign Diseases to evaluate treatment standards in Germany.

Methods and materials

Questionnaires were mailed to all radiation therapy facilities in Germany. We assessed the treatment equipment, annual number of patients, treatment indications, and, in particular, treatment strategies in patients with benign diseases in 2014.

Results

We evaluated questionnaires returned by 116 participating institutions, of which 41 were ambulatory health care centers, 28 were private institutions, 27 were community hospitals, and 20 were university hospitals. On average, 2 linac accelerators and 2 megavoltage units were available in each institution. In 2014, a total of 36,830 patients were treated for benign diseases: 16,989 for degenerative diseases (peritendinitis humeroscapularis n = 2691; epicondylitis humeri n = 3788; heel spur n = 10,510); 14,936 for osteoarthritis (coxarthrosis n = 2230; gonarthrosis n = 2623; omarthrosis n = 2691; rhizarthrosis n = 2440; polyarthrosis n = 2297; others n = 2655); 1563 for hyperproliferative diseases (morbus Dupuytren n = 960; morbus Ledderhose n = 441; keloids n = 139; pterygium of the conjunctiva n = 3; other hyperproliferative diseases n = 20); 2440 for functional disorders (gynecomastia n = 843; Graves' disease n = 205; lymphatic fistula n = 178; heterotopic ossification prophylaxis n = 1214); 859 for stereotactic RT in the central nervous system (arteriovenous malformation n = 53; meningioma n = 425; acoustic neuroma n = 201; pituitary adenoma n = 131; others n = 49), and 43 for rare indications (pigmented villonodular synovitis n = 20 or vertebral hemangioma n = 23). The mean whole dose was <10 Gy in the treatment of degenerative disorders, 25 Gy for hyperproliferative diseases, 15 Gy for functional disorders, and <50 Gy for stereotactic RT.

Conclusions

In 2014, RT had an important role in the treatment of benign diseases. Because treatment concepts are inherent, we recommend treatment based on the guidelines written by the German Cooperative Group on Benign Diseases.

Retrospective evaluation of the effectiveness of radiotherapy in patients with plantar fascitis (heel spurs)

AIM

The aim of the study was the evaluation of the effectiveness of radiotherapy in patients with the feet pain caused by heel spurs.

BACKGROUND

Treatment options for patients reporting these symptoms include use of suitable orthopedic footwear, the use of general or topical non-steroidal anti-inflammatory drugs or steroids, physiotherapy, manual therapy, shock wave or appropriate surgical procedures. Radiotherapy is one of the method used in patients with chronic pain syndrome.

MATERIALS AND METHODS

The material consisted of 47 patients treated in Radiotherapy Department at the Holycross Cancer Center. The time of follow-up ranged from 1 to 129 months. After treatment patients were observed.

RESULTS

During the first follow-up visit a complete relief of symptoms was observed in 37 patients, and the pain was felt by 10 patients for 4 months after the treatment. One patient was re-irradiated 6 months after treatment because of persistent pain. At 16 and 17 months after the onset of treatment, pain was reported by two patients. These patients were re-irradiated. One patient had recurrence of pain 48 months after completion of radiation. After the second irradiation the pain was relieved. The remaining patients, with the exception of two, experienced remission of pain, which has been documented. Tolerance of the treatment was very good. No complications of radiation were observed.

CONCLUSIONS

Radiotherapy remains an attractive treatment for patients with inflammation of the heel fascia.

The plantar calcaneal spur: a review of anatomy, histology, etiology and key associations

The plantar calcaneal spur (PCS) is a bony outgrowth from the calcaneal tuberosity and has been studied using various methods including cadavers, radiography, histology and surgery. However, there are currently a number of discrepancies in the literature regarding the anatomical relations, histological descriptions and clinical associations of PCS. Historically, authors have described the intrinsic muscles of the foot and/or the plantar fascia as attaching to the PCS. In this article we review the relationship between the PCS and surrounding soft tissues as well as examining the histology of the PCS. We identify a number of key associations with PCS, including age, weight, gender, arthritides, plantar fasciitis and foot position; these factors may function as risk factors in PCS formation. The etiology of these spurs is a contentious issue and it has been explained through a number of theories including the degenerative, inflammatory, traction, repetitive trauma, bone-formers and vertical compression theories. We review these and finish by looking clinically at the evidence that PCS causes heel pain.

Cancer risk after radiotherapy for benign diseases

Radiotherapy with low to intermediate doses has been historically employed for the management of several benign diseases. The exposure to ionizing radiation may increase the probability for carcinogenesis. The knowledge of this probability is of value for weighting the benefits and risks of radiotherapy against different therapeutic approaches. This study initially reviews the epidemiologic data associated with the cancer induction due to radiotherapy for non-malignant conditions in previous decades. Most of these data were derived from patients irradiated with conventional techniques, which are no longer applied, for some benign diseases not treated with radiotherapy nowadays. The follow-up of a series of patients undergoing modern radiotherapy for benign disorders may be used for estimating the radiation-induced cancer risk. The realization of this process is often difficult due to the relatively small number of patients undergoing radiation therapy for such diseases in many countries and due to long latent period for the appearance of a malignancy after exposure. The combination of dosimetric data, which can be obtained by phantom measurements or treatment planning systems or Monte Carlo calculations, with the appropriate linear and non-linear risk models may lead to theoretical estimates of the radiotherapy-induced cancer risks. The limitations of the method providing a whole-body cancer risk based on the effective dose concept are presented. The theoretical organ-specific risks for carcinogenesis give useful information about the development of malignancies at any in-field, partially in-field and out-of-field critical site. The uncertainties of the organ-dependent cancer risk estimates are discussed.

Treatment of Chronic Plantar Fasciitis With Percutaneous Latticed Plantar Fasciotomy

Plantar fasciitis, the most common cause of pain in the inferior heel, accounts for 11% to 15% of all foot symptoms requiring professional care among adults. The present study reports the results of a minimally invasive surgical treatment of chronic plantar fasciitis. All patients with plantar fasciitis who had undergone percutaneous latticed plantar fasciotomy at 3 clinical sites from March 2008 to March 2009 were included in the present study. The follow-up evaluations for this treatment were conducted using the Mayo clinical scoring system. We investigated 17 patients with recalcitrant chronic plantar fasciitis who had undergone this treatment within a follow-up period of ≥13 months. All procedures were performed in the clinic with the patient under local anesthesia. No wound infections or blood vessel or nerve damage occurred. At a mean follow-up period of 16.0 ± 2.29 (range 13 to 21) months, significant improvement was seen in the preoperative mean Mayo score (from 12.06 ± 2.54 to 89.76 ± 4.28, p < .001) and no patient had developed symptom recurrence. Also, none of the patients had developed complex regional pain syndrome. All patients were able to return to regular shoe wear by 3 weeks postoperatively. The technique of plantar fasciitis with percutaneous latticed plantar fasciotomy could be a promising treatment option for patients with recalcitrant chronic plantar fasciitis.

Low dose radiotherapy for plantar fasciitis. Treatment outcome of 171 patients

BACKGROUND

Although the effectiveness of low-dose radiotherapy for chronic degenerative and inflammatory diseases has been documented in previous studies, patient-reported clinical outcomes are rarely available.

OBJECTIVE

This study aimed to determine the effect of low-dose radiotherapy on patients with painful plantar fasciitis.

METHOD

From 2002 to 2008, 200 patients older than 65 years of age with painful plantar fasciitis were treated in our hospital. Records from 171 of these patients were available for analysis. All patients were treated with an identical dose of 3Gy using identical equipment and techniques. Response was evaluated with patient-reported questionnaires and clinical visits.

RESULTS

Minimum-term follow-up was 18 months, with mean follow-up at 54 months. Three months after receiving low-dose radiotherapy, 67.3% of patients had no or mild pain, and 57.9% had no or discrete mobility restriction. At a mean of 54 months, 61.4% of patients had no or mild pain and 64.9% of patients had no or discrete mobility restriction; 60.8% of patients reported improved quality of life.

CONCLUSION

Low-dose radiotherapy is effective in most patients with painful plantar fasciitis. Due to minimal side effects and low costs, it represents an excellent treatment option compared to conventional therapies or surgery.

A study of calcaneal enthesophytes (spurs) in Indian population

INTRODUCTION

Calcaneus or os calcis forms a major component of the skeleton of foot providing posterior pillars for bony arches of the foot. It is largest of seven tarsal bones of foot and forms prominence of heel. Many times anterior to calcaneal tuberosity an osteophytic outgrowth has been observed (calcaneal or heel spur) extending along entire width, for about 2-2.5 cm. The apex of spur seen embedded in plantar fascia, directly anterior to its origin. Hence, the study of calcaneal spurs has been undertaken.

MATERIALS AND METHODS

The material for the study consisted of 200 dry (100 right and 100 left), adult calcanei of unknown age and sex obtained from Department of Anatomy. The calcaneal enthesophytes/spurs were studied in detail and classified according to types of calcaneum.

RESULTS

Maximum incidence of calcaneal spurs were found in Type I calcanei (11%) and no calcaneal spurs were found in Type III calcanei. Total incidence of dorsal calcaneal spurs in all types of calcanei was maximal (15.5%). The incidence of plantar spurs was 6.5% being highest in Type I calcanei (4%). The incidence and type of calcaneal spurs were compared with those of previous studies and etiology of heel pain has been discussed. Correlation between type of calcanei and spurs has been studied for the 1(st) time.

CONCLUSION

Calcaneal spurs are related to type of calcanei with the highest frequency in Type I and least in Type III (no spurs seen in Type III and least in Type IV). Other factors, which contribute toward increase in incidence of spurs, are increasing age and weight, concurrent orthopedic diseases, and heel pain.

[Radiotherapy indications for non-malignant diseases in 2014]

This review updates the radiotherapy indications for non-malignant diseases, except those treated by radiosurgery. Since the last 2005 review, there have been no major changes in the indications: the prevention of heteropic bone formation and keloids remain classical indications, while the treatment of macular degeneration or the prevention of coronary restenosis are now past history. Nevertheless, the radiation treatment for benign diseases should have the same criteria as for malignant diseases: information of the patient on risks, benefits and treatment quality.

Re-irradiation for painful heel spur syndrome. Retrospective analysis of 101 heels

PURPOSE

Painful heel spur syndrome is a common disease with a lifetime prevalence of approximately 10 %. One of the most effective treatment options is radiotherapy. Many authors recommend a second or third series of radiation for recurrent pain and partial or no response to the initial treatment. As the results of re-irradiation have not been systematically analyzed the aim of this study was to document the results of repeated radiation treatment and to identify patients who could benefit from this treatment.

MATERIAL AND METHODS

The analysis was performed on patients from 2 German radiotherapy institutions and included 101 re-irradiated heels. Pain was documented with the numeric rating scale (NRS) and carried out before and directly after each radiation therapy as well as for the follow-up period of 24 months. The median age of the patients was 56 years with 30.1 % male and 69.9 % female patients. Pain was caused by plantar fasciitis in 72.3 %, Haglund's exostosis in 15.8 % and Achilles tendinitis in 11.9 %. Repeated radiation was indicated because the initial radiotherapy resulted in no response in 35.6 % of patients, partial response in 39.6 % and recurrent pain in 24.8 %.

RESULTS

A significant response to re-irradiation could be found. For the whole sample the median NRS pain score was 6 before re-irradiation, 2 after 6 weeks and 0 after 12 and 24 months. Of the patients 73.6 % were free of pain 24 months after re-irradiation. All subgroups, notably those with no response, partial response and recurrent pain had a significant reduction of pain.

CONCLUSION

Re-irradiation of painful heel spur syndrome is an effective and safe treatment. All subgroups showed a good response to re-irradiation for at least 24 months.

Painful plantar heel spur treatment with Co-60 teletherapy: factors influencing treatment outcome

Background

Painful plantar heel spur (PPHS) is a benign disorder with painful heels as a result of plantar calcaneal bone spur. Exact etiological factors are still unclear. Treatment typically consists of osteoarthritis tretment schedules and surgical techniques. External radiotherapy is another treatment option. This study is aimed to determine effectiveness and treatment outcomes of external radiotherapy in patients with PPHS.

Methods

Sixty-two patients with PPHS were analysed for radiotherapy success and other possible prognostic factors. All patients were treated with Co-60 units from parallel opposed lateral portals, to a total dose of 8 Gy. Responses to radiotherapy was assessed by visual analogue scale (VAS) of pain. Follow-up completed in December 2012 with 28 months median duration (range 22 to 35 months). Age, sex, patient number, spur settlement site, prior treatments, time interval between diagnosis and radiotherapy, pain scores (before and after radiotherapy), plantar fat-pillow thickness (PFPT; thickness of the plantar fat pad) and Böhler’s angle estimations were analysed.

Results

Study included 53 female and 9 male patients with median age 57 (range 43–70). Time interval between PPHS diagnosis and radiotherapy were median 33 months (range10-60). Radiotherapy response time interval were 6 months (range 3–10 months). Responses to radiotherapy were no response in 13 patients (21%), partial response in 13 patients (21%)- pain relief below 50% and complete response - no pain in 36 patients (58%) respectively. Median PFPT of patients were 3.5 cm (range 1.20–4.50 cm). Complete response rate was statistically significant in patients whom PFPT is greater than 3.5 cm. The Böhler’s angle range is about 20–40 deg. Complete response rates were higher in patients with degree of Böhler’s Angle 30 and below.

Conclusions

Simplicity of treatment, lack of acute adverse effects and low cost, seem to make radiotherapy one of the safest, cheapest and also an effective treatment modality for PPHS.

Radiotherapy for calcaneodynia. Results of a single center prospective randomized dose optimization trial

PURPOSE

The aim of this work was to compare the efficacy of two different dose fractionation schedules for radiotherapy of patients with calcaneodynia.

PATIENTS AND METHODS

Between February 2006 and April 2010, 457 consecutive evaluable patients were recruited for this prospective randomized trial. All patients received radiotherapy using the orthovoltage technique. One radiotherapy series consisted of 6 single fractions/3 weeks. In case of insufficient remission of pain after 6 weeks a second radiation series was performed. Patients were randomly assigned to receive either single doses of 0.5 or 1.0 Gy. Endpoint was pain reduction. Pain was measured before, immediately after, and 6 weeks after radiotherapy using a visual analogue scale (VAS) and a comprehensive pain score (CPS).

RESULTS

The overall response rate for all patients was 87 % directly after and 88 % 6 weeks after radiotherapy. The mean VAS values before, immediately after, and 6 weeks after treatment for the 0.5 and 1.0 Gy groups were 65.5 ± 22.1 and 64.0 ± 20.5 (p = 0.188), 34.8 ± 24.7 and 39.0 ± 26.3 (p = 0.122), and 25.1 ± 26.8 and 28.9 ± 26.8 (p = 0.156), respectively. The mean CPS before, immediately after, and 6 weeks after treatment was 10.1 ± 2.7 and 10.0 ± 3.0 (p = 0.783), 5.6 ± 3.7 and 6.0 ± 3.9 (p = 0.336), 4.0 ± 4.1 and 4.3 ± 3.6 (p = 0.257), respectively. No statistically significant differences between the two single dose trial arms for early (p = 0.216) and delayed response (p = 0.080) were found.

CONCLUSION

Radiotherapy is an effective treatment option for the management of calcaneodynia. For radiation protection reasons, the dose for a radiotherapy series is recommended not to exceed 3-6 Gy.

Immunomodulatory properties and molecular effects in inflammatory diseases of low-dose x-irradiation

Inflammatory diseases are the result of complex and pathologically unbalanced multicellular interactions. For decades, low-dose X-irradiation therapy (LD-RT) has been clinically documented to exert an anti-inflammatory effect on benign diseases and chronic degenerative disorders. By contrast, experimental studies to confirm the effectiveness and to reveal underlying cellular and molecular mechanisms are still at their early stages. During the last decade, however, the modulation of a multitude of immunological processes by LD-RT has been explored in vitro and in vivo. These include leukocyte/endothelial cell adhesion, adhesion molecule and cytokine/chemokine expression, apoptosis induction, and mononuclear/polymorphonuclear cell metabolism and activity. Interestingly, these mechanisms display comparable dose dependences and dose-effect relationships with a maximum effect in the range between 0.3 and 0.7 Gy, already empirically identified to be most effective in the clinical routine. This review summarizes data and models exploring the mechanisms underlying the immunomodulatory properties of LD-RT that may serve as a prerequisite for further systematic analyses to optimize low-dose irradiation procedures in future clinical practice.

Calcaneal spurs: examining etiology using prehistoric skeletal remains to understand present day heel pain

BACKGROUND

Calcanei are the most common sites for bony spurs. Although calcaneal enthesophytes have been extensively researched, many unknowns remain. Whether biological factors, such as age, weight and genetics, play a greater role in calcaneal spur etiology than activity is still unknown.

OBJECTIVES

The current study examines 121 adults from a prehistoric hunter-gatherer population to aid in understanding bony spur etiology.

METHODS

Calcaneal spurs are scored as present or absent on the dorsal or plantar side; they are analyzed in regards to their relationships with age, sex, osteoarthritis, cortical index, femoral head breadth and muscle markers.

RESULTS

Dorsal and plantar spurs frequencies increase with age (chi-squares=16.90, 7.268, Ps<0.05, respectively). Dorsal spurs were more frequent than plantar spurs (chi-square=38.000; P<0.0001). There is a positive relationship with calcaneal spurs and upper limb and lower limb osteoarthritis (chi-squares=5.587, 7.640, Ps<0.05, respectively).

CONCLUSIONS

The data presented support that dorsal spurs are in part the result of activities, but plantar spurs may be a more modern phenomena resulting from long periods of standing and excess weight.

Anti-inflammatory effects of low-dose radiotherapy. Indications, dose, and radiobiological mechanisms involved

Low-dose radiotherapy (LD-RT) has been used for several benign diseases, including arthrodegenerative and inflammatory pathologies. Despite its effectiveness in clinical practice, little is known about the mechanisms through which LD-RT modulates the various phases of the inflammatory response and about the optimal dose fractionation. The objective of this review is to deepen knowledge about the most effective LD-RT treatment schedule and radiobiological mechanisms underlying the anti-inflammatory effects of LD-RT in various in vitro experiments, in vivo studies, and clinical studies.

Demographic, clinical and treatment related predictors for event-free probability following low-dose radiotherapy for painful heel spurs - a retrospective multicenter study of 502 patients

A total of 502 patients treated between 1990 and 2002 with low-dose radiotherapy (RT) for painful heel spurs were analysed for prognostic factors for long-term treatment success. The median follow-up was 26 months, ranging from 1 to 103 months. Events were defined as (1) slightly improved or unchanged pain after therapy, or (2) recurrent pain sensations during the follow-up period. Overall 8-year event-free probability was 60.9%. Event-free probabilities of patients with one/two series (414/88) were 69.7%/32.2% (p<0.001); >58/ < or = 58 years (236/266), 81.3%/47.9% (p=0.001); high voltage/orthovoltage (341/161), 67.9%/60.6% (p=0.019); pain anamnesis < or = 6 months/ >6 months (308/194), 76.3%/43.9% (p=0.001); single dose 0.5/1.0 Gy (100/401), 86.2%/55.1% (p=0.009); without/with prior treatment (121/381), 83.1%/54.9% (p=0.023); men/women (165/337), 61.2%/61.5% (p=0.059). The multivariate Cox regression analysis with inclusion of the number of treatment series, age, photon energy, pain history, single-dose and prior treatments revealed patients with only one treatment series (p<0.001), an age >58 years (p=0.011) and therapy with high voltage photons (p=0.050) to be significant prognostic factors for pain relief. Overall low-dose RT is a very effective treatment in painful heel spurs.

Radiotherapy in oncological emergencies--final results of a patterns of care study in Germany, Austria and Switzerland

Radiotherapy (RT) is an important treatment option for emergencies in oncology. A multicenter patterns of care study (PCS) was conducted in all RT institutions in Germany, Austria and Switzerland. In 2003 a standardized structured questionnaire was sent to all RT institutions. Number and type of staff involved, number of patients, over time distribution and expense, treatment indications and concepts of emergency RT were assessed. In addition, treatment outcome for the different indications was evaluated. The PCS was structured and analyzed according to the model for quality assessment set up by Donabedian in three major components: structure, process and outcome. One hundred and forty institutions (70%) answered the questionnaire. For the baseline of 2003 a total of 3244 emergency radiotherapy indications with a mean of 28 per institution were reported. Forty percent of all institutions provide a special 24 h service at night or weekends. Seventy percent of the emergency indications were irradiated between Monday and Thursday, 30% between Friday and Sunday. Ninety percent of all emergencies were referred to RT between 8 a.m. and 6 p.m., 10% between 6 p.m. and 8 a.m. The applied doses for emergency RT ranged between 2 Gy and 8 Gy (median: 3.5 Gy). Time expense was reported with a median of 90 min. The outcome analysis based on the treatment results of 1 033 patients: There was an improvement of myelocompression in 50% of the cases, vena cava superior compression in 70%, bronchial obstruction in 70% and bleedings in 80%. A clear dose-response relationship could not be established, but single doses of over 3 Gy in vena cava superior syndrome exhibited a significant advantage. This study represents the largest database in literature on emergency RT. RT was shown to be fast, time sparing and a very effective treatment option for special oncological emergencies.

Retrospective evaluation of radiotherapy in plantar fasciitis

Plantar fasciitis is a common painful syndrome that is usually treated by irradiation with a fraction dose (fd) of 1 Gy up to a total dose (TD) of 6 Gy according to clinical experience. By analysing our experiences with numerous former patients, we have attempted to find the relationship between dose and effect. To evaluate the effectiveness of radiotherapy and assess the impact of fd and TD in plantar fasciitis radiotherapy, we assessed 1624 irradiations (856 patients) performed using a fd of 1-3 Gy and a TD of 1-45 Gy. Analysis was carried out on the 623 irradiations (327 patients) for which complete follow-up data were available. The mean follow-up period was 74 months. The following parameters were evaluated: pain relief level; period of anaesthetic effect preservation after treatment; presence of pain and the timing of its appearance; and the intake of analgesic drugs at the last follow-up. After treatment, 48% of the patients reported a lack of pain, 21% reported pain relief greater than 50% and 17% reported pain relief less than 50%. The mean pain relief duration was 72 months. The last follow-up found that pain at rest afflicted 25% of the patients, and pain during walking afflicted 32%. A dose-effect relationship was not found. In conclusion, radiotherapy is an effective treatment for plantar fasciitis. A fd of 1.5 Gy and TD of 9 Gy should probably not be exceeded.

Radiobiological mechanisms in inflammatory diseases of low-dose radiation therapy

PURPOSE

Whereas X-irradiation with high doses is established to exert pro-inflammatory effects, low-dose radiotherapy (LD-RT) with single fractions below 1.0 Gy and a total dose below 12 Gy is clinically well known to exert anti-inflammatory and analgesic effects on several inflammatory diseases and painful degenerative disorders. Experimental studies to confirm the effectiveness, the empirical dose and fractionation schemes, and the underlying radiobiological mechanisms are still fragmentary.

METHOD

The anti-inflammatory efficiency of LD-RT was confirmed in several experimental in vitro and in vivo models.

RESULTS

In vitro studies revealed a variety of mechanisms related to the anti-inflammatory effect, in particular the modulation of cytokine and adhesion molecule expression on activated endothelial cells and leukocytes, and of nitric oxide (NO) production and oxidative burst in activated macrophages and native granulocytes.

CONCLUSION

Inflammatory diseases are the result of complex and pathologically unbalanced multicellular interactions. It is, therefore, reasonable to assume that further molecular pathways and cellular components contribute to the anti-inflammatory effect of LD-RT. This review discusses data and models revealing aspects of the mechanisms underlying the anti-inflammation induced by low doses of X-irradiation and may serve as a basis for systematic analyses, necessary to optimize LD-RT in clinical practice.

Heel spur radiotherapy and radiation carcinogenesis risk estimation

PURPOSE

Radiotherapy is a nonsurgical alternative therapy of painful heel spur patients. Nonetheless, cancer induction is the most important somatic effect of ionizing radiation. This study was designed to evaluate the carcinogenesis risk factor in benign painful heel spur patients treated by radiotherapy.

MATERIALS AND METHODS

Between 1974 and 1999, a total of 20 patients received mean 8.16 Gy total irradiation dose in two fractions. Thermoluminescent dosimeters (TLD(100)) were placed on multiple phantom sites in vivo within the irradiated volume to verify irradiation accuracy and carcinogenesis risk factor calculation. The 20 still-alive patients, who had a minimum 5-year and maximum 29-year follow-up (mean 11.9 years), have been evaluated by carcinogenic radiation risk factor on the basis of tissue weighting factors as defined by the International Commission on Radiological Protection Publication 60.

RESULTS

Reasonable pain relief has been obtained in all 20 patients. The calculated mean carcinogenesis risk factor is 1.3% for radiation portals in the whole group, and no secondary cancer has been clinically observed.

CONCLUSION

Radiotherapy is an effective treatment modality for relieving pain in calcaneal spur patients. The estimated secondary cancer risk factor for irradiation of this benign lesion is not as high as was feared.

Anti-inflammatory effects of low-dose radiotherapy in an experimental model of systemic inflammation in mice

PURPOSE

The aim of this study was to determine the effects of low-dose radiotherapy (LD-RT) on the inflammatory response and to characterize the potential mechanisms underlying these effects.

METHODS AND MATERIALS

Mice were irradiated with 0.1, 0.3, 0.6 Gy, or sham radiation before lipopolysaccharide (LPS) challenge. Leukocyte-endothelial cell interactions in intestinal venules were assessed using intravital microscopy. Intercellular adhesion molecule-1 (ICAM-1) expression was determined using radiolabeled antibodies 5 h after irradiation. Production of transforming growth factor-beta1 (TGF-beta1) was measured by enzyme-linked immunosorbent assay and its in vivo functional relevance by immunoneutralization.

RESULTS

Compared with vehicle treated animals, LPS induced a marked increase in leukocyte adhesion (0.13+/-0.59 vs. 5.89+/-1.03, p<0.0001) in intestinal venules. The number of adherent leukocytes was significantly reduced by the 3 doses of LD-RT tested; the highest inhibition was observed with 0.3 Gy (0.66+/-1.96, p<0.0001). LPS-induced ICAM-1 upregulation was not modified by LD-RT. Circulating levels of TGF-beta1 were significantly increased in response to LD-RT in controls and LPS challenged animals. Neutralization of TGF-beta1 partially restored LPS-induced adhesion (4.83+/-1.41, p<0.05).

CONCLUSIONS

LD-RT has a significant anti-inflammatory effect, inhibiting leukocyte recruitment, which is maximal at 0.3 Gy. This effect results in part from increased TGF-beta1 production and is not related to modulation of ICAM-1 expression.

La radiothérapie des affections bénignes : quelles indications huit ans plus tard ?

The authors present an update version of the indications for radiotherapy in the management of benign diseases. This is based on available randomized trials and recent international meetings. Validated indications remain the prevention of resected heterotopic bone ossifications, keloïds scars and pterygium and also treatment of arteriovenous malformations; the place of radiotherapy for malignant exophtalmia is more and more restricted. Randomized trials have demonstrated the efficacy of endobrachytherapy in the prevention of restenosis after angioplasty but the use of embedded stent has replaced this indication. Macular degeneration is no more an indication of radiotherapy. Quality requirements for radiotherapy are identical for benign or malignant indications.

[Plantar fasciitis and radiotherapy. Clinical and radiobiological treatment results]

Patients with plantar fasciitis and pain refractory to conventional therapy are treated with low-dose radiotherapy (RT), but no conclusive evidence-based and radiobiological studies had been performed. In 2001 the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) carried out a study by mailing a standardized questionnaire. A total of 136 institutions treated 3621 patients/year with chronic or refractory pain. The median total dose was 6 Gy (median single dose: 1 Gy); 76 institutions reported data of their clinical evaluation of a total of 7947 patients. Pain relief lasting for at least 3 months was reported in 70% and persistent pain relief in 65%. There were no acute or chronic radiogenic side effects observed. The radiobiological studies showed a significant increase of granulocyte function at 1.5 Gy and a significant decrease at 3.5 and 4.0 Gy. These results may provide a possible explanation for a local anti-inflammatory effect of low-dose RT. RT may be an excellent alternative for patients with contraindications to long-term treatment with steroids or NSAID.

Radiation therapy for aggressive fibromatosis (desmoid tumors): results of a national Patterns of Care Study

PURPOSE

After a general Patterns of Care Study (PCS) the German Cooperative Group on Radiotherapy for Benign Diseases (GCG-BD) initiated a multicenter cohort study to analyze the radiation therapy practice for aggressive fibromatosis.

METHODS AND MATERIALS

In 2002 a PCS was conducted in all German radiotherapy (RT) institutions by mailing a standardized structured questionnaire, to assess patients accrual, number, pretreatment, treatment indications, RT, and target volume concepts for irradiation in aggressive fibromatosis. In addition, the treatment outcome of individual patients was evaluated. The PCS was structured and analyzed according to the model for quality assessment by Donabedian in three major components: structure, process, and outcome evaluation.

RESULTS

A total of 101 institutions returned the questionnaire: 52.7% reported satisfactory clinical data and experience for inclusion in this analysis. A total accrual rate of 278 patients per year was reported with median number of 2 cases (1-7 cases) per institution. Satisfactory data for a long-term clinical evaluation was reported for 345 patients from 19 different institutions. The applied total doses ranged between 36 and 65 Gy (median, 60 Gy). The local control rate was 81.4% in primary RT for unresectable tumors and 79.6% in postoperative RT. No acute or late radiation toxicities > Grade 2 (RTOG) were observed. No clear dose-response relationship could be established, but there was a tendency toward a lower local control rate in patients with a higher number of operative procedures before RT and patients treated for recurrent aggressive fibromatosis.

CONCLUSIONS

This study comprises the largest database of cases reported for RT in aggressive fibromatosis. Radiotherapy provides a high local control rate in the postoperative setting and in unresectable tumors. This PCS may serve as a starting point for a national or international prospective multicenter study or registry, or both.