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Taisa Polishchuk
Clinical Practicum I
February 18, 2015
Contracture of the left palmar fascia (Dupuytrens of the left palm) Treatment Planning
Case Study
History of Present Illness: KE is a 46 year old female who presented with newly diagnosed
Dupuytrens of the left palm on December 15, 2014. The patient reported that she had a
traumatic wood working accident a year ago, that required reconstructive surgery to her left
palm. In one of the follow ups with the plastic surgeon (around 6 months after the surgery), the
patient noticed a nodule in the distribution of the 4th digit in the left palm. Both the plastic
surgeon and the primary care physician suggested surgery as a method of treatment of the left
palmar contracture. After doing independent research the patient self-referred to Virginia
Commonwealth University Health System Massey Cancer Center for discussion of radiation
therapy. The physical exam performed by the radiation oncologist revealed two neighboring 1.0
cm nodules that were palpable over the 4th metacarpal area of the left palm. There were no cord
formations and no contractures of the bilateral palms. The contracture was staged N Dupuytrens
of the left palm with 2 nodules in the left 4th digit distribution. The oncologist explained that the
goal of the radiation therapy would be to halt the progression of the disease. Risks, benefits, and
side effects of radiation therapy for the early stage Dupuytrens were discussed with the patient
and decision was made to start treatments in January of 2015.
The incidence of Dupuytrens disease in the United States is estimated to be 1% based on
physician and/or surgical treatment, but may be upwards of 7% when including patient reported
early symptoms.1 This roughly equates to 3 cases per 10,000 US adults. Dupuytrens disease is a
superficial, spontaneously occurring, benign disorder involving the connective tissue of the
hands and feet.2 Disease specifically attacks palmar and plantar fascia. There are different ways
to treat Dupuytrens disease, among which are hand surgery, needle aponeurotomy, collagenase
injection, and radiation therapy.3
Past Medical History: The patient has a past medical history of hypertension and asthma, and
no history of diabetes. Left reconstructive surgery of the palm was reported. KE has no allergic
reaction to medications, foods, or latex.

Social History: KE works at the Pentagon, and is going to start a new job at American
University in Washington DC. The patient is married and has children. KE denies the use of
drugs, alcohol and tobacco. The patients mother was diagnosed with Dupuytrens disease and
underwent surgery to treat her condition. KE has no history of other cancers, and no previous
radiation.
Medications: KE uses the following medications: Valsartan/Hydrochlorothiazide, Nifedipine,
and Albuterol.
Diagnostic Imaging: The patient underwent an extensive physical exam of the left palm, in
addition to CT simulation scan.
Recommendations: The patient was recommended to receive definitive radiation therapy for the
treatment of her left palm. The oncologist discussed participation in a retrospective study to
investigate the effectiveness of radiation treatment to which KE verbally agreed. The physician
shared the initial results of the retrospective study analysis that was presented at the ASTRO
meeting in 2014 and the patient agreed to participate in the study protocol. The consent was
signed and the side effects of the radiation treatment were discussed again.
The Plan (Prescription): The radiation treatment plan was designed for the patient to receive a
total of 3000 cGy at 300 cGy for 10 fractions with a 6- to 8-week break after 1500 cGy.
Electrons with 6MeV energy were utilized to deliver the dose.
Patient Setup/Immobilization: The patient was treated standing by the left side of the table
with a sponge under the left hand (for leveling), 1.0 cm bolus under and above the hand and
taped for immobility. A Philips Brilliance CT was used for the simulation in order to distinguish
the treatment depth.
Anatomic Contouring: After completion of the CT simulation scan, the physician mapped the
treatment area with the permanent marker (Figure 1). The margin of approximately 1-2 cm were
given. The dosimetrist transferred the marked area onto the template in order to create a custom
cutout for electron treatments (Figure 2). The data obtained during simulation was transferred
into the Philips Pinnacle3 9.6 radiation treatment planning system in order to obtain maximum
treatment depth of 0.72 cm. There was no need to contour organs at risk due to the location of the
treatment and critical structures being away from the field. Treatment plan was calculated
utilizing electron spread sheet.

Beam Isocenter/Arrangement: A Varian 2300Trilogy linear accelerator was used for treating
the patient. A single 6MeV electron field was used to deliver the treatment dose. The patient was
standing by the left side of the treatment table with the sponge under the left hand for leveling
and tape was used to immobilize the hand from movement (Figure 3). Gantry was set up at 0
degrees, collimator was setup at 90 degrees, and couch was at 0 degrees. An electron cutout
measuring 7.1 cm by 6.3 cm was used to deliver the dose to the treatment area.
Treatment planning: The Philips Pinnacle3 treatment planning system version 9.6 was utilized
to assess extent of the disease and determine the depth of disease aiding in choosing an
appropriate energy for treatment. 6 mega-electron-volt (MeV) electron energy was used to treat
the nodules of the left hand. Source to skin distance of 100cm was chosen and the dose was
prescribed to the 90% isodose line. In addition 1.0 cm bolus was placed on top and bottom of the
patients hand. The top 1.0 cm bolus was placed in order to properly deliver the dose to the
nodules located 0.45cm and 0.72 cm deep (Figure 4,5). The bolus under the hand was placed to
take care of the backscatter from electrons. The values were plugged into the electron calculation
sheet by the dosimetrist and 332 monitor units (MU) were calculated (Figure 6).
Monitor Unit Check/ Quality Assurance Checks: MU check was performed by the physicist
utilizing RadCalc electron spread sheet. The percent difference of -2.0% was calculated (Figure
7). The acceptable limit is within 3%, therefore 332 MU were approved for the treatment. No
additional calculation checks were performed. Both the physicist and the physician signed off the
calculation retrieved from the RadCalc.
Conclusion: Orthovoltage treatments, as well as electron treatments using 6MeV or 9MeV
energies are widely used throughout the United States.2 Virginia Commonwealth University
Health System Massey Cancer Center is one of the 22 clinical sites in US currently treating
Dupuytrens disease and it was rather interesting to participate and observe such a unique case.4
Utilization of electrons is a very important aspect in radiation therapy and is widely used in
different circumstances. Understanding what energy to use and how to prescribe the dose is one
of the important skills any dosimetrist must obtain. I was able to evaluate percent depth dose
graphs in order to select a proper energy for treatment and perform the electron computation.
This case gave me a good representation of what some of the future dosimetry tasks might be
and how I would approach the treatment planning process.

References
1. DiBenedettiD, Nguyen D, ZogrfosL, ZiemeckiR, Zhou X. Prevalence, incidence, and
treatments of dupuytrens disease in the united states: results from a population based study.
Hand. 2011;6(2):149-158. doi 10.1007/s11552-010-9306-4
2. Betz W, OttO, AdamietzB, et al. Radiotherapy in early-stage dupuytrens contracture: long
term results after 13 years. StrahlmerOnkol. 2010;2 82-90. doi 10.1007/s00066-010-2063-z
3. Rayan G. Dupuytren disease: anatomy, pathology, presentation, and treatment. J Bone Joint
Surg. 2007;89A:190-198.
4. Clinics and hospitals providing radiation therapy. International Dupuytren Society Web Site.
http://www.dupuytren-online.info/radiotherapy_clinics.html. Updated February 19, 2015.
Accessed February 19, 2015.

Figures

Figure 1. The treatment was mapped out on the patients palm.

Figure 2.
The
template of a custom cutout for electron treatments.

Figure 3. Patient treatment setup.

Figure 4. Nodules of the left palm.

Figure 5. Nodules 0.45

cm and 0.72 cm deep.

Figure 6. Electron
calculation sheet.

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Figure 7. RadCalc electron MU calculation sheet