AU2012255624B2

AU2012255624B2 - Method of treating excessive collagen formation

Info

Publication number: AU2012255624B2
Application number: AU2012255624A
Authority: AU
Inventors: David Chin
Original assignee: Individual
Current assignee: Individual
Priority date: 2011-05-18
Filing date: 2012-05-18
Publication date: 2016-06-09
Anticipated expiration: 2032-05-18
Also published as: AU2012255624A1; WO2012155212A1

Abstract

A treatment for fibromatosis is provided and, particularly, a treatment for palmar and/or plantar fascial fibromatosis is provided. The administration of a plasminogen activator locally to the affected tissue has been found to greatly improve the range of motion to the affected region, to reduce the appearance of the formed cords and nodules and to facilitate easier removal of these structures, if required.

Description

METHOD OF TREATING EXCESSIVE COLLAGEN FORMATION FIELD OF THE INVENTION

The present invention relates to a method of treating a disease characterised by excessive collagen formation. Particularly, the present invention relates to a method of treating fascial fibromatosis.

BACKGROUND OF THE INVENTION

Dupuytren’s disease (also known as Dupuytren’s contracture, morbus Dupuytren or palmar fascial fibromatosis) is a fascial fibromatosis characterised by the formation of nodules in the palmar and digital fascia. The nodules eventually grow into cords of contracted tissue which gradually pull one or more of the sufferer's fingers towards their palm resulting in that finger adopting a permanently flexed position.

The underlying cause of Dupuytren’s disease is not well understood. It is believed that the disease develops in three stages whereby, in the first stage, a proliferation of myofibroblast cells is observed. In the second stage the myofibroblasts align along lines of tension in the fascia leading to the third stage wherein the affected tissue becomes mostly acellular and only thick bands of collagen remain. Studies have shown that these bands show a high ratio of type III to type I collagen which is in contrast to the predominantly type I collagen found in normal palmar fascia.

Dupuytren’s disease is a relatively common condition with its prevalence varying in different populations. Over 30 percent of Northern European males may be affected at 50 years old and 40 percent for those 80 years and older. It has a negative effect on a patient’s quality of life as, once contracture reaches an advanced stage, they find themselves unable to perform simple tasks requiring fine control of the fingers.

The traditional treatment for Dupuytren’s disease, in so far as it returns hand function, has, until recently, been largely surgical. A number of incisions will be made on the skin of the palm and affected fingers and the thickened cords are excised. A fasciectomy is sometimes performed, to varying extents, to remove some of the diseased fascia. The surgery is followed by an extensive period of rehabilitation of the hand involving initial splinting and then a program of physiotherapy.

There are a number of concerns regarding this type of surgical procedure including the risk of nerve or artery damage as well as postoperative infection. Major complications have been estimated to occur in up to 16% of cases and a typical initial recovery time is 4 to 6 weeks.

The most recent treatment introduced for Dupuytren’s disease is the injection of collagenase Clostridium histolyticum into the thickened cords of the sufferer. This is available as a commercial formulation known as Xiaflex™. The formulation is injected into the cord in a number of different places and acts to weaken the cord. The patient will then need to re-present the following day at which point a doctor will manually straighten the finger to break the cord, which is a painful procedure.

Xiaflex™ has a number of potentially serious side effects. Allergic reactions are a serious concern due to the injection into the body of foreign protein being the bacterial collagenase enzyme. This can lead to swelling of the face, breathing difficulties and chest pain. Another major risk is that of tendon or ligament rupture or damage which can result in the need for surgical intervention to repair the damage and restore function. Finally, there is also a concern that nerve injury can occur which can present as pain in the treated finger or hand generally.

Peyronie’s disease (penile fascial fibromatosis) and Ledderhose disease (plantar fascial fibromatosis) are considered to be related diseases to Dupuytren’s due to the similar underlying collagen and connective tissue problems. Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis which may result in an abnormal curvature. It has been reported that approximately 30% of men who suffer from Peyronie’s disease will also develop fibrosis in other parts of the body such as the hand (Dupuytren’s disease) or the foot (Ledderhose disease). Ledderhose disease is a nonmalignant thickening of the feet's deep connective tissue. In the initial stages of the disease nodules or cords start growing along tendons of the foot (in the same manner as occurs in Dupuytren s disease) which may become tender. Eventually the cords thicken, the toes stiffen and bend and walking becomes extremely painful. It has been found that the histological and ultrastructural features of Ledderhose and Dupuytren's disease are the same and so it is believed they have a common etiology and pathogenesis. Treatments for Ledderhose disease are limited as surgery can worsen the condition with further plantar fascia thickening and formation of nodules causing further discomfort for the patient and postoperative rehabilitation is relatively long and painful.

SUMMARY OF THE INVENTION

The present invention addresses one or more of the deficiencies of the prior art by providing a method of treating fibromatosis which avoids or reduces the risk of one or more of the side effects of current injectable treatments. Preferably, the fibromatosis is a fascial fibromatosis.

Suitably, the fascial fibromatosis is a disease selected from the group consisting of Dupuytren’s disease, Peyronie's disease and Ledderhose disease.

In a first aspect, the invention provides for a method of treating palmar and/or plantar fascial fibromatosis in a subject, including the step of administering to the subject an effective amount of an activator of a collagenase production pathway, to thereby treat the palmar and/or plantar fascial fibromatosis.

Suitably, the activator of the collagenase production pathway is an agent which, directly or indirectly, increases the conversion of pro-collagenase to collagenase.

Preferably, the activator of the collagenase production pathway is a plasminogen activator. in one embodiment, the plasminogen activator is a serine protease.

Preferably, the serine protease is one which acts to convert plasminogen to plasmin.

Suitably, the plasminogen activator is a tissue plasminogen activator.

The tissue plasminogen activator is preferably a recombinant tissue plasminogen activator.

Preferably, the recombinant tissue plasminogen activator is alteplase.

The activator of the collagenase production pathway may thus be an activator isolated from natural tissue sources or a synthetic activator.

The effective amount of the activator of the collagenase production pathway may be administered locally to tissue affected by fibromatosis.

Preferably, the administration is by injection.

Suitably, the subject is a human.

In a second aspect, the invention resides in a method of assessing the need for treatment of fibromatosis in a subject with an activator of a collagenase production pathway including the steps of: (a) detecting the level of urokinase-type plasminogen activator (uPA) in the fibromatosed tissue; (b) detecting the level of urokinase-type plasminogen activator (uPA) in normal tissue; and (c) comparing the level of uPA detected in step (a) with that detected in step (b), whereby a reduced level in the fibromatosed tissue correlates with a positive diagnosis, to thereby assess the need for treatment.

The reduced level is assessed by comparison to normal or nondiseased tissue in the same subject or that found in the same tissue of a healthy subject. The reduced level may be a substantially reduced level or may indicate a substantial absence of the uPA.

In a third aspect, the invention resides in a kit when used to assess the need for treatment of palmar and/or plantar fascial fibromatosis in a subject with an activator of a collagenase production pathway, the kit comprising one or more reagents for detecting the level of urokinase-type plasminogen activator (uPA) in affected tissue, whereby a reduced level in comparison to that found in normal tissue correlates with a positive need for such treatment.

In a fourth aspect, the invention resides in a pharmaceutical composition for the treatment of palmar and/or plantar fascial fibromatosis comprising an effective amount of an activator of a collagenase production pathway, or a pharmaceutically acceptable salt thereof, and a pharmaceutically acceptable carrier and/or diluent and/or excipient.

The activator may be as described for the first aspect.

In a fifth aspect, the invention provides for the use of an activator of a collagenase production pathway, or a pharmaceutically acceptable salt thereof, in the manufacture of a medicament for the treatment of palmar and/or plantar fascial fibromatosis.

The activator may be as described for the first aspect.

The various features and embodiments of the present invention, referred to in individual sections above apply, as appropriate, to other sections, mutatis mutandis. Consequently features specified in one section may be combined with features specified in other sections as appropriate.

Further features of the present invention will become apparent from the following detailed description. .

BRIEF DESCRIPTION OF THE FIGURES

In order that the invention may be readily understood and put into practical effect, preferred embodiments will now be described by way of example with reference to the accompanying figures wherein: FIG 1 is a diagrammatic representation of a collagenase production pathway: FIG 2A is a graphical reproduction of a photograph of both hands of a patient suffering from Dupuytren’s disease prior to treatment: FIG 2B is a graphical reproduction of a photograph of both hands of the same patient shown in FIG 2A after treatment according to the present invention; FIG 3A is a graphical reproduction of a photograph of the left hand of a patient suffering from Dupuytren’s disease prior to treatment; FIG 3B is a graphical reproduction of a photograph of the left hand of the same patient shown in FIG 3A after treatment according to the present invention; FIG 4A is a graphical reproduction of a photograph of the right hand of a patient suffering from Dupuytren’s disease prior to treatment; FIG 4B is a graphical reproduction of a photograph of the right hand of the same patient shown in FIG 4A after treatment according to the present invention; FIG 5A is a graphical reproduction of a photograph of both hands of a patient suffering from Dupuytren’s disease prior to treatment; and FIG 5B is a graphical reproduction of a photograph of both hands of the same patient shown in FIG 5A after treatment according to the present invention.

DETAILED DESCRIPTION OF THE INVENTION

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art (e.g. in pharmaceutical chemistry and the field of medicine generally).

Unless contraindicated or noted otherwise, in these descriptions and throughout this specification, the terms "a" and "an" mean one or more, the term "or" means and/or.

By "comprising" is meant including, but not limited to, whatever follows the word "comprising". Thus, use of the term "comprising" indicates that the listed elements are required or mandatory, but that other elements are optional and may or may not be present.

As used herein, "subject" or "individual" or "patient" refers to any subject for whom or which therapy is desired, and generally refers to the recipient of the therapy to be practiced according to the invention. The subject will be a mammal. If a mammal, the subject will preferably be a . human, but may also be a domestic livestock, laboratory subject or pet animal. The subject is most preferably a human adult who is or has been the object of treatment, observation or experiment.

As used herein, unless the context demands otherwise, the terms “treat," “treating,” or “treatment” as used herein means to counteract a medical condition (e.g., palmar and/or plantar and/or penile fascial fibromatosis) to the extent that the medical condition is improved, at least temporarily, according to clinically acceptable standard(s). For example, “treating palmar and/or plantar fascial fibromatosis” means to improve the disorder or relieve symptoms of the particular disorder in a patient, such as improving the range of motion of the affected finger(s), wherein the improvement and relief are evaluated with a clinically acceptable standardized test (e.g., a patient self-assessment scale involving improvement in the range of motion of affected digits) and/or an empirical test and wherein the improvement may be permanent or temporary. “Treat,” “treating,” or “treatment” as used herein may also include prophylactic treatment unless the context requires otherwise.

As used herein, the term “activator” means any agent which results in an increase in levels of a desired end product due to activation of one or more elements of a natural pathway or cascade. For example, an “activator of the collagenase production pathway” may be any agent which results in an increased production of endogenous collagenase and a “plasminogen activator” is any agent which activates plasminogen by converting it into the active plasmin form.

It will be appreciated that the “activator” may be in the form of a pharmaceutically effective or acceptable salt and the activator may be one which has been isolated from a tissue or generated synthetically such as by use of recombinant DNA techniques.

The term "fibromatosis” refers to a condition characterized by the proliferation of generally mature fibroblasts associated with mature collagen and the formation of fibrous nodules and/or cords arising from the fascia. The term is particularly used herein in relation to fibromatosis of the fascia of the palmar (Dupuytren’s disease), plantar (Ledderhose disease) and penile (Peyronie’s disease) tissue.

The terms palmar, plantar and penile fascial fibromatosis will be used interchangeably with the terms Dupuytren’s disease, Ledderhose disease and Peyronie’s disease, respectively.

The term "effective amount" or "therapeutically effective amount" means that amount of active agent (activator) that elicits the biological or medicinal response in a tissue system, animal or human that is being sought by a researcher, veterinarian, medical doctor or other clinician, which includes alleviation of one or more of the symptoms of the disease or disorder being treated; reduction of the severity of one or more of the symptoms of the disease or disorder being treated; or otherwise provides the desired effect. The precise dosage may vary according to a variety of factors such as subject-dependent variables (e.g., age, medical history, etc.), the disorder or condition, and the treatment being affected.

In a first aspect, the invention provides for a method of treating palmar and/or plantar fascial fibromatosis in a subject, including the step of administering to the subject an effective amount of an activator of a collagenase production pathway, to thereby treat the palmar and/or plantar fascial fibromatosis. FIG 1 is a diagrammatic representation of one such collagenase production pathway.

In the flow diagram shown it can be seen that plasminogen must first be converted to the active plasmin form before this can then act to bring about the conversion of pro-collagenase into collagenase. Urokinase, also known as urokinase-type plasminogen activator (uPA), and tissue plasminogen activator (tPA) are responsible, at least in part, for the conversion of the zymogen form, plasminogen, into the active plasmin.

Thus, references herein to a “collagenase production pathway” are directed to a pathway such as that shown in FIG 1, which results in the production of endogenous collagenase.

The present inventor has surprisingly found that the uPA in Dupuytren’s pre-tendinous cords is present at a greatly reduced level, or may even be absent, by comparison to that level found in normal palmar fascia. This has not been previously documented. Although not wishing to be bound by any particular theory, it is postulated that the reduction in or absence of uPA allows the unimpeded formation of excess collagen into the observed contractures since the collagenase production pathway is not being activated to a sufficient extent to maintain the natural status quo between formation and break down. Given how closely related Dupuytren’s disease is to Peyronie's disease and Ledderhose disease it is reasonably predictable that the same underlying reduced levels of uPA will also be responsible for the fibrosis/collagen formation observed in these diseases.

Similarly, the present treatment may be generally applicable to a wide range of conditions sharing an underlying etiology and demonstrating fibromatosis in relation to the formation of fibrous nodules and/or cords arising from the fascia due to uncontrolled collagen deposition. Thus the present invention provides a method of treating fibromatosis in a subject, including the step of administering to the affected tissue of the subject an effective amount of an activator of a collagenase production pathway, to thereby treat the fibromatosis. The activator may be as is described herein in relation to the first aspect.

Preferably, the fibromatosis is a fascial fibromatosis.

Suitably, the fascial fibromatosis is a disease selected from the group consisting of Dupuytren's disease, Peyronie’s disease and Ledderhose disease.

In addition to the pathway shown in FIG 1 it is believed that uPA has other cellular effects relating to cell migration as well as tissue degradation and remodelling such as its interactions with various growth factors, matrix metalloproteinases (MMPs), cathepsins, stromlysins, as well as a role in the degradation of fibronectin, activation of collagenase (V and its role in mitogenesis. It thus plays a key role in regulating tissue structure.

The present treatment attempts to counteract this imbalance and restore proper functionality to the tissue to thereby bring about degradation of the collagen cords underlying Dupuytren’s disease, Peyronie's disease and Ledderhose disease by treating affected subjects with an activator of the collagenase production pathway. This may involve activating the conversion of plasminogen to plasmin to thereby effectively replace the role of the uPA with a functionally similar activator. Alternatively, it may involve treatment of the patient with an activator which acts more directly to produce, switch or otherwise activate one or more collagenase enzymes.

Suitably, the activator of the collagenase production pathway of the first aspect is an agent which, directly or indirectly, increases the production of collagenase and, more particularly, the conversion of pro-collagenase to collagenase. Any agent which can act upon a component of the collagen production pathway to bring about an increase in collagenase levels may be suitable. For example, the activator may increase the activation of plasminogen into plasmin, as described, or it may have a separate action on pro-collagenase to increase the rate of its conversion to collagenase. The activator also plays a role in cell migration and tissue remodeling. The activator may not only activate or promote the degradation of collagen but, just as importantly, restores the primitive, immature collagen and stroma tissue matrix to a pre-morbid state.

Preferably, the activator of the collagenase production pathway is a plasminogen activator such as, but not limited to, uPA, tPA, kallikrein, Factor XII and their functional and synthetic analogues. One or more of matrix metalloprotease 12 (MMP12) (as an important tissue remodelling protein), the stromelysins (MMP 3, 10, 11) and the gelatinases MMP 2, 9 may also play a role in this activation process. The activator may be isolated from a natural source or may be synthetic. Various co-factors as may be required to aid function of the activator or the targeted enzyme are also considered within the scope of the present invention.

In one preferred embodiment, the plasminogen activator is a serine protease. Preferably, the plasminogen activator is a serine protease which can activate plasminogen to plasmin. Isolated or synthetic urokinase (uPA), tPA and kallikrein are all suitable serine proteases.

Preferably, the plasminogen activator is a tissue plasminogen activator. More preferably, the plasminogen activator is a recombinant tissue plasminogen activator. One preferred example of such a recombinant tissue plasminogen activator (rt-PA) is alteplase which is available as a commercial formulation ‘Actilyse™’ from Boehringer Ingelheim for the treatment of ischaemic stroke. This is a version of naturally occurring tPA produced by recombinant biotechnology techniques which would be available and well known to a person of skill in the art.

The effective amount of the activator of the collagenase production pathway is administered locally to tissue demonstrating the fascial fibromatosis i.e. tissue affected by Dupuytren’s disease, Peyronie’s disease or Ledderhose disease. Preferably, the administration is by injection. The injection may be directly into the cord and/or into the surrounding tissues. Preferably, the subject is a human.

The effective amount of the activator of the collagenase pathway may vary slightly from patient to patient but an injection of 10-20mg of alteplase in 5mls of sterilised water (intralesional and subdermal injection)1 is a typical approach.

The treatment of Dupuytren’s disease with a plasminogen activator such as an rt-PA or a uPA analogue or substitute has been found to be a much safer approach than the direct injection of a bacterial collagenase enzyme, such as with Xiaflex™. The injection of collagenase directly into the tissue of the hands results in a situation where it is difficult to control the level of collagenase breakdown and thus leads to the observed side effects of ruptured tendons and ligaments. Thus, the activator of the collagenase production pathway, according to the present invention, is not a collagenase. The present use of a tissue remodeling enzyme / tissue plasminogen activator, or like analogues, such as alteplase, is a much more controlled approach which provides similar or improved benefits of contracture weakening while minimizing the side effects of damage to surrounding tendons and ligaments. Further, the remodeling properties of alteplase differentiates or separates the overlying disease affected skin from the underlying Dupuytren’s cord and allows easy ‘stripping’ of the · cord, if desirable subsequent to treatment. The use of recombinant analogues of endogenous plasminogen activator enzymes also avoids the potential allergic reactions which users of bacterial collagenase may experience. Further, it has been found that the present treatment brings about a general softening of the tissues surrounding the cord and so, if it is desirable to remove the cord by surgery, the surgical process of separation of the cord from the skin and surrounding fascia is greatly simplified.

The Examples section discusses the treatment of a number of subjects suffering from Dupuytren’s disease using alteplase as the activator of a collagenase production pathway, in accordance with an embodiment of the invention.

Briefly, the observable cord and/or the surrounding tissue is injected with an amount of the rt-PA (alteplase) in a suitable carrier, such as sterilized water. The procedure is a simple injection which can be carried out in a doctor’s surgery in a short period of time. The patient can then go home without any need for further splinting or breaking of the cord as is necessary with direct bacterial collagenase injection treatment. Many patients find that the contracture softens to such a degree that they do not actually need to have the cord removed at all thereby removing the need for surgery. A large degree of motion is returned to the patients fingers and often they can be fully extendable after the treatment has taken effect.

As indicated above, it has been found that the treatment softens the tissue surrounding the cords such that skin which was previously tightly adhered to the cord, causing noticeable dimples or puckering, is now relatively malleable resulting in improvement in the physical appearance of the skin. If the cord is at such an advanced stage that it is preferable to have it surgically removed, for functional and/or cosmetic reasons, then the present treatment has also demonstrated benefits in facilitating the ease of separation of the cords from surrounding tissue thereby simplifying surgery and reducing the risk of complications.

From the results achieved it is apparent that the present invention is efficacious in softening or reducing cords and other tissue fibrosis associated with Dupuytren's disease to restore a substantial degree of function to the patient's hand. In many cases a single injection treatment is sufficient to restore substantially complete functionality or a sufficient degree such that the patient’s quality of life is greatly improved. No tendon or ligament damage has been observed, no severe allergic reactions have presented and there is no need to painfully manually break the cord.

The present treatment may be repeated, if required, to provide further improvements in functionality and may be used as a stand alone treatment or in conjunction with subsequent surgery to facilitate the stripping out of the collagen cord(s) and/or nodules. The stripping of the cord is typically not necessary, following one or two rounds of the present treatment, to return substantially normal functionality to the affected tissue.

The reduced level is assessed by comparison to normal or nondiseased tissue in the same subject or to the same tissue froma different, healthy subject. The reduced level may be a substantially reduced level or may be seen as a substantial absence of the uPA.

Preferably, the fibromatosis is a fascial fibromatosis.

Although diagnosis of Dupuytren’s disease, Peyronie’s disease or Ledderhose disease in a subject typically focuses on palpation to identify characteristic nodules and/or cords as well as observing contracture, it may be useful to look for reduced levels of uPA as a biochemical marker. This may provide an early detection of fibromatosis when palpation exams are inconclusive. Alternatively, it may provide an indication of the particular suitability of that tissue to treatment by the present method i.e. the suitability of the fibrosed tissue to treatment with an activator of a collagenase production pathway. Techniques which may be used to detect levels of uPA in a tissue would be well known in the art and may include enzyme-linked immunosorbent assay (ELISA) techniques such as that described in the examples section.

In a third aspect, the invention resides in a kit when used to assess the need for treatment of palmar and/or plantar fascial fibromatosis in a subject with an activator of a collagenase production pathway, the kit comprising one or more reagents for detecting the level of urokinase-type plasminogen activator (uPA) in affected tissue, whereby a reduced level correlates with a positive need for such treatment.

The kit may comprise those diagnostic reagents such as have been considered suitable for use in the second aspect, such as commercially available ELISA kits for detecting uPA.

The activator may be as described for the first aspect.

The pharmaceutical composition may comprise a tissue plasminogen activator, recombinant or otherwise, such as those recited above and including but not limited to rt-PA (e.g. alteplase) and other isolated or synthetic analogues of tPA and/or uPA. When, in a preferred embodiment, the activator is alteplase, then it can be purchased as the Actilyse™ formulation being a powder containing alteplase, L-arginine, phosphoric acid and polysorbate 80 which can be made into a solution of an appropriate concentration in sterilised water. The use of about 1020mg of alteplase in 5 mis of water is a useful treatment level providing a mass concentration of 2-4 mg/mL: A concentration range of 0.1 to 20 mg/mL may be suitable, preferably 0.5 to 10 mg/mL, even more preferably 1 to 8 mg/mL.

The composition may further include a local anaesthetic, such as lignocaine, an amount of bicarbonate to balance the pH and hyaluronic acid. It will be appreciated that these additives may not affect the clinical outcome but rather ease the discomfort of the injection treatment for the patient.

The activator of the collagenase production pathway may be an isolated or synthetic activator.

Suitably, the activator of the collagenase production pathway is an agent which increases the conversion of pro-collagenase to collagenase.

Preferably, the activator of the collagenase production pathway is a plasminogen activator. In one embodiment, the plasminogen activator is a serine protease which can convert plasminogen to plasmin.

Suitably, the plasminogen activator is a recombinant tissue plasminogen activator.

Preferably, the recombinant tissue plasminogen activator is . alteplase.

In the following examples the treatment of a number of patients suffering from Dupuytren's disease (palmar fascial fibromatosis) will be discussed. To date 100 patients suffering from Dupuytren’s disease and 4 patients suffering from Ledderhose disease have been treated by the method of the invention using a recombinant tissue plasminogen activator. Specifically, the recombinant tissue plasminogen activator used is Alteplase as part of the commercially available formulation Actilyse™.

In general terms, at least 95% of the patient’s suffering from Dupuytren’s disease have reported satisfaction with the outcome after one or two rounds of treatment due to a greatly increased range of motion in the affected digits/regions. For those presenting with very pronounced cords or nodules then stripping out of the cord/nodule may be desirable for at least cosmetic reasons. In these cases the stripping procedure is also greatly simplified as a result of the treatment of the invention by comparison to surgery on a Dupuytren’s patient who has not had the present treatment. This is as a result of the softening of the tissue.

The outcome of the present treatment was even better for patients suffering from Ledderhose disease in that all patients reported complete satisfaction with the return to function of the affected tissue.

It will be appreciated that, due to the nature of the conditions treated involving changes of physical appearance of the skin over affected tissues and alterations in the range of motion of areas of the hands and/or feet, it is difficult to quantitatively define the outcome of treatment in a patient. Since the efficacy of treatment is best observed visually the results presented herein are shown in representations of photographs taken of the hands of Dupuytren’s patients both before and after treatment. For the sake of clarity of the changes wrought by treatment colour images of the photographs themselves are also provided to allow the reader to make a full assessment of the impact of the treatment.

EXAMPLES

Identification of uPA levels in Dupuvtren’s disease tissue A. Protein Analysis ' .

Abnormal fascial bands from eighteen patients with Dupuytren’s contracture were harvested. The cords were then carefully micro-dissected free from any other interstitial tissues from the palm, snap frozen in liquid nitrogen and stored at -70°C. Similarly, normal palmar fascia was taken from ten patients having routine open carpal tunnel release and treated in the same manner.

All tissues were later homogenised and the total protein extracted using 50nM Tris-HCI (pH 7.4) containing 1% Triton X-100 with 2mls per 100 mg of tissues. The cytosols were vortexed for 30 seconds and agitated for 20 minutes at 4°C followed by centrifugation at 13,000 g for 20 minutes at 4°C. The supernatant containing the protein was removed and the pellet stored. The total protein concentrations from the samples were determined using the enhanced method with BCA Protein Assay Reagent (Pierce, Rockford, lllinios, USA).

The concentration of uPA in the tissues was determined using the ELISA technique (American Diagnostica, Greenwich). The ELISA plate is coated with an antibody that binds to both free uPA or receptor bound uPA and has a sensitivity of detecting uPA at concentrations from 0.02 ng uPA/mg (American Diagnostica, Greenwich). B. cDNA Profiling (i) RNA extraction and purification of Dupuytren’s and normal palmar fascia: The Qiagen RNeasy kit mini system was used to extract high quality RNA suitable for microarray analysis. (ii) Reference RNA: RNA from Colo-16 SCC cell line labelled with Cy 5 and run on both arrays (Dupuytren’s tissue and normal palmar fascia) was employed as a normalising reference. (iii) c-DNA microarray technique: 4,800 genes chip with duplicate used. Cy 3 florescent dye was used for labelling in Dupuytren’s tissue and normal palmar fascia. (iv) Analysis of data: Imagene and GeneSpring software.

Results;

The results are summarised in Table 1. uPA was undetectable in all eighteen Dupuytren's fascia bands. The average value of uPA detected in the ten ‘normal’ palmar fascia was 14 rig uPA/mg protein and in normal palmar skin it was 200 ng uPA/mg protein.

The average values of the receptor uPAR and inhibitor (PAI-1) were low in Dupuytren’s tissues and elevated in rheumatoid tissues.

Table 1. uPA levels in Dupuytren’s and normal palmar tissues Treatment of Dupuytren’s disease using alteolase

Treatment 100 subjects suffering from Dupuytren's disease and 4 suffering from Ledderhose disease were treated with, initially, a single injection of 10-20 mg of alteplase dissolved in 5 mL of sterilised water. A local anaesthetic can be applied to the area of the skin to be injected to reduce discomfort for the patient.

The injection is placed either directly into the visible cord or partially into the cord and the remainder into the surrounding fascia. The patient is then free to go home without the need for splinting or isolation of the hand or affected fingers. The full effect of the treatment will be felt after a period of approximately 2 weeks.

At this point if the affected fingers are not fully extendable then a second injection may be necessary.

For many patients this treatment regime is sufficient to return a substantial range of motion to the affected fingers and no further treatment is necessary. In fact, the inventor has found that at least about 95% of Dupuytren’s patients and all of the Ledderhose patients have a satisfactory outcome such that surgery is not required. For those showing prominent cords or nodules or having a region of skin adhered to the underlying cord such that cosmetic appearance of the hand is negatively impacted it may be desirable to strip out the cord.

Results

Of the 100 Dupuytren's patients and 4 Ledderhose patients treated by the present method none have represented after a second round of treatment. FIGs 2A through to 5B show graphical reproductions of before and after photographs for four Dupuytren’s sufferers treated by the present method and indicate the benefits provided.

For the small number of patients for whom subsequent cord stripping was desirable, it was noted by the surgeon that the tissue adhered to the cord was greatly softened compared to untreated cases and so the procedure of cord removal was greatly assisted by treatment.

In the figures some of the more extreme cases presenting have been shown and so stripping of the cord was, in most cases, desirable for cosmetic and personal comfort reasons. FIGs 2A and 2B show a dramatic change from the pre-treatment (FIG 2A) to post-treatment (FIG 2B) state. Both of the hands of this patient were affected by Dupuytren’s disease and most of the fingers are permanently flexed. FIG 2B shows the patient after two rounds of injection followed by stripping of the large cord. It is clear that the fingers are now all close to being fully extended apart from the little finger. For the little finger the problem is that the flexion is at the proximal interphalangeal (PIP) joint and this is not due to a cord or collagen band but rather a different underlying issue within the joint itself. Thus surgery is also required to unlock the PIP joint (focusing on the volar plate) and no existing non-surgical treatment exists for this problem. The result achieved in FIG 2B thus represents an excellent clinical outcome.

In FIG 3A the cord extending to the patients little finger is highly visible and has brought about a pronounced flexion. The treatment involved a single round of injection with alteplase, as described above, followed by surgical stripping of the cord. FIG 3B shows the same hand after treatment and the improvement in the range of extension of the little finger is clear. The cord is still partially visible but the present treatment has softened or broken it down to such an extent that a near normal range of motion has been achieved. It is likely a further treatment round would diminish the cord even further.

The contracture of another patient’s right hand is shown in FIG 4A. Flexion of the ring finger is particularly prominent. FIG 4B shows the same hand after treatment involving 2 rounds of injection with alteplase, as described, followed by stripping of the cord and the return to normal motion of the fingers is shown. The patient also displayed nodules on his thumb, prior to treatment, which have reduced significantly in size to the point of barely being visible in FIG 4B thereby obviating the need for surgical intervention in this area.

Treatment of the patient whose hands are shown in FIG 5A was potentially complicated as this patient is also a diabetic. Surgery can be high risk for diabetic Dupuytren’s sufferers as the risk of post-operative complications is greater. The patient is a musician and so fine control of the fingers is crucial. The patient was treated with a single injection according to the method of the invention and no surgical stripping of the cord was considered necessary. FIG 5B shows the considerable improvement in finger function/range of motion following only this single injection.

Thus, 100 patients with palmar fascial fibromatosis (Dupuytren's disease) and 4 with plantar fascial fibromatosis (Ledderhose disease) have been successfully treated using injections of a collagenase production pathway activator, specifically alteplase, into the cords and/or immediately surrounding tissue. uPA has been demonstrated to be a powerful proteolytic enzyme in 're- organising' the tissue plane between the palmar cutaneous skin and the underlying Dupuytren's disease cords. The absence of uPA is postulated to be responsible for, or at least a contributing factor to, Dupuytren’s disease, Peyronie’s disease and Ledderhose disease. Administration of a synthetic plasminogen activator, rt-PA, has been demonstrated to be a safe and effective treatment to re-establish the natural plane between the fibroses skin and the underlying cords.

Throughout the specification the aim has been to describe preferred embodiments of the invention without limiting the invention to any one embodiment or specific collection of features. It will be appreciated by those of skill in the art that, in light of the present disclosure, various modifications and changes can be made in the particular embodiments exemplified without departing from the scope of the invention.

Throughout this specification, unless the context requires otherwise, the word "comprise" or variations such as "comprises" or "comprising", will be understood to imply "the inclusion of a stated element or integer or method step or group of elements or integers or method steps but not the exclusion of any element or integer or method step or group of elements or integers or method steps.

The reference in this specification to any prior publication (or information derived: from it), or to any matter which is known, is not, and should not be taken as an acknowledgement or admission Or any form of suggestion that the prior publication (or information derived from, it) or known matter forms part of the common general knowledge in the field of endeavour to which this specification relates.

Claims

CLAIMS:

1. A method of treating palmar and/or plantar fascial fibromatosis in a subject, including the step of administering to the subject an effective amount of an activator of a collagenase production pathway selected from the list consisting of tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA), to thereby treat the palmar and/or plantar fascial fibromatosis.
2. The method of Claim 1 wherein the tPA or uPA is recombinant tPA or recombinant uPA.
3. The method of Claim 2 wherein the recombinant tPA is alteplase.
4. The method of Claim 1 or 2 or 3 wherein the effective amount of the tPA or uPA is administered locally to tissue affected by the palmar and/or plantar fascial fibromatosis.
5. The method of Claim 4 wherein the administration is by injection.
6. The method of any one of the preceding claims wherein the subject is a human.
7. The method of Claim 6 wherein the fascial fibromatosis is Dupuytren's disease, Peyronie's disease or Ledderhose disease.
8. A method of assessing the need for treatment of fibromatosis in a subject with an activator of a collagenase production pathway selected from the list consisting of tPA and uPA including the steps of: (a) detecting the level of uPA in the fibromatosed tissue; (b) detecting the level of uPA in normal tissue; and (c) comparing the level of uPA detected in step (a) with that detected in step (b), whereby a reduced level in the fibromatosed tissue correlates with a positive diagnosis, to thereby assess the need for treatment by tPA or uPA.
9. A kit when used to assess the need for treatment of palmar and/or plantar fascial fibromatosis in a subject with an activator of a collagenase production pathway, the kit comprising one or more reagents for detecting the level of uPA in affected tissue, whereby a reduced level in comparison to that found in normal tissue correlates with a positive need for such treatment by tPA or uPA.
10. A pharmaceutical composition when used for the treatment of palmar and/or plantar fascial fibromatosis comprising an effective amount of tPA or uPA, or a pharmaceutical acceptable salt thereof, and a pharmaceutical acceptable carrier and/or diluent and/or excipient.
11. The composition of Claim 10 comprising water as a diluent.
12. The composition of Claim 10 or 11 further comprising an agent selected from the group consisting of a local anaesthetic agent, a pH adjustment agent and hyaluronic acid.
13. Use of tPA or uPA, or a pharmaceutical acceptable salt thereof, in the manufacture of a medicament for the treatment of palmar and/or plantar fascial fibromatosis.
14. A method according to any one of Claims 1 to 8 or a kit according to Claim 9 or a pharmaceutical composition according to any one of Claims 10 to 12 or a use of Claim 13 substantially as herein described with reference to the Figures and/or Examples.