La curiethérapie interstitielle périoperatoire dans le traitement des cicatrices chéloïdes récidivantes

Efficacy of Surgical Excision and Brachytherapy in the Treatment of Keloids: A Retrospective Cohort Study

OBJECTIVE

To demonstrate the efficacy of a protocol combining surgical excision and high-dose-rate brachytherapy for treatment of keloids.

METHODS

The authors performed a unicentric retrospective cohort study between 2013 and 2018. The minimum follow-up was 12 months. All patients treated for keloids at the authors' institution were included. Extralesional excision was performed with placement of a brachytherapy sheath under the skin. The total dose of irradiation was 18 Gy. The postoperative results were evaluated for aesthetic and functional outcomes with a validated scale, as well as the presence or absence of recurrence.

RESULTS

Fifteen patients were lost to follow-up. Thirty-eight patients with 67 keloids were included. The control rate was 94%. The aesthetic and functional outcomes were considered good in 62% of cases. The main limitation of the study was the small patient population.

CONCLUSIONS

Extralesional excision combined with postoperative high-dose-rate brachytherapy seems to be one of the most effective invasive protocols to treat and prevent keloids.

A new therapeutic protocol for the treatment of keloid scars: a retrospective study

OBJECTIVE

There are few means to treat large keloid scars, as exeresis-even if partial-impedes direct closure without tension in the absence of a flap or a skin graft. This study evaluates the efficacy, indications for use and limitations of a new therapeutic protocol, combining an extralesional keloid excision left to heal by secondary intention with a paraffin dressing and glucocorticoid ointment, followed by monthly intrascar injections of corticosteroids upon full re-epithelialisation.

METHOD

A retrospective study of patients treated for keloid scars by using the new therapeutic protocol. Scars were categorised as either healed or recurring. Their recurrence was scored according to the changes in functional signs and the scar volume.

RESULTS

A total of 36 scars were studied. The mean follow-up was 14.1 months. Healing occurred in a mean of 6.8 weeks. The mean surface area was 21.6cm². Healing rate was 30.5%. Scar volume was improved in 60% of recurrent cases and functional signs in 56%. Based on adherence with the corticotherapy, two patient groups could be discerned. For patients in the 'adherent' group, the healing rate was 40%, and scar volume was improved in 75% of recurrent cases and the functional signs in 83% of cases.

CONCLUSIONS

The healing rate in this study was close to that reported in the literature. Excision-healing by secondary intention could therefore be offered to patients for whom adherence is uncertain. The protocol in this study offers a straightforward, fast, accessible solution that does not appear to entail any risk of additional keloids. It could potentially offer a treatment option in case of failure of other treatments, large keloid scars or scalp keloids.

Adjuvance in refractory keloids using electron beams with a spoiler: Recent results

AIM

To present clinical results of adjuvant irradiation of excised refractory keloid wounds using a novel bolus-free technique developed within our group to irradiate the skin surface with a linear accelerator.

BACKGROUND

The use of a bolus to increase surface dose over a newly excised keloid presents several problems. Previous solutions are unsatisfactory. Our technique is promising but needs to be evaluated in practice.

MATERIALS AND METHODS

Twenty refractory skin keloids in 19 patients were excised and irradiated in Hospital Plató (Barcelona, Spain) using a 6 MeV electron beam with a 4-mm aluminium spoiler. 15 Gy in fractions of 3 Gy were delivered to the excision site plus a safety margin. All patients were examined during the follow-up (median: 40 months, interval: 12-68 months) and toxicities were recovered.

RESULTS

At the end of the follow-up period, 76% of the cases had not recurred, while the complete response rate amounted to 53%. Residual hypertrophic scars were classified as partial responses. After therapy, itching and pain were observed in 30% of the patients, as well as one telangiectasia and two hyperchromatic scars.

CONCLUSION

Our technique avoids using a bolus while combining the benefits of electron beam therapy in keloids (fewer secondary effects, and fewer and shorter treatments) with a dose deposition adequate for skin surface treatments. Our results are in line with the most successful therapies evaluated in the literature, as secondary effects are acceptable and recurrence rates are low.

[Adjuvant treatment of keloid scars: electrons or brachytherapy?]

PURPOSE

Evaluation of perioperative treatment of keloid scars with electron beam therapy or iridium 192 low dose rate brachytherapy.

PATIENTS AND METHODS

From 1994 to 2010, 95 patients with 142 keloid scars have been treated by immediate perioperative irradiation and retrospectively reviewed in our institute: 116 scars were treated by electrontherapy and 26 by brachytherapy.

RESULTS

In the electrontherapy group treated locations were: earlobe (n=88, 76%), thorax (n=14, 12%), neck (n=9, 8%), limbs (n=5, 4%). The median size of lesions was 3cm (range [R]: 0.5-18cm). In 95.6% of cases, a dose of 15Gy was delivered in five fractions of 3Gy. The median follow-up was 70 months (R: 7-161 months). The 2-year and 5-year local control were respectively 69% (95% confidence interval [95% CI]: 59-76%) and 55% (95% CI: 45-64%). In the brachytherapy group treated locations were: neck (n=3, 11%), earlobe (n=8, 32%), abdomen (n=3, 11%), thorax (n=2, 8%), limbs (n=10, 38%). The median size of lesions was 6.6cm (R: 1.7-28cm). The median dose delivered at 5mm from the source was 20Gy (R: 15-20.69). The median follow-up was 113 months (R: 21-219 months). The 2-year and 5-year local control were respectively 84.6% (95% CI: 64-94%) and 73.5% (95% CI: 49-87%). So far, no radiation-induced cancer has occurred. A trend to a better local control with brachytherapy was noted (compared to electrontherapy, 2-year relapse is halved with brachytherapy) though this difference did not reach the significance (P=0.0991), probably due to the reduced number of patients in the brachytherapy group.

CONCLUSION

Brachytherapy seems to provide better local control compared to electrontherapy, and should be proposed as first line treatment. However, electrontherapy is an interesting alternative in case of difficulty to realize brachytherapy. There is probably a dose effect: according to published data, 25 to 30Gy should at least be proposed.