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

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.

Adjuvant Radiotherapy after Surgical Excision in Keloids

Keloids are a benign fibroproliferative disease with a high tendency of recurrence. Keloids cause functional impairment, disfigurement, pruritus, and low quality of life. Many therapeutic options have been used for keloids. However, the high recurrence rates have led to the use of adjuvant therapy after surgical keloid excision. There are different radiotherapy regimens available, and the advantages and disadvantages of each are still unclear. The aim of this review is to explain the appropriate radiotherapy regimen for keloids as well as discuss the recent reports on keloid management with radiotherapy. Adjuvant radiotherapy after surgical excision for keloids yields excellent local control with tolerable side effects. Hypofractionated radiotherapy with a BED of more than 28 Gy (α/β value of 10) after excision is recommended in the light of its biologic background.

The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective.

OBJECTIVE

To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy).

MATERIALS AND METHODS

Systematic literature review and meta-analysis of combination treatment for keloids.

RESULTS

After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099).

CONCLUSION

Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Single Institution Experience of Postoperative Electron Beam Radiation Therapy in the Treatment of Keloids

Purpose

Surgical excision followed by postoperative radiation therapy is an accepted modality to prevent keloid recurrence. Our practice has been to use electron beam radiation postoperatively to prevent recurrence, and we share our experience with this method in this study.

Methods and Materials

Twenty-two patients with 40 keloids treated postoperatively with electron beam radiation at our institution from 2014 to 2019 were analyzed retrospectively. Electron beam radiation was used for treatment in all cases, and radiation was initiated within 24 hours of surgery. A dose of 20 Gy in 5 fractions was delivered to the postoperative scar in 95% of the sites, and 8 Gy to 10 Gy in a single fraction was delivered to the remaining 5%. The patients were followed up, and recurrences were documented.

Results

At a mean follow-up of 35 months (range, 7-66 months), local control and cosmesis were achieved in 90% (36 of 40) of the treated sites with electron beam radiation therapy delivered at a dose of 20 Gy in 5 fractions. All recurrent keloids were located on the anterior chest wall over the sternum. There was no difference in outcome based on age, sex, or keloid length.

Conclusions

Electron beam radiation therapy is a feasible, convenient, and safe modality for postoperative treatment of keloids. It achieves excellent local control with no grade 3 or higher toxicities.

Lasers and ancillary treatments for scar management Part 2: Keloid, hypertrophic, pigmented and acne scars

The formation of a wide range of excessive scars following various skin injuries is a natural consequence of healing. Scars resulting from surgery or trauma affect approximately 100 million people per annum in the developed world and can have profound physical, aesthetic, psychological and social consequences. Thus, scar treatment is a priority for patient and physician alike. Laser treatment plays an important role in scar management with additional support from ancillary modalities. Subsequent to part 1: Burns scars, part 2 focuses on our strategies and literature review of treatment of keloid, hypertrophic, pigmented and acne scars where lasers are used in conjunction with other measures, and illustrated with case studies.

Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis

BACKGROUND

Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities.

OBJECTIVES

We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy.

METHODS

One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05.

RESULTS

Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01).

CONCLUSIONS

Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.

[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.

Up-to-date approach to manage keloids and hypertrophic scars: a useful guide

Keloids and hypertrophic scars occur anywhere from 30 to 90% of patients, and are characterized by pathologically excessive dermal fibrosis and aberrant wound healing. Both entities have different clinical and histochemical characteristics, and unfortunately still represent a great challenge for clinicians due to lack of efficacious treatments. Current advances in molecular biology and genetics reveal new preventive and therapeutical options which represent a hope to manage this highly prevalent, chronic and disabling problem, with long-term beneficial outcomes and improvement of quality of life. While we wait for these translational clinical products to be marketed, however, it is imperative to know the basics of the currently existing wide array of strategies to deal with excessive scars: from the classical corticotherapy, to the most recent botulinum toxin and lasers. The main aim of this review paper is to offer a useful up-to-date guideline to prevent and treat keloids and hypertrophic scars.