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Fernandes J, Liao D, Dasgupta A, Tsao MN, Barnes EA. A Single-Institution Review of the Use of Radiation in the Adjuvant and Definitive Management of Keloids. Clin Oncol (R Coll Radiol) 2024; 36:e163-e167. [PMID: 38582626 DOI: 10.1016/j.clon.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/31/2024] [Accepted: 03/12/2024] [Indexed: 04/08/2024]
Abstract
AIMS Many individuals suffer from keloids that are refractory to standard treatment modalities, including surgical excision alone. Radiation therapy can be used to reduce the risk of recurrent keloids post-operatively, as well as be used as primary treatment for keloids not amenable to surgical resection. The purpose of this study was to review our institutional experience of radiation therapy for keloid management. MATERIALS AND METHODS A retrospective review of patients treated with radiation therapy for keloids between 2014 and 2020 at our institution was performed. RESULTS A total of 70 keloids in 41 patients were treated. For the 55 keloids treated with post-operative radiation therapy (16Gy delivered in 2 fractions), 82.5% (33/40) of evaluable lesions did not recur. Among the 15 keloids treated with definitive radiation therapy (24Gy delivered in 3 fractions), 78.6% (11/14) of evaluable keloids showed complete flattening, and 14.3% (2/14) had partial flattening. Both acute and late toxicities were mild, with only a single instance of grade 3 toxicity (dermatitis). CONCLUSION Our study confirms that radiation therapy has a role in reducing the risk of keloid recurrence post-operatively, and plays an important role in the definitive management of unresectable keloids.
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Affiliation(s)
- J Fernandes
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - D Liao
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - A Dasgupta
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M N Tsao
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - E A Barnes
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada.
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Chen J, Mo Y, Chen Y, Ma Z, Shen S, Sang H, Tan Q, Mo R. Application and effect of tension-reducing suture in surgical treatment of hypertrophic scar. BMC Surg 2024; 24:119. [PMID: 38654240 PMCID: PMC11036683 DOI: 10.1186/s12893-024-02390-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 03/16/2024] [Indexed: 04/25/2024] Open
Abstract
PURPOSE To investigate the application and effectiveness of tension-reducing suture in the repair of hypertrophic scars. METHODS A retrospective analysis of clinical data was conducted on 82 patients with hypertrophic scars treated at the Department of Burns and Plastic Surgery of Nanjing Drum Tower Hospital from September 2021 to December 2022. Patients were operated with combination of heart-shaped tension-reducing suturing technique and looped, broad, and deep buried (LBD) suturing technique or conventional suture method. Outcomes of surgical treatment were assessed before and 6 months after surgery using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS). RESULTS Improvements were achieved on scar quality compared to that preoperatively, with a reduction in scar width (1.7 ± 0.6 cm vs. 0.7 ± 0.2 cm, P < 0.001). Assessment using the POSAS and VSS scales showed significant improvements in each single parameter and total score compared to preoperative values (P < 0.05). The Combination method group achieved better score in total score of VSS scale, in color, stiffness, thickness and overall opinion of PSAS scale, and in vascularity, thickness, pliability and overall opinion of OSAS scale. CONCLUSION The amalgamation of the heart-shaped tension-reducing suturing technique and the LBD suturing technique has shown promising outcomes, garnering notably high levels of patient satisfaction in the context of hypertrophic scar repair. Patients have exhibited favorable postoperative recoveries, underscoring the clinical merit and the prospective broader applicability of this approach in the realm of hypertrophic scar management.
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Affiliation(s)
- Jingjing Chen
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China
| | - Yan Mo
- Department of Dermatology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China
- Department of Dermatology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yadan Chen
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, NO. 321, Zhongshan Road, Nanjing, Jiangsu, China
| | - Zhouji Ma
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, NO. 321, Zhongshan Road, Nanjing, Jiangsu, China
| | - Siyun Shen
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China
| | - Hong Sang
- Department of Dermatology, Nanjing Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
| | - Qian Tan
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China.
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, NO. 321, Zhongshan Road, Nanjing, Jiangsu, China.
| | - Ran Mo
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, NO. 321, Zhongshan Road, Nanjing, China.
- Department of Burns & Plastic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, NO. 321, Zhongshan Road, Nanjing, Jiangsu, China.
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Franzetti J, Durante S, Mastroleo F, Volpe S, De Lorenzi F, Rotondi M, Lorubbio C, Vitullo A, Frassoni S, Bagnardi V, Cambria R, Cattani F, Vavassori A, Jereczek-Fossa BA. Post-operative KEloids iRradiation (POKER): does the surgery/high-dose interventional radiotherapy association make a winning hand? LA RADIOLOGIA MEDICA 2024; 129:328-334. [PMID: 38280971 PMCID: PMC10879234 DOI: 10.1007/s11547-024-01756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
PURPOSE To report the results involving post-operative interventional radiotherapy (POIRT) in a homogenous cohort of patients affected by keloid and treated at a single institution with the same fractionation schedule. PATIENTS AND METHODS Inclusion criteria were: surgery with a histopathological diagnosis of keloid, subsequent high-dose rate interventional radiotherapy (HDR-IRT)-12 Gy in 4 fractions (3 Gy/fr) twice a day-and follow-up period ≥ 24 months. RESULTS One-hundred and two patients and a total of 135 keloids were eligible for the analyses. Median follow-up was 64 [IQR: 25-103] months. Thirty-six (26.7%) recurrences were observed, 12-months and 36-months cumulative incidence of recurrence were 20.7% (95% CI 12.2-28.5) and 23.8% (95% CI 14.9-31.7) respectively. History of spontaneous keloids (HR = 7.00, 95% CI 2.79-17.6, p < 0.001), spontaneous cheloid as keloid cause (HR = 6.97, 95% CI 2.05-23.7, p = 0.002) and sternal (HR = 10.6, 95% CI 3.08-36.8, p < 0.001), ear (HR = 6.03, 95% CI 1.71-21.3, p = 0.005) or limb (HR = 18.8, 95% CI 5.14-68.7, p < 0.001) keloid sites were significantly associated to a higher risk of recurrence. CONCLUSIONS The findings support the use of surgery and POIRT as an effective strategy for controlling keloid relapses. Further studies should focus on determining the optimal Biologically Effective Dose and on establishing a scoring system for patient selection.
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Affiliation(s)
- Jessica Franzetti
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Stefano Durante
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Federico Mastroleo
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy.
- Department of Translational Medicine, University of Piemonte Orientale (UPO), 28100, Novara, Italy.
| | - Stefania Volpe
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Francesca De Lorenzi
- Department of Plastic and Reconstructive Surgery, European Institute of Oncology, IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Marco Rotondi
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Chiara Lorubbio
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Angelo Vitullo
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Raffaella Cambria
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, European Institute of Oncology IRCCS, Milan, Italy
| | - Andrea Vavassori
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO European Institute of Oncology IRCCS, Via Ripamonti, 435, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
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Liu C. Risk factors for recurrence after keloid surgery with electron radiotherapy. Medicine (Baltimore) 2023; 102:e35683. [PMID: 37904431 PMCID: PMC10615486 DOI: 10.1097/md.0000000000035683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/26/2023] [Indexed: 11/01/2023] Open
Abstract
The aim of this study was to investigate the effect of postoperative electron radiotherapy (RT) on local control for keloids and to identify risk factors for recurrence. The clinical data of 82 patients treated at our institution from January 2015 to October 2019 were collected. The data included the general condition of the patients, clinical characteristics of the keloids, treatment plan, local control, and treatment side effects. A total of 82 patients (129 keloids) were included. The study included 23 men (28%) and 59 females (72%). The median patient age was 32 years (range, 18-67 years). Twenty-six recurrences were observed, and the 1-, 3-, and 5-year local control rates were 93%, 81%, and 73%, respectively. Univariate analysis revealed that age (P = .03), hypertension (P = .04), scar shape (P < .001), primary site (P = .02), maximum lesion diameter (P < .001), pain and itching (P = .005), local tension (P = .005), and infection (P < .001) were risk factors for local recurrence. Multivariable analysis revealed that maximum lesion diameter (P < .001), infection (P < .001), interval between surgery and RT (P = .02), and previous treatment (P = .02) were independent risk factors. Complete excision of keloids combined with electron RT is safe and seemingly effective. For keloids with a high risk of recurrence, more aggressive treatment should be chosen, and further prospective studies are needed to explore the optimal treatment.
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Affiliation(s)
- Chunlei Liu
- Chifeng Municipal Hospital, Chifeng Clinical Medical School of Inner Mongolia Medical University, Chifeng, China
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Laspro M, Onuh OC, Cohen RF, Cooper BT, Chiu ES. The Role of Radiation Therapy in Adult and Pediatric Keloid Management: A National Survey of Radiation Oncologists. Ann Plast Surg 2023; 91:215-219. [PMID: 37489962 DOI: 10.1097/sap.0000000000003609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Radiation therapy is a promising modality for treating keloids after surgical excision. However, it is currently not standard practice among physicians because of concern surrounding the risk of radiation-induced secondary cancers, especially among pediatric patients. There is minimal research assessing the complications for radiation therapy in keloid management. AIM The goal of this study was to determine radiation oncologists' perspectives about the utility and appropriateness of radiation therapy for keloid management in both adult and pediatric patients. This study also aimed to characterize radiation modality, dose, fractionation, and secondary complications observed by providers. METHODS An electronic survey was delivered to 3102 members of the American Society for Radiation Oncology. The survey subjects were radiation oncologists who are currently practicing in the United States. Rates of responses were analyzed. RESULTS A total of 114 responses from practicing radiation oncologists were received. Of these, 113 providers (99.1%) supported radiation therapy for keloid management in adults, whereas only 54.9% supported radiation therapy for pediatric patients. Of 101 providers that treated adults in the past year, the majority used external beam: electrons (84.2%), applied 3 fraction regimens (54.4%), and delivered radiation within 24 hours postexcision (45.5%). In pediatric patients, only 42 providers reported treating at least 1 patient. The majority used electron beam radiation (76.2%), applied 3 faction regimens (65%), and delivered radiation on the same day of keloid excision (50.0%) The main concern when treating pediatric patients were risk of secondary malignancy (92.1%). CONCLUSION Although radiation therapy appears to be a widely accepted adjuvant treatment option for adults with keloids, the use of radiation therapy for pediatric patients is less widely accepted because of concerns regarding secondary malignancy. The findings suggest additional studies need to be carried out to assess the risk of those complications.
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Affiliation(s)
- Matteo Laspro
- From the Hansjörg Wyss Department of Plastic Surgery
| | | | - Richard F Cohen
- Department of Radiation Oncology, New York University, Langone Health, New York, NY
| | - Benjamin T Cooper
- Department of Radiation Oncology, New York University, Langone Health, New York, NY
| | - Ernest S Chiu
- From the Hansjörg Wyss Department of Plastic Surgery
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Razmjoo S, Shahbazian H, Hosseini SM, Feli M, Mohammadian F, Bagheri A. Therapeutic and prophylactic effects of radiation therapy in the management of recurrent granulation tissue induced tracheal stenosis: a review on the role of Endobronchial brachytherapy and external beam radiation therapy. Brachytherapy 2023; 22:389-399. [PMID: 36922243 DOI: 10.1016/j.brachy.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/09/2023] [Accepted: 01/15/2023] [Indexed: 03/15/2023]
Abstract
PURPOSE Granulation tissue-induced tracheal stenosis (mainly secondary to intubation or lung transplantation) is one of the most common etiologies of benign airway obstructions. Recurrence rates after standard treatment options (surgical resection and/or endobronchial interventions) can inadvertently worsen the stricture through the stimulation of more granulation tissue generation (via increased fibroblast activity and roliferation). Low-dose radiotherapy could be a promising tool to prevent granulation tissue formation after surgery and/or endobronchial interventions regarding its established role in the treatment of keloids or hypertrophic scars, two benign diseases with similar a pathophysiology to tracheal stenosis. This study reviews case reports and small series that used endobronchial brachytherapy (EBBT) or external beam radiotherapy (EBRT) for the management of refractory granulation tissue-induced tracheal stenosis after surgery and/or endobronchial interventions. METHODS AND MATERIALS Case reports and series (published up to October 2022) that reported outcomes of patients with recurrent granulation tissue-induced tracheal stenosis (after surgery and/or endobronchial interventions) treated by EBBT or EBRT (in definitive or prophylactic settings) were eligible. RESULTS Sixteen studies (EBBT: nine studies including 69 patients, EBRT: seven studies including 32 patients) were reviewed. The pooled success rate across all studies was 74% and 97% for EBBT and EBRT, respectively. CONCLUSIONS Radiation therapy appears to be effective in the management of selected patients with recurrent/refractory tracheal stenosis. Response to this treatment is usually good, but further studies with a larger number of patients and long-term followup are necessary to determine the optimal technique, dose, and timing of radiation therapy, late complications, the durability of response, and criteria for patient selection.
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Affiliation(s)
- Sasan Razmjoo
- Department of Clinical Oncology and Clinical Research Development Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hodjatollah Shahbazian
- Department of Clinical Oncology and Clinical Research Development Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Seyed-Mohammad Hosseini
- Department of Clinical Oncology and Clinical Research Development Center, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maryam Feli
- Interventional Radiotherapy Ward, Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Fatemeh Mohammadian
- Interventional Radiotherapy Ward, Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ali Bagheri
- Interventional Radiotherapy Ward, Department of Radiation Oncology, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Sakai Y, Monzen H, Tamura M, Nakamura K, Nishimura Y. Double enhancement effect of a surface dose with tungsten rubber bolus in photon radiotherapy for keloids and superficial tumors. Phys Eng Sci Med 2023; 46:179-184. [PMID: 36484890 DOI: 10.1007/s13246-022-01208-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022]
Abstract
To clarify the dosimetric characteristics of a real-time variable shape rubber-containing tungsten (STR) bolus in a clinical plan and investigate the efficacy of the STR bolus in photon radiotherapy for keloids and other superficial tumors. A 5 mm gel bolus or 1 mm STR bolus was placed on a solid water phantom. Tangential irradiation was performed using a TomoTherapy Radixact-X9 and 6 MV X-ray flattening-filter-free beam, and the surface dose was measured with radiochromic film. Clinical-like plans (TomoDirect; TD and TomoHelical; TH) were applied with the same geometry and the dose distributions were measured. The increase in surface dose by the build-up effect and backscatter was 37.7% and 8.0% for the gel bolus, and 40.5% and 26.4% for the STR bolus, respectively. In the TD and TH plans, the increase in surface dose was 27.4% and 48.3% for the gel bolus, and 39.0% and 63.2% for the STR bolus. Similary, changes in the sagittal plane dose were - 3.9% and 6.1% for the gel bolus, and - 6.3% and 6.9% for the STR bolus. The STR bolus effectively increased the surface dose by the build-up effect and backscatter in photon radiotherapy for keloids and other superficial tumors.
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Affiliation(s)
- Yusuke Sakai
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
- Department of Radiotherapy, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Hajime Monzen
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan.
| | - Mikoto Tamura
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
| | - Kenji Nakamura
- Department of Medical Physics, Graduate School of Medical Sciences, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
- Department of Radiotherapy, Takarazuka City Hospital, 4-5-1 Kohama, Takarazuka, Hyogo, 665-0827, Japan
| | - Yasumasa Nishimura
- Department of Radiation Oncology, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan
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Siavashpour Z, Houshyari M, Dadkhahfar S, Jafari A. Top cited publications for treatment of keloid with radiotherapy: A Bibliometric analysis. J Cancer Res Ther 2023; 19:S472-S476. [PMID: 38384007 DOI: 10.4103/jcrt.jcrt_1235_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/13/2022] [Indexed: 02/23/2024]
Abstract
ABSTRACTS The use of radiation to treat keloid scars has gained popularity during the last few decades. However, few bibliometric analyses have been performed on the published articles. This research aimed to demonstrate and evaluate the trends, top-cited articles, and frontier areas. In this cross-sectional study, Web of Science (WOS) and Scopus database literature was searched for all MESH terms related to "keloid" and "radiotherapy." The bibliometric analysis was carried out by VOSviewer 1.6.15. Articles with Web of Science-based citations of ≥20 were included. The citation per year index (CPYI) of articles was calculated for further inclusion of papers if they had CPYI higher than the mean value. There were 95 papers on keloid radiation that satisfied the inclusion criteria and were published between 1942 and 2019. The CPYI ranged from 0.38 to 11.3. Most studies were published in the "International Journal of Radiation Oncology, Biology, and Physics" (9 papers). The United States has the most papers (14), followed by Japan (9), the Netherlands (7), and Germany (5). To the best of our knowledge, this is the first bibliometric analysis of top-cited papers on keloid radiotherapy. From 2014 to the present, it seems that this title has resurfaced as a popular topic, with radiotherapy within 24 h of surgery being the most commonly recommended treatment plan. Since around 2011, high-dose-rate brachytherapy (HDR-BT) has been used as an effective treatment for keloid control. Individualization of therapy and dose/technique based on the location is strongly suggested.
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Affiliation(s)
- Zahra Siavashpour
- Department of Radiation Oncology, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Mohammad Houshyari
- Department of Radiation Oncology, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Sahar Dadkhahfar
- Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Anya Jafari
- Department of Radiation Oncology, Shahid Beheshti University of Medical Science, Tehran, Iran
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Chen F, Kuo YR, Huang CJ, Tang JY, Chiang CH, Huang MY. Lesion Site Is the Key Prognostic Factor for Keloid Patients Receiving Surgery With Adjuvant Radiotherapy. Ann Plast Surg 2022; 89:626-630. [PMID: 36416688 PMCID: PMC9704806 DOI: 10.1097/sap.0000000000003315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/10/2022] [Accepted: 09/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Keloid is a benign tumor with high recurrence rate; accordingly, complete surgical excision with adjuvant radiotherapy is one of the most effective treatments. This study reviewed outcomes of keloid patients receiving surgery and adjuvant radiotherapy in Kaohsiung Medical University Hospital. MATERIALS AND METHODS All patients received radiation dose with 15 Gy, with their first radiotherapy within 24 hours after surgical excision. The end points were recurrence rate and local recurrence-free interval (LRFI), defined clinically as palpable gross tumor over the treatment site and duration from the last day of radiotherapy to disease recurrence. RESULTS From May 2017 to July 2020, 32 patients with 40 keloid lesions were included. The mean age for these patients was 37.6 years, and the median follow-up time was 15.3 months. The overall recurrence rate was 52.5%, and the median LRFI was 9.7 months. Recurrence rates for males and females were 46.7% and 56% ( P = 0.567), respectively; for head and ear, chest, shoulder and upper extremities, and abdomen and back were 12.5%, 61.5%, 63.6%, and 62.5% ( P = 0.093); for lesions over 20 cm 2 and below 20 cm 2 were 62.5% and 50% ( P = 0.527); and for megavoltage electron beam and kilovoltage photon beam were 56.7% and 40% ( P = 0.361), respectively. Patients were further classified into 2 groups by lesion sites, which showed lower recurrence rate ( P = 0.011) and longer LRFI ( P = 0.028) with lesions over the head and ear than other sites. CONCLUSIONS We found that lesion site might be a prognostic factor for keloid recurrence. Adjuvant radiation dose escalation for high-recurrence risk areas (other than the head and ear) might be required.
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Affiliation(s)
- Frank Chen
- From the Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University
| | - Yur-Ren Kuo
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University
- Division of Plastic Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Jen Huang
- From the Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
| | - Jen-Yang Tang
- From the Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
| | - Chen-Han Chiang
- From the Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
| | - Ming-Yii Huang
- From the Department of Radiation Oncology, Kaohsiung Medical University Hospital, Kaohsiung Medical University
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University
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Wang W, Zhao J, Zhang C, Zhang W, Jin M, Shao Y. Current advances in the selection of adjuvant radiotherapy regimens for keloid. Front Med (Lausanne) 2022; 9:1043840. [DOI: 10.3389/fmed.2022.1043840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
Keloid is a common benign skin tumor in the outpatient department, and patients are often accompanied by itching and pain. Since the pathogenesis is unknown, the effect of single method treatment is unsatisfactory, and therefore the recurrence rate is high. Therefore, comprehensive treatment is mostly used in clinical treatment. Adjuvant radiotherapy is currently one of the most effective treatments for keloid. After long-term clinical practice, brachytherapy and electron beam radiotherapy has increasingly become the gold standard of treatment, because brachytherapy provides more focused radiation treatment to focal tissue to significantly reduce recurrence rate, and better preserve normal tissue. With the development of new radiotherapy techniques, more options for the treatment of keloid. Currently, adjuvant radiotherapy has been widely recognized, but there is no consensus on the optimal protocol for adjuvant radiotherapy for keloids. This review provides a review of published treatment options and new radiotherapy techniques for adjuvant radiotherapy of keloids and gives a comprehensive evaluation for clinical treatment.
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Gao Y, Hou X, Dai Y, Yang T, Chen K. Radiation-induced FAP + fibroblasts are involved in keloid recurrence after radiotherapy. Front Cell Dev Biol 2022; 10:957363. [PMID: 36092734 PMCID: PMC9449371 DOI: 10.3389/fcell.2022.957363] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/04/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Keloid scars (KSs), which are composed of abnormal hyperplastic scar tissue, form during skin wound healing due to excessive fibroblast activation and collagen secretion. Although surgical resection and radiation therapy are used to prevent recurrence, KS recurrence rates range from 15 to 23%, and the underlying mechanism is unclear. Methods: To elucidate the mechanism of keloid recurrence, we established a PDX model and the grafts remained for over 20 weeks after transplantation on the bilateral backs of the NCG mice. Results: RNA-seq revealed that KS tissue gene expression was highly consistent before and after transplantation. Then, one side of the KS graft was irradiated with electron beam therapy (10 Gy), significant increases in vimentin and fibroblast activation protein alpha (FAP) expression were observed after irradiation and were accompanied by severe microvascular destruction. Surprisingly, 4 weeks after irradiation, significantly increased recurrence was observed with increased FAP + tissue and cell cycle regulator expression, resulting in a remarkable altered graft volume. Moreover, irradiation-induced FAP upregulation markedly facilitated radiation resistance and increased cell cycle progression, decreased senescence, and increased energy production. Conclusion: Our findings revealed that irradiation causes increased abundance of FAP + cells, which was associated with cell proliferation and delayed cellular senescence, accompanied by ATP production.
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Affiliation(s)
- Yan Gao
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - Xue Hou
- Department of Radiation Oncology and Therapy, The First Hospital of Jilin University, Changchun, China
| | - Yuyin Dai
- Department of Nuclear Medicine, The First Hospital of Jilin University, Changchun, China
| | - Ting Yang
- Laboratory of Cancer Precision Medicine, The First Hospital of Jilin University, Changchun, China
| | - Kexin Chen
- Institute of Translational Medicine, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Kexin Chen,
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Hwang NH, Chang JH, Lee NK, Yang KS. Effect of the biologically effective dose of electron beam radiation therapy on recurrence rate after keloid excision: A meta-analysis. Radiother Oncol 2022; 173:146-153. [DOI: 10.1016/j.radonc.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/29/2022] [Accepted: 06/03/2022] [Indexed: 11/26/2022]
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Radiation therapy modalities for keloid management: a critical review. J Plast Reconstr Aesthet Surg 2022; 75:2455-2465. [DOI: 10.1016/j.bjps.2022.04.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
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Hwang NH, Lee NK, Chae JH, Park SH, Yoon ES. The Efficacy of CT-Based Conformal Electron Beam Radiation Therapy After Keloid Excision. Dermatol Surg 2022; 48:435-440. [PMID: 35125441 PMCID: PMC8963517 DOI: 10.1097/dss.0000000000003398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Adjuvant computed tomography-based conformal electron beam radiation therapy (RT) for patients with keloids enables radiation oncologists to customize the target volume with precision and deliver the maximal prescription dose while sparing normal surrounding tissues. OBJECTIVE To report treatment and cosmetic outcomes by the patient's self-assessment survey. METHODS Medical records of patients with keloids, who were treated with postoperative electron beam RT between January 2015 and December 2020, were reviewed. A total of 85 consecutive patients with 136 keloids were included in this study. Subjective cosmetic outcomes were scored by each patient using a 5-point Likert scale survey. RESULTS The median follow-up time was 29.0 months (range, 12.1-77.9 months), and local recurrence was observed in 10 lesions (7.4%). The recurrence rate of keloids occurring in the ear was 5.4%, whereas the recurrence rate of keloids occurring at other body sites was 11.4%. Among the patients who responded to the questionnaire about the cosmetic outcome, 70.2% of patients declared being either very satisfied (44.7%) or satisfied (25.5%). CONCLUSION Surgical excision, followed by CT-based conformal electron beam RT, for patients with keloids ensures a high degree of local control resulting in good cosmetic outcomes.
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Affiliation(s)
- Na-Hyun Hwang
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Nam Kwon Lee
- Department of Radiation Oncology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jung Hyun Chae
- Korea University Medical Center, Seoul, Republic of Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Optimizing surgical outcome of auricular keloid with a novel multimodal approach. Sci Rep 2022; 12:3533. [PMID: 35241718 PMCID: PMC8894473 DOI: 10.1038/s41598-022-07255-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 02/04/2022] [Indexed: 11/12/2022] Open
Abstract
Various treatments are available for auricular keloids, but none has an absolute advantage. A practical and safe therapy to optimize the surgical outcome for auricular keloids is needed. We adopted a multimodal treatment of surgical enucleation, core fillet flap reconstruction, intraoperative corticosteroid injection, and immediate postoperative radiotherapy. There were no routine intralesional corticosteroid injections during follow-up. Keloid recurrences, complications, and risk factors for recurrences were analyzed. The outcome was compared with other published literatures. 45 auricular keloids were included in this study. 85.7% were female with an average age of 27.1 ± 7.5 years, and averaged size was 1.8 × 1.2 ± 0.9 × 0.6 cm. 71.1% were located at ear helix with 28.9% at the ear lobe. Nine keloids were classified as Chang-Park classification type I, 30 for type II, two for type III, and four for IV. The average radiation dosage was 1578.6 cGy. The recurrence rate was 6.7% at an average 24.1-month follow-up. There were no complications of surgery, radiotherapy, and intralesional corticosteroid injection. Our recurrence rate was lower than those in mono-adjuvant therapies of intraoperative corticosteroid injection or radiotherapy. This one-session multimodal approach optimizes treating auricular keloids with a low recurrence rate and minimal post-radiation and long-term corticosteroid injection-related complications.
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Dong W, Qiu B, Fan F. Adjuvant Radiotherapy for Keloids. Aesthetic Plast Surg 2022; 46:489-499. [PMID: 34415398 DOI: 10.1007/s00266-021-02442-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/20/2021] [Indexed: 11/24/2022]
Abstract
Radiotherapy is one of the therapeutic methods for keloids, and the irradiation technique has innovated from superficial X-ray to brachytherapy after decades of clinical practice. At present, the application of adjuvant radiotherapy has been widely accepted by clinicians, while the consensus of optimal adjuvant radiotherapy strategies for keloids has not been reached. Factors such as radiation timing, dose, fractions, and lesion locations may be associated with the clinical outcomes of patients with keloids after radiotherapy while a comprehensive review is lacking. Herein, this review summarized the published literature of adjuvant radiotherapy for keloids involving mechanism, timing, dose, fractions, and complications, etc., which may facilitate clinical decision making.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Wenfang Dong
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Badachu Road, Shijingshan District, Beijing, 100144, China
| | - Bin Qiu
- Department of Radiation Oncology, Peking University Third Hospital, Beijing, 100191, China
| | - Fei Fan
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 33 Badachu Road, Shijingshan District, Beijing, 100144, China.
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Immediate Postoperative Treatment of Keloids with Intraoperative Radiation Therapy Technology: A Pilot Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3738. [PMID: 34548996 PMCID: PMC8447990 DOI: 10.1097/gox.0000000000003738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/08/2021] [Indexed: 01/22/2023]
Abstract
Background The combination of surgery and postoperative radiotherapy allows for the most effective results with keloids. In this trial, surgery and intraoperative radiation therapy (IORT) technology were used-the hypothesis being that the earlier the application of postoperative radiotherapy, the better the wound healing evolution. Methods The study included 16 patients with 21 keloids. The keloids were radically excised and repaired with direct suture or local skin flaps. Collimated electron radiotherapy was applied within 45 minutes of surgery. The outcomes were assessed according to the modified Patient and Observer Scar Assessment Scale; the modified Vancouver Scar Scale; and the modified Common Terminology Criteria for Adverse Events v. 4.0 for skin and subcutaneous tissue disorders. Results Recurrences were observed in one out of 16 patients, and in two out of 21 keloids (9.5%). The modified Patient and Observer Scar Assessment Scale demonstrated a statistically significant improvement in pain, itching, color, stiffness, thickness, and irregularity after the treatment. The modified Patient and Observer Scar Assessment Scale displayed a statistically significant improvement in the scar vascularity, pigmentation, thickness, and pliability after the treatment. The modified Vancouver Scar Scale demonstrated a statistically significant improvement in 90.48% of the scars after the treatment. The modified Common Terminology Criteria for Adverse Events v. 4.0 for skin and subcutaneous tissue disorders demonstrated an improvement in erythema multiforme and skin pain across the whole sample, with a temporary hyperpigmentation in 19% of the scars after the treatment. Conclusion The combination of surgery and collimated electron radiotherapy with IORT technology demonstrated favorable results in 90.5% of the cases.
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Lee JW, Seol KH. Adjuvant Radiotherapy after Surgical Excision in Keloids. ACTA ACUST UNITED AC 2021; 57:medicina57070730. [PMID: 34357011 PMCID: PMC8306494 DOI: 10.3390/medicina57070730] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/14/2021] [Accepted: 07/18/2021] [Indexed: 01/28/2023]
Abstract
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.
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Wang ZH, Sun XY, Zhang JJ, Giampieri F, Jiang CJ, Feng TT, Wang ZW, Chen RY, Battino M, Zhou Y. A six-herb Chinese medicine composition ointment as a promising candidate for treatment of hypertrophic scars. CHINESE HERBAL MEDICINES 2021; 13:210-220. [PMID: 36117509 PMCID: PMC9476741 DOI: 10.1016/j.chmed.2020.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/26/2020] [Accepted: 08/06/2020] [Indexed: 11/24/2022] Open
Abstract
Objective To study the anti-hypertrophic scar effect of the six-herb Chinese medicine composition (SCMC) ointment on the rabbit ear hypertrophic scar models. Methods The optimal formulation of SCMC ointment matrix was screened by the orthogonal designs and a series of evaluation tests. The SCMC ointment was prepared through emulsifying method. The rabbit ear hypertrophic scar models were established and used to investigate the anti-hypertrophic scar effect of SCMC ointment. Results Our results demonstrated that all the quality control indications of the SCMC ointment met the requirements. Anti-hypertrophic scar activity results showed that all the rabbit ear scar tissues appeared different degrees of shrink and fading, and took an unobvious but palpable shift from hard to soft texture with the low, middle and high concentration SCMC ointments treatments in vivo. Additionally, on 21st day the scar area and thickness in different concentrations of SCMC ointment groups were significantly reduced than control group, in a concentration-dependent manner. The immunohistochemical results also indicated that the SCMC ointment had good anti-hypertrophic scar properties and could inhibit hypertrophic scar formation. Conclusion The SCMC ointment could improve the blood circulation condition of hypertrophic scar tissues. Our research has demonstrated the Chinese medicine composition ointment with good anti-hypertrophic scar properties that could be used to treat hypertrophic scars. Meanwhile, it provides a theoretical basis for further clinical application.
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Affiliation(s)
- Zu-hua Wang
- College of Pharmaceutical Sciences, Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
- Nano-drug Technology Research Center of Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
| | - Xue-yan Sun
- College of Pharmaceutical Sciences, Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
| | - Jiao-jiao Zhang
- Nano-drug Technology Research Center of Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
- Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Ancona 60131, Italy
- School of Medicine, Southern Medical University, Guangzhou 510091, China
| | - Francesca Giampieri
- Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Ancona 60131, Italy
- Department of Biochemistry, Faculty of Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Cheng-ju Jiang
- QianDongNan Vocational & Technical College for Nationalities, Kaili 556000, China
| | - Ting-ting Feng
- College of Pharmaceutical Sciences, Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
| | - Zhi-wei Wang
- College of Pharmaceutical Sciences, Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
- Nano-drug Technology Research Center of Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
| | - Rong-yi Chen
- School of Medicine, Southern Medical University, Guangzhou 510091, China
| | - Maurizio Battino
- Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Ancona 60131, Italy
- International Research Center for Food Nutrition and Safety, Jiangsu University, Zhenjiang 212013, China
- Corresponding authors at: Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Ancona 60131, Italy.
| | - Ying Zhou
- College of Pharmaceutical Sciences, Guizhou University of Traditional Chinese Medicine, Guiyang 550025, China
- Corresponding authors at: Department of Clinical Sciences, Faculty of Medicine, Università Politecnica delle Marche, Ancona 60131, Italy.
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Yuce Sari S, Yilmaz MT, Yazici G, Uzun H, Yedekci FY, Ozyigit G. A hesitated approach: primary radiotherapy for keloids-a case series. Strahlenther Onkol 2021; 197:909-915. [PMID: 33394057 DOI: 10.1007/s00066-020-01736-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/09/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To assess the efficacy and toxicity of hypofractionated radiotherapy (RT) alone in treatment-resistant symptomatic keloids. METHODS Six patients with a total of 13 inoperable large keloid lesions and no response to previous treatments were admitted to our department between 2017 and 2019. All patients were examined for detailed wound localization, size, contour, and color assessment, and for objective and subjective symptoms. Response to treatment was graded as "complete remission" in case of full symptomatic relief and >75% decrease in lesion size, as "partial remission" in case of partial symptomatic relief and 25-75% decrease in lesion size, and as "stable disease" in case of no symptomatic relief or <25% decrease in lesion size. Patients were followed up monthly for the first 3 months and every 3 months thereafter by physical examination. RESULTS A total dose of 37.5 Gy external RT in five fractions was prescribed by 6‑MeV electrons in 4 patients and 6‑MV photons in 2 patients. Complete response was obtained in all patients at the 6‑month control. All patients were satisfied with cosmetic results at their last control. Grade 2 dermatitis developed in all patients during the second week of RT but resolved completely in all after 6 months following the end of RT. CONCLUSION In keloids that are unresponsive to standard treatment, hypofractionated RT using a total dose of 37.5 Gy in five fractions is feasible.
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Affiliation(s)
- Sezin Yuce Sari
- Department of Radiation Oncology, Hacettepe University Medical School, 06100, Ankara, Turkey
| | - Melek Tugce Yilmaz
- Department of Radiation Oncology, Hacettepe University Medical School, 06100, Ankara, Turkey
| | - Gozde Yazici
- Department of Radiation Oncology, Hacettepe University Medical School, 06100, Ankara, Turkey.
| | - Hakan Uzun
- Department of Plastic and Reconstructive Surgery, Hacettepe University Medical School, Ankara, Turkey
| | - Fazli Yagiz Yedekci
- Department of Radiation Oncology, Hacettepe University Medical School, 06100, Ankara, Turkey
| | - Gokhan Ozyigit
- Department of Radiation Oncology, Hacettepe University Medical School, 06100, Ankara, Turkey
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Bağlı İ, Ogawa R, Bakır S, Taşın C, Yıldırım A, Öcal E, Yavuz M, Bala M, Turan G. Predictors of the recurrence of surgically removed previous caesarean skin scars at caesarean section: A retrospective cohort study. Scars Burn Heal 2021; 7:20595131211023388. [PMID: 34262789 PMCID: PMC8246489 DOI: 10.1177/20595131211023388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Caesarean skin scars (CSS; hypertrophic scars and keloids) are very stressful for women and treatment strategies vary. However, there is a lack of knowledge about the outcome of surgical excision of CSS during caesarean section (CS). The study aims to determine the rate of recurrence and risk factors of recurrence for surgically removed CSS. METHOD This is a retrospective cohort study that used STROBE guidelines. Pfannenstiel incisions of 145 patients were evaluated. Patients were divided into two groups: recurred (group 1, n = 19) and non-recurred group (group 2, n = 126). The groups were compared. RESULTS The rate of recurrence of CSS was 13% in the total cohort (19/145), one of the main outcomes of the study. While emergency CS was performed for 12 patients in group 1 (63%), CS was carried out in 25 patients in group 2 (20%); this difference was significant (P = 0.001). Before surgery, white blood cell and neutrophil counts were significantly higher in group 1 (P = 0.014 and P = 0.023, respectively). There were 11 dark-skinned women (26%; Fitzpatrick type 4) in group 1 and 31 (74%) in group 2. This difference was statistically significant (P = 0.031). As the other main outcome, emergency CS could be accepted as a risk factor for recurrence in the multivariate regression analysis (P = 0.060; odds ratio = 5.07; 95% confidence interval = 0.93-17.51). CONCLUSION The rate of recurrence of surgically removed previous CSS at CS is promising without adjunct therapy. Emergency CS was found to be a risk factor for recurrence. LAY SUMMARY Background Caesarean skin scars (CSS; hypertrophic scars and keloids) are very stressful and are generally itchy and painful for women. Treatment strategies vary. However, there is a lack of knowledge about the outcome of only surgical excision of CSS scars during caesarean section (CS). The issue being explored There are few data in the literature for CSS in the lower abdomen. These scars can be removed during the second or third CS, but the results are not known exactly. How was the work conducted? In our clinic, 145 patients with CSS were given a CS and their scars were removed at the same time. While most of these scars were reported as hypertrophic by pathological examination, some were reported as keloid. At the earliest, one year after surgery, the rate of recurrence was found to be 13%. What we learned from the study Asymptomatic patients who are planning another pregnancy and do not want to receive any other radiotherapy or steroid injection therapy can wait to remove their CSS at the next CS, especially elective CS with or without adjunct therapy. Emergency CS was found to be a risk factor for the recurrence of these scars.
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Affiliation(s)
- İhsan Bağlı
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Sait Bakır
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Cuma Taşın
- Obstetrics and Gynecology, Mersin University, School of Medicine, Mersin, Turkey
| | - Ayhan Yıldırım
- Department of Pathology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Ece Öcal
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Mustafa Yavuz
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Mesut Bala
- Department of Obstetrics and Gynecology, University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Diyarbakır, Turkey
| | - Gökçe Turan
- Department of Perinatology, Gazi University, Ankara, Turkey
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Rishi KS, Sarkar N, Kesari P, Pathikonda M, Ramachandra P, Donapati PKR, Giri GV, Srinath BS. Single Institution Experience of Postoperative Electron Beam Radiation Therapy in the Treatment of Keloids. Adv Radiat Oncol 2020; 6:100596. [PMID: 33732956 PMCID: PMC7940783 DOI: 10.1016/j.adro.2020.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 09/27/2020] [Accepted: 10/13/2020] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Karthik S Rishi
- Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | - Nivedita Sarkar
- Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | - Prashanta Kesari
- Department of Plastic Surgery, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | - Muddappa Pathikonda
- Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | - Prakash Ramachandra
- Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | | | - G V Giri
- Department of Radiation Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
| | - B S Srinath
- Department of Surgical Oncology, Sri Shankara Cancer Hospital and Research Center, Karnataka, India
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Keloids: Which Types Can Be Excised without Risk of Recurrence? A New Clinical Classification. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2582. [PMID: 32537319 PMCID: PMC7253266 DOI: 10.1097/gox.0000000000002582] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 10/22/2019] [Indexed: 11/25/2022]
Abstract
A surgical team from Interplast-Germany removed 387 keloids in 302 patients during 4 visits to Goma, Democratic Republic of the Congo, from 2015-2018. Preoperative and postoperative photographs and a thorough anamnesis of keloids were done for all patients. In addition, 18 selected biopsies from 4 types of keloids were histologically examined in Germany. Methods Treatment options were tested and keloid recurrence rates were compared with data from questionnaires, photographs, and histology. Results Keloids were classified accordingly as follows: (1) fresh nodular (continuously growing) keloids had a 30% recurrence rate after surgery: no common adjuvant therapy but triamcinolone acetonide (TAC) injections on onset, only; (a) earlobe keloids had the lowest recurrence rate after complete excision with negative resection margins; (2) superficial spreading (or butterfly) keloids were treated with TAC injections only; (3) mature (nongrowing or burned-out) keloids had also a low recurrence rate of 4.5%, which were then treated with TAC on onset, only; and (4) multiple keloids comprise various types in different stages. Conclusions According to this classification, about 50% of keloids may be removed surgically without risk of recurrence in the examined patient population in Africa, where only TAC injections, but no radiation, are available. Adjuvant TAC or radiation should be started at the onset of recurrence and not generally.
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Wang Y, Ma J, Zhang Z, Shen H. Combined surgical excision and electron external beam radiation improves the treatment of keloids: A descriptive study. Dermatol Ther 2020; 33:e13494. [PMID: 32363669 DOI: 10.1111/dth.13494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/26/2020] [Indexed: 01/12/2023]
Abstract
Keloids are firm, fibrous nodules that form on an individual's skin and are associated with difficult symptoms as well as high recurrence rates. This study aims to improve the surgical techniques that reduce local tension after surgical excision of keloids as well as applying adjuvant radiotherapy to suppress scar formation. A total of 58 patients aged between 21 and 76 years received surgical incision of keloid and immediate postoperation low-dose radiotherapy. All patient follow-ups were performed at the out-patient department. Any sign of a keloid at the incision site was defined as treatment failure or keloid recurrence, regardless of the size. At a median follow-up of 22 months, the overall recurrence for all lesions was 8.6%, which is improved compared with previous study. In addition, all incisions performed during surgeries were healed and no signs of necrosis or the development of ulcers was observed. Our study suggests that this combined therapy provides excellent local control of keloids and shows promise for future therapy.
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Affiliation(s)
- Yinmin Wang
- Department of Plastic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jie Ma
- Department of Plastic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhaofeng Zhang
- Department of Plastic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Hua Shen
- Department of Plastic Surgery, Shanghai First People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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Betarbet U, Blalock TW. Keloids: A Review of Etiology, Prevention, and Treatment. THE JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY 2020; 13:33-43. [PMID: 32308783 PMCID: PMC7158916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Keloids are abnormal scars that cause significant emotional and physical distress in patients when inadequately treated. Keloid formation is theorized to occur as a result of an imbalance between an increased synthesis of collagen and extracellular matrix and decreased degradation of these products. Inflammatory mediators- namely, transforming growth factor beta-have been proposed to influence the dysregulation of collagen remodeling in the scar healing process. Though limited, current knowledge of keloid pathophysiology has guided clinicians to explore novel therapies for keloid prevention and treatment. In addition to conducting research refining the use of common therapies, such as steroids and radiation, clinicians have evaluated the potential of anti-inflammatory and chemotherapeutic molecules to suppress keloid recurrence. Procedural focused therapies, such as cryotherapy and lasers, have also found a role in reducing keloid symptomatology. The purpose of this report is to examine the current literature and review the mechanisms of action, efficacy, and side effects of different keloid therapies. Despite the growing literature investigating reliable methods for keloid management, there are no standardized guidelines or treatment protocols supported by academic governing bodies. Stronger evidence with high-fidelity randomized clinical trials will be needed to determine the optimal therapy regimens for keloids.
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Affiliation(s)
- Udayan Betarbet
- Dr. Betarbet is with the Emory University School of Medicine in Atlanta, Georgia and the Division of Plastic Surgery at The University of Texas Medical Branch in Galveston, Texas
- Dr. Blalock is with the Department of Dermatology at Emory University School of Medicine in Atlanta, Georgia
| | - Travis W Blalock
- Dr. Betarbet is with the Emory University School of Medicine in Atlanta, Georgia and the Division of Plastic Surgery at The University of Texas Medical Branch in Galveston, Texas
- Dr. Blalock is with the Department of Dermatology at Emory University School of Medicine in Atlanta, Georgia
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Shirakami E, Yamakawa S, Hayashida K. Strategies to prevent hypertrophic scar formation: a review of therapeutic interventions based on molecular evidence. BURNS & TRAUMA 2020; 8:tkz003. [PMID: 32341924 PMCID: PMC7175766 DOI: 10.1093/burnst/tkz003] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 08/28/2019] [Indexed: 12/31/2022]
Abstract
Once scar tissues mature, it is impossible for the surrounding tissue to regenerate normal dermal tissue. Therefore, it is essential to understand the fundamental mechanisms and establish effective strategies to inhibit aberrant scar formation. Hypertrophic scar formation is considered a result of the imbalance between extracellular matrix synthesis and degradation during wound healing. However, the underlying mechanisms of hypertrophic scar development are poorly understood. The purpose of this review was to outline the management in the early stage after wound healing to prevent hypertrophic scar formation, focusing on strategies excluding therapeutic agents of internal use. Treatment aimed at molecular targets, including cytokines, will be future options to prevent and treat hypertrophic scars. More basic studies and clinical trials, including combination therapy, are required to investigate the mechanisms and prevent hypertrophic scar formation.
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Affiliation(s)
- Eri Shirakami
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
| | - Sho Yamakawa
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
| | - Kenji Hayashida
- Division of Plastic and Reconstructive Surgery, Shimane University Faculty of Medicine, 89-1 Enya-cho, Izumo, Shimane 693-8501, Japan
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Z-plasty and Postoperative Radiotherapy for Anterior Chest Wall Keloids: An Analysis of 141 Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2177. [PMID: 31044131 PMCID: PMC6467632 DOI: 10.1097/gox.0000000000002177] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 01/14/2019] [Indexed: 01/28/2023]
Abstract
Background The therapies for anterior chest wall keloids include surgical excision, postoperative radiotherapy, silicone taping stabilization, and steroid plaster. However, to date, there is no universally accepted combination treatment strategy for anterior chest wall keloids. Methods All consecutive patients with single or multiple anterior chest wall keloids who underwent keloid excision, tension-reducing suturing, z-plasty, and postoperative radiotherapy in 2013-2016 in Nippon Medical School were included in this case series study. Only keloids that arose from small injuries such as folliculitis or acne were selected. The surgery was followed by tension-reducing self-management of the wounds with silicone tape and steroid plaster. The postsurgical radiotherapy modality was 18 Gy administered in 3 fractions over 3 days. The primary study outcome was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the development of stiff and red lesions in even a small part of the scar that did not respond to 6 months of steroid plaster therapy. Results In total, 141 patients with 141 lesions were enrolled. Of the 141 lesions, 15 (10.6%) recurred. All recurrences were successfully treated by steroid plaster and steroid injection. The recurrence patients did not differ from the nonrecurrence patients in terms of the size of the original keloid or gender distribution. Conclusions Anterior chest wall keloids can be successfully treated by customized plans that involve appropriate surgical modalities (including z-plasty) followed by postoperative radiotherapy (18 Gy in 3 fractions over 3 days) and scar self-management with silicone tape and steroid plaster.
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Roos DE, Smith JG. In Regard to Renz et al. Int J Radiat Oncol Biol Phys 2019; 103:1011. [DOI: 10.1016/j.ijrobp.2018.11.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 10/30/2018] [Accepted: 11/10/2018] [Indexed: 11/15/2022]
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