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Hsieh CL, Chi KY, Lin WY, Lee LTJ. Timing of Adjuvant Radiotherapy After Keloid Excision: A Systematic Review and Meta-Analysis. Dermatol Surg 2021; 47:1438-1443. [PMID: 34417379 DOI: 10.1097/dss.0000000000003165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND No consensus exists regarding the appropriate timing of adjuvant radiotherapy administration after surgical excision of keloids. OBJECTIVE This study investigated the appropriate timing of adjuvant radiotherapy. MATERIALS AND METHODS A systematic review and meta-analysis of randomized controlled trials and observational cohort studies was performed. A pooled estimate of the incidence rate was performed using a random-effects model. Subgroup analyses based on different anatomic region, biologically effective dose, keloid length, and radiotherapy regimen were also conducted. RESULTS Sixteen observational cohort studies (1,908 keloid lesions) met the inclusion criteria. The incidence rate was significantly lower in the group treated with electron beam therapy more than 24 hours after surgery (3.80%; 95% confidence interval [CI], 1.78%-8.13%) than that in the group treated with the same therapy within 24 hours of surgery (37.16%; 95% CI, 20.80%-66.37%; p < .0001), but no significant difference was observed between the groups regarding brachytherapy and x-ray treatments. CONCLUSION Immediate adjuvant radiotherapy did not significantly reduce the incidence rate of recurrent keloids.
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Affiliation(s)
- Chin-Ling Hsieh
- Department of Dermatology, Mackay Memorial Hospital, Taipei, Taiwan
- Department of General Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Kuan-Yu Chi
- Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Wan-Ying Lin
- Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Leon Tsung-Ju Lee
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
- Graduate Institute of Biomedical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan
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Boccara D, Serror K, Chatelain S, Chaouat M, Mimoun M, Azoulay L. A new therapeutic protocol for the treatment of keloid scars: a retrospective study. J Wound Care 2021; 30:184-190. [PMID: 33729847 DOI: 10.12968/jowc.2021.30.3.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- David Boccara
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Kevin Serror
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Sarah Chatelain
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Marc Chaouat
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Maurice Mimoun
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Laura Azoulay
- Saint-Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France
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Gold MH, Nestor MS, Berman B, Goldberg D. Assessing keloid recurrence following surgical excision and radiation. BURNS & TRAUMA 2020; 8:tkaa031. [PMID: 33225004 PMCID: PMC7666880 DOI: 10.1093/burnst/tkaa031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/02/2020] [Accepted: 06/28/2020] [Indexed: 01/01/2023]
Abstract
Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.
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Affiliation(s)
- Michael H Gold
- Gold Skin Care Center, 2000 Richard Jones Road, Suite 220, Nashville, TN 37215
| | - Mark S Nestor
- Center for Clinical and Cosmetic Research, 2925 NE 199th St, Suite 205, Aventura, FL 33180
| | - Brian Berman
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - David Goldberg
- Skin Laser & Surgery Specialists of NY/NJ, 110 E. 55th Street, 13th floor, New York, NY 10022
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Anderson EM, David J, Phillips T, Demarco J, Reznik RS, Mirhadi AJ, Kamrava M. Interstitial high-dose-rate brachytherapy in the treatment of keloids: Moving toward a volumetric approach. Brachytherapy 2020; 20:185-188. [PMID: 32811762 DOI: 10.1016/j.brachy.2020.07.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/04/2020] [Accepted: 07/08/2020] [Indexed: 11/15/2022]
Abstract
PURPOSE Brachytherapy (BT) after surgical resection of keloids reduces the risk of local recurrence, but standardization of dose/technique is lacking. Typical keloid BT treatment utilizes a single-channel source prescribed to 5-mm depth. We investigated the dosimetry of a volume-based target definition for interstitial high-dose-rate BT treatment of keloids. METHODS AND MATERIALS We retrospectively identified consecutive 14 patients who had a total of 20 keloids treated with interstitial high-dose-rate BT for keloids at our institution between 2004 and 2014. Keloids were treated with a single 8 Gy fraction prescribed to 5 mm beneath the scar within 36 h of surgery. Retrospectively, a 3-mm skin high-risk clinical target volume (HR-CTV) was contoured under the scar for volume-based dose calculations. RESULTS Mean (SD) HR-CTV was 3.91 cm3 (3.1) and mean (SD) HR-CTV dose was 11.3 Gy (3.6). Mean D90 (SD) was 62.9% (25.8) and mean V100 (SD) was 56.5% (26.4). The mean V150 (SD), V200 (SD), and V300 (SD) were as follows: 37.6% (19.9), 25.1% (14.4), and 11.3% (6.5), respectively. No local failures were reported at 9 months median followup. There were no Grade 2 or higher late toxicities. CONCLUSIONS Using a volume-based target definition, a wide range of target coverage was observed. This is likely a consequence of the curvature of the skin and the challenges of keeping the catheter equidistant from the skin across the target. Additional data are needed to define the potential clinical impact on outcomes/toxicities of dosimetric correlates with single-catheter BT keloid treatment.
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Affiliation(s)
- Eric M Anderson
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA.
| | - John David
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
| | - Tiffany Phillips
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
| | - John Demarco
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
| | - Robert S Reznik
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
| | - Amin J Mirhadi
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
| | - Mitchell Kamrava
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Samuel Oschin Comprehensive Cancer Institute, Los Angeles, CA
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Eng TY, Abugideiri M, Chen TW, Madden N, Morgan T, Tanenbaum D, Wandrey N, Westergaard S, Xu K, Jane Sudmeier L. Radiation Therapy for Benign Disease: Keloids, Macular Degeneration, Orbital Pseudotumor, Pterygium, Peyronie Disease, Trigeminal Neuralgia. Hematol Oncol Clin North Am 2019; 34:229-251. [PMID: 31739946 DOI: 10.1016/j.hoc.2019.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although the use of ionizing radiation on malignant conditions has been well established, its application on benign conditions has not been fully accepted and has been inadequately recognized by health care providers outside of radiation therapy. Most frequently, radiation therapy in these benign conditions is used along with other treatment modalities, such as surgery, when the condition causes significant disability or could even lead to death. Radiation therapy can be helpful for inflammatory/proliferative disorders. This article discusses the present use of radiation therapy for some of the most common benign conditions.
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Affiliation(s)
- Tony Y Eng
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA.
| | - Mustafa Abugideiri
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Tiffany W Chen
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, 7979 Wurzbach Road, San Antonio, TX 78229, USA
| | - Nicholas Madden
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Tiffany Morgan
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Daniel Tanenbaum
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Narine Wandrey
- Department of Radiation Oncology, University of Texas Health Science Center at San Antonio, 7979 Wurzbach Road, San Antonio, TX 78229, USA
| | - Sarah Westergaard
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Karen Xu
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
| | - Lisa Jane Sudmeier
- Radiation Oncology Department, Winship Cancer Institute of Emory University, 1365 Clifton Road Northeast, Building C, Atlanta, GA 30322, USA
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Xu J, Yang E, Yu NZ, Long X. Radiation Therapy in Keloids Treatment: History, Strategy, Effectiveness, and Complication. Chin Med J (Engl) 2018; 130:1715-1721. [PMID: 28685723 PMCID: PMC5520560 DOI: 10.4103/0366-6999.209896] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective: Radiation therapy combined with surgical excision was considered as one of the most effective treatment plans for keloid lesions. However, there was no unanimity found over present literatures regarding the issue on optimized treatment strategy for keloids. We here provide a comprehensive review over this issue and emphasize on the influencing factors. Data Sources: The data analyzed in this review were searched from articles included in PubMed and EMBASE databases. Study Selection: The original articles and critical reviews discussing the application of radiation therapy in keloids treatment were selected for this review. Results: The application of radiation therapy has transitioned from simple superficial X-ray irradiation to brachytherapy. Furthermore, several factors including radiation type, dose, fraction, interval, and complications were reviewed, and the results revealed that these factors were significant toward clinical outcome at various levels. Conclusions: Both past and present evidence support the idea that combination therapy of radiation and surgical therapy is safe and feasible. However, the optimization of treatment strategy was based on different radiation types and should take dose, fractions, interval, and complications into consideration, which will then decrease the rate of recurrence and increase the level of satisfaction.
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Affiliation(s)
- Jing Xu
- Peking Union Medical College, Beijing 100730, China
| | - Elan Yang
- Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Nan-Ze Yu
- Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing 100730, China
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7
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Guinot JL, Rembielak A, Perez-Calatayud J, Rodríguez-Villalba S, Skowronek J, Tagliaferri L, Guix B, Gonzalez-Perez V, Valentini V, Kovacs G. GEC-ESTRO ACROP recommendations in skin brachytherapy. Radiother Oncol 2018; 126:377-385. [PMID: 29455924 DOI: 10.1016/j.radonc.2018.01.013] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 01/18/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE The aim of this publication is to compile available literature data and expert experience regarding skin brachytherapy (BT) in order to produce general recommendations on behalf of the GEC-ESTRO Group. METHODS We have done an exhaustive review of published articles to look for general recommendations. RESULTS Randomized controlled trials, systemic reviews and meta-analysis are lacking in literature and there is wide variety of prescription techniques successfully used across the radiotherapy centers. BT can be delivered as superficial application (also called contact BT or plesiotherapy) or as interstitial for tumours thicker than 5 mm within any surface, including very irregular. In selected cases, particularly in tumours located within curved surfaces, BT can be advantageous modality from dosimetric and planning point of view when compared to external beam radiotherapy. The general rule in skin BT is that the smaller the target volume, the highest dose per fraction and the shortest overall length of treatment can be used. CONCLUSION Skin cancer incidence is rising worldwide. BT offers an effective non-invasive or minimally invasive and relative short treatment that particularly appeals to elder and frail population.
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Affiliation(s)
- Jose L Guinot
- Department of Radiation Oncology, Foundation Instituto Valenciano de Oncologia (I.V.O.), Valencia, Spain
| | - Agata Rembielak
- Department of Clinical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Jose Perez-Calatayud
- Department of Radiation Oncology, La Fe University Hospital-IRIMED, Valencia, Spain
| | | | - Janusz Skowronek
- Brachytherapy Department, Greater Poland Cancer Centre, Poznań, Poland; Electroradiology Department, Poznan University of Medical Sciences, Poland
| | - Luca Tagliaferri
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Benjamin Guix
- Department of Radiation Oncology, Foundation IMOR, Barcelona, Spain
| | - Victor Gonzalez-Perez
- Department of Radiation Physics, Foundation Instituto Valenciano de Oncologia (I.V.O.), Valencia, Spain
| | - Vincenzo Valentini
- Polo Scienze Oncologiche ed Ematologiche, Istituto di Radiologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - György Kovacs
- Interdisciplinary Brachytherapy Unit, UKSH CL, Lübeck, Germany
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Rödel F, Fournier C, Wiedemann J, Merz F, Gaipl US, Frey B, Keilholz L, Seegenschmiedt MH, Rödel C, Hehlgans S. Basics of Radiation Biology When Treating Hyperproliferative Benign Diseases. Front Immunol 2017; 8:519. [PMID: 28515727 PMCID: PMC5413517 DOI: 10.3389/fimmu.2017.00519] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/18/2017] [Indexed: 01/08/2023] Open
Abstract
For decades, low- and moderate-dose radiation therapy (RT) has been shown to exert a beneficial therapeutic effect in a multitude of non-malignant conditions including painful degenerative muscoloskeletal and hyperproliferative disorders. Dupuytren and Ledderhose diseases are benign fibroproliferative diseases of the hand/foot with fibrotic nodules and fascial cords, which determine debilitating contractures and deformities of fingers/toes, while keloids are exuberant scar formations following burn damage, surgery, and trauma. Although RT has become an established and effective option in the management of these diseases, experimental studies to illustrate cellular composites and factors involved remain to be elucidated. More recent findings, however, indicate the involvement of radiation-sensitive targets like mitotic fibroblasts/myofibroblasts as well as inflammatory cells. Radiation-related molecular mechanisms affecting these target cells include the production of free radicals to hamper proliferative activity and interference with growth factors and cytokines. Moreover, an impairment of activated immune cells involved in both myofibroblast proliferative and inflammatory processes may further contribute to the clinical effects. We here aim at briefly describing mechanisms contributing to a modulation of proliferative and inflammatory processes and to summarize current concepts of treating hyperproliferative diseases by low and moderate doses of ionizing radiation.
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Affiliation(s)
- Franz Rödel
- Department of Radiotherapy and Oncology, University Hospital of Frankfurt, Goethe-Universität, Frankfurt am Main, Germany
| | - Claudia Fournier
- Department of Biophysics, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Julia Wiedemann
- Department of Biophysics, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Felicitas Merz
- Department of Biophysics, GSI Helmholtz Centre for Heavy Ion Research, Darmstadt, Germany
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ludwig Keilholz
- Department of Radiotherapy, Clinical Center Bayreuth, Bayreuth, Germany
| | | | - Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital of Frankfurt, Goethe-Universität, Frankfurt am Main, Germany
| | - Stephanie Hehlgans
- Department of Radiotherapy and Oncology, University Hospital of Frankfurt, Goethe-Universität, Frankfurt am Main, Germany
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Goutos I, Ogawa R. Brachytherapy in the adjuvant management of keloid scars: literature review. Scars Burn Heal 2017; 3:2059513117735483. [PMID: 29799578 PMCID: PMC5965342 DOI: 10.1177/2059513117735483] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Radiation therapy is a well-recognised modality for the adjuvant treatment of keloid scars. It can be conventionally delivered as external beam using a large apparatus at a distance from the lesion or as brachytherapy with specialised equipment to enable the delivery of treatment in the immediate vicinity of the keloidal tissue. METHODS An English literature review was performed with keywords 'brachytherapy' and 'keloid' using the databases PubMed, Embase and Web of Science from their individual dates of inception until June 2017. Studies pertinent to the field are presented in a chronological manner to depict the evolution of different brachytherapy strategies over the last decades. We also discuss considerations relating to the risk of secondary carcinogenesis, which are relevant to shared decision-making in the clinical setting. DISCUSSION Low dose rate interstitial brachytherapy was first introduced in the English literature in 1976 and currently appears to have been superseded by more modern approaches, including high dose rate interstitial brachytherapy. This modality compares favourably to more traditional modes of radiotherapy in terms of recurrence as well as rates of symptomatic relief from keloidal symptoms. Superficial brachytherapy was introduced more recently in the relevant literature and appears to be associated with favourable therapeutic outcomes compared to external beam radiation therapy. CONCLUSION Brachytherapy is a valid modality of radiotherapy for the adjuvant treatment of keloid scars, with high dose rate interstitial and surface regimens gaining in popularity over recent years. Further research needs to focus on randomised controlled trials to further establish the role of different radiotherapy modalities in keloid scar management.
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Affiliation(s)
- Ioannis Goutos
- Centre for Cutaneous Research, Blizard
Institute, London, UK
| | - Rei Ogawa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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Surgical Excision with Adjuvant Irradiation for Treatment of Keloid Scars: A Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e440. [PMID: 26301129 PMCID: PMC4527614 DOI: 10.1097/gox.0000000000000357] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/20/2015] [Indexed: 11/26/2022]
Abstract
Background: Excision followed by adjuvant irradiation is considered safe and most efficacious for treatment of keloid scars. Recently, different authors published successful treatment protocols and recommended the following: (1) the use of high-dose-rate brachytherapy instead of low-dose-rate brachytherapy or external radiation; (2) a short-time interval between operation and irradiation; (3) single fraction instead of multifraction irradiation; and (4) a minimum of 12- to 24-month follow-up post treatment. Methods: This study evaluates the above recommendations with a systematic review of the English-language literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Both PubMed and EMBASE were searched. Studies were graded according to the American Society of Plastic Surgeons Rating Levels of Evidence. Results: Thirty-three studies were selected. Six studies were graded as level of evidence type II studies and 27 as type III. High-dose-rate brachytherapy showed lower recurrence rates compared with low-dose-rate brachytherapy and external radiation. A short-time (<7 hours) interval between scar excision and irradiation results in a lower recurrence rate compared with long-time intervals (>24 hours). Single-fraction irradiation showed promising results in terms of recurrence rate and patient convenience. Finally, scar recurrences were seen between 2 and 36 months, with a mean of 15 months. Conclusions: Based on this systematic review of the literature, the evidence confirms the recommendations stated by authors in the recent years. However, due to the lack of high-quality randomized studies, the quality of this evidence is limited. More randomized studies will generate stronger recommendations.
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Intralesional Cryotherapy for the Treatment of Keloid Scars: Evaluating Effectiveness. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2015; 3:e437. [PMID: 26180738 PMCID: PMC4494507 DOI: 10.1097/gox.0000000000000348] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 03/04/2015] [Indexed: 12/11/2022]
Abstract
Background: Intralesional (IL) cryotherapy is a novel treatment technique for keloid scars, in which the scar is frozen from inside. Over the past decade, several studies have been published with varying outcomes. A critical analysis of the current literature is, therefore, warranted to determine whether IL cryotherapy is an alternative to established keloid scar treatments. Methods: A comprehensive review was performed, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. PubMed and EMBASE were searched from inception. Studies and level of recommendation were graded according to the American Society of Plastic Surgeons criteria. Results: Eight studies meeting the inclusion criteria were selected. The average scar volume decrease ranged from 51% to 63%, but no complete scar eradication was achieved on average. Scar recurrence ranged from 0% to 24%. Hypopigmentation posttreatment was seen mostly in Fitzpatrick 4–6 skin type patients. Finally, complaints of pain and pruritus decreased significantly in most studies. Conclusions: IL cryotherapy for the treatment of keloid scars shows favorable results in terms of volume reduction and alleviated complaints of pain and pruritus. However, no complete scar eradication is established, and recurrences are seen. Also, persistent hypopigmentation proved a problem in Fitzpatrick 4–6 skin type patients. Summarized, the evidence proved limited and inconsistent resulting in an American Society of Plastic Surgeons grade C recommendation for this type of treatment of keloid scars.
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van Leeuwen MCE, van der Wal MBA, Bulstra AEJ, Galindo-Garre F, Molier J, van Zuijlen PPM, van Leeuwen PAM, Niessen FB. Intralesional cryotherapy for treatment of keloid scars: a prospective study. Plast Reconstr Surg 2015; 135:580-589. [PMID: 25626801 DOI: 10.1097/prs.0000000000000911] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intralesional cryotherapy is a novel treatment for keloid scars in which the scar is frozen from inside. Published results are promising, but the treatment has only been tested in a Caucasian patient population. Therefore, the authors evaluated intralesional cryotherapy in a patient population including different Fitzpatrick skin types (I through VI). METHODS This prospective multicenter study with a 1-year follow-up included 27 patients with 29 keloid scars. Intralesional cryotherapy was administered with a disposable liquid nitrogen-based device called CryoShape. Scar assessment was performed using the Patient and Observer Scar Assessment Scale and four objective devices to determine scar color, scar elasticity, scar volume, and patient skin type. RESULTS Keloid scars showed an average volume decrease of 63 percent (range, 16 to 100 percent) after 12 months, compared with baseline (p < 0.01). Recurrence was seen in seven keloids (24 percent) and hypopigmentation recovered in 69 percent of all keloid scars within 12 months. Scar assessment with the Patient and Observer Scar Assessment Scale showed an overall improvement according to both doctors and patients. In addition, complaints of pain and itching were reduced. When analyzing the results per Fitzpatrick skin type, African American patients showed a higher incidence of persistent hypopigmentation (p = 0.02). CONCLUSIONS Intralesional cryotherapy for the treatment of keloid scars shows favorable results in terms of reduction of volume and complaints of pain and pruritus. However, no complete eradication was obtained in some cases and recurring scars were seen. In addition, persistent hypopigmentation proved a problem in non-Caucasian patients. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Michiel C E van Leeuwen
- Amsterdam and Beverwijk, The Netherlands From the Departments of Plastic and Reconstructive Surgery, Biostatistics, and Surgery, and the MOVE Institute, VU University Medical Center; and the Department of Plastic and Reconstructive Surgery and the Burn Center, Red Cross Hospital
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High-dose-rate brachytherapy for the treatment of recalcitrant keloids: a unique, effective treatment protocol. Plast Reconstr Surg 2014; 134:527-534. [PMID: 25158710 DOI: 10.1097/prs.0000000000000415] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature. METHODS This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale. RESULTS The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals. CONCLUSIONS The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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De Cicco L, Vischioni B, Vavassori A, Gherardi F, Jereczek-Fossa BA, Lazzari R, Cattani F, Comi S, De Lorenzi F, Martella S, Orecchia R. Postoperative management of keloids: low-dose-rate and high-dose-rate brachytherapy. Brachytherapy 2014; 13:508-13. [PMID: 24556345 DOI: 10.1016/j.brachy.2014.01.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 01/09/2014] [Accepted: 01/10/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE We report the experience of the Radiation Oncology Department of the European Institute of Oncology in Milan, Italy, on the adjuvant low-dose-rate (LDR) and high-dose-rate (HDR) interstitial brachytherapy. Brachytherapy might be useful to improve keloids recurrence rate or reduce keloids treatment side effects instead of external beam radiotherapy. METHODS AND MATERIALS Data on 70 consecutive patients treated after complete keloid surgical excision were retrospectively analyzed. First 38 patients and 46 keloids were treated with adjuvant LDR brachytherapy and the following 39 patients and 50 keloids underwent HDR treatment. Median delivered dose of LDR therapy was 16 Gy; HDR median dose was 12 Gy. Sixty-four keloids (66.7%) were symptomatic at diagnosis with pain, itching, or stress. RESULTS Fourteen relapses over 46 treated keloids (30.4%) were observed in the LDR group and 19 of 50 keloids (38%) in the HDR group (p = 0.521). Recurrence rate was significantly higher in males (p = 0.009), in patients younger than 44 years (p < 0.0001), for arms, neck, and chest wall anatomic sites (p = 0.0001) and for symptomatic keloids (p = 0.017). Aesthetic outcome was better in case of larger keloids (>8 cm) (p = 0.064). Symptomatic relief was achieved in 92% of HDR patients and only 68% of LDR patients (p = 0.032). CONCLUSIONS Postoperative brachytherapy is an effective treatment for keloids. In our study, LDR and HDR treatments resulted in similar recurrence rate. Better symptomatic relief was reported in case of HDR treatment compared with the LDR regimen.
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Affiliation(s)
- Luigi De Cicco
- Division of Radiotherapy, Ospedale di Circolo di Busto Arsizio, Busto Arsizio, Varese, Italy
| | - Barbara Vischioni
- Division of Radiation Oncology and Radiobiology, National Center for Oncological Hadrontherapy CNAO, Pavia, Italy
| | - Andrea Vavassori
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy.
| | - Federica Gherardi
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | | | - Roberta Lazzari
- Division of Radiotherapy, European Institute of Oncology, Milan, Italy
| | - Federica Cattani
- Division of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Stefania Comi
- Division of Medical Physics, European Institute of Oncology, Milan, Italy
| | - Francesca De Lorenzi
- Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy
| | - Stefano Martella
- Plastic and Reconstructive Surgery, European Institute of Oncology, Milan, Italy
| | - Roberto Orecchia
- Division of Radiation Oncology and Radiobiology, National Center for Oncological Hadrontherapy CNAO, Pavia, Italy; Division of Radiotherapy, European Institute of Oncology, Milan, Italy; University of Milan, Milan, Italy
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Absorbed dose simulations in near-surface regions using high dose rate Iridium-192 sources applied for brachytherapy. Radiat Phys Chem Oxf Engl 1993 2014. [DOI: 10.1016/j.radphyschem.2013.01.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Nijhawan RI, Alexis AF. Practical approaches to medical and cosmetic dermatology in skin of color patients. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.10.75] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Bijlard E, Timman R, Verduijn GM, Niessen FB, van Neck JW, Busschbach JJV, Mureau MAM. Intralesional cryotherapy versus excision and corticosteroids or brachytherapy for keloid treatment: study protocol for a randomised controlled trial. Trials 2013; 14:439. [PMID: 24354714 PMCID: PMC3878407 DOI: 10.1186/1745-6215-14-439] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 12/09/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Keloids are a burden for patients due to physical, aesthetic and social complaints and treatment remains a challenge because of therapy resistance and high recurrence rates. The main goal of treatment is to improve the quality of life (QoL); this implies that, apart from surgical outcomes, patient-reported outcome measures (PROMs) need to be taken into account. Decision making in keloid treatment is difficult due to heterogeneity of the condition and the lack of comparative studies. METHODS/DESIGN This is a multicentre, randomised controlled open trial that compares 1) intralesional cryotherapy versus excision and corticosteroids for primary keloids, and 2) intralesional cryotherapy versus excision and brachytherapy for therapy-resistant keloids. The primary outcome is the Patient and Observer Scar Assessment Scale (POSAS), a 12-item scale (with score 12 indicating the best and 120 indicating the worst scar imaginable). A difference of six points on the total score is considered to be of clinical importance. Secondary outcomes are recurrence rates, volume reduction, Skindex-29 scores, SF-36 scores and complication rates. Primary and secondary outcome measurements are taken at baseline, and at 2, 12, 26 and 52 weeks postoperatively. For analysis, a linear mixed model is used. A total of 176 patients will be included over a period of 2.5 years. The protocol is approved by the Medical Ethics Committee of the Erasmus University Medical Centre Rotterdam and follows good clinical practice guidelines. DISCUSSION The outcomes of this study will improve evidence-based decision making for the treatment of keloids, as well as patient education. TRIAL REGISTRATION Dutch Trial Register NTR4151.
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Affiliation(s)
- Eveline Bijlard
- Department of Plastic Reconstructive and Hand Surgery ErasmusMC, Erasmus University Medical Centre Rotterdam Room EE1591 Dr, Molewaterplein, 50 3015 GE, Rotterdam, Netherlands.
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Karim R, Conway RM. Conservative resection and adjuvant plaque brachytherapy for early-stage conjunctival melanoma. Clin Exp Ophthalmol 2011; 39:293-8. [PMID: 21105970 DOI: 10.1111/j.1442-9071.2010.02469.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To describe the outcome of patients treated by conservative surgical excision followed by adjuvant plaque brachytherapy for early-stage primary or recurrent conjunctival melanoma. DESIGN Retrospective, non-comparative, interventional case series. PARTICIPANTS We reviewed 19 eyes in 19 consecutive patients presenting with biopsy proven conjunctival melanoma with pathologic stage pT1c or less. METHODS Patients with primary or recurrent early-stage conjunctival melanoma were identified and treated using a conservative resection technique (tractional micro-dissection) involving avoidance of deep dissection and modest lateral clearance followed by adjuvant plaque brachytherapy. MAIN OUTCOME MEASURE Local recurrence and ocular complications. RESULTS Mean age was 55.2 years and male : female (8:11). Mean follow up was 43.1 months (range 30.1-54.3 months). All patients were treated by conservative resection followed by adjuvant Iodine-125 plaque brachytherapy. The treatment dose was 100 Gy to a depth of 1.5-3.0 mm. OUTCOMES median visual acuity and intraocular pressure were unchanged after surgery. Six patients experienced corneal ulceration in the immediate postoperative period. No patients experienced recurrence at the treatment site or metastases. Three patients experienced new lesions distant from the treatment site. CONCLUSIONS Conservative resection and adjuvant plaque brachytherapy is an effective and well-tolerated modality for the management of patients with early-stage conjunctival melanoma.
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Affiliation(s)
- Rushmia Karim
- Sydney Eye Hospital and Ocular Oncology Centre, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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