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Ramelyte E, Welti M, Gardin F, Maul JT, Dummer R, Imhof L. Post-Excision Soft X-Ray Radiotherapy for Keloids: Experience in a Tertiary Referral Center. Dermatology 2024; 240:572-580. [PMID: 38897192 PMCID: PMC11309064 DOI: 10.1159/000539782] [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: 07/21/2023] [Accepted: 06/02/2024] [Indexed: 06/21/2024] Open
Abstract
INTRODUCTION Keloid is an abnormal proliferation of scar tissue that grows beyond the original margins of the injury. Even after complete resection, recurrences are common and pose a poorly understood challenge in dermatology. There is lack of large prospective clinical trials; thus, treatment recommendations are based on retrospective analyses and small cohort studies. Superficial radiotherapy is recommended in recurrent keloids; however, the successful treatment rates vary greatly. The aim of this study was to evaluate the keloid recurrence rate after post-excision soft X-ray radiotherapy and the associated factors. METHODS We reviewed retrospective data of all patients, treated with adjuvant post-excision soft X-ray radiotherapy with 12 Gy in 6 sessions at the tertiary referral center, Department of Dermatology, University Hospital Zurich, Switzerland, between 2005 and 2018. We analyzed individual keloids as separate cases. Successful treatment was defined as no sign of recurrence within 2 years. RESULTS Of the 200 identified patients, 90 met the inclusion criteria and were included in the final analysis. In 90 patients, 104 cases of treated keloids were analyzed. Keloids were mainly located on the trunk (49%) and were mostly caused by previous surgery (52.2%). 50% of the keloids did not relapse within 2 years after therapy. A significant factor leading to recurrence was the presence of previous therapy, with prior topical therapies, such as steroid injections or 5-fluorouracil, leading to most relapses. 69.2% of keloid cases who relapsed were pretreated. Soft X-ray radiotherapy was well tolerated, with posttreatment hyperpigmentation noted in 34% of patients, particularly in patients with non-Caucasian origin (61.3%). CONCLUSION Treatment of refractory keloids is difficult. Post-excision radiotherapy is an established adjuvant treatment option; nevertheless, recurrence rates are high, especially in pretreated keloids. Prospective studies determining the exact dosage and fraction of post-excisional radiotherapy are needed to determine the optimal radiation parameters.
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Affiliation(s)
- Egle Ramelyte
- Department of Dermatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Michèle Welti
- Department of Dermatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Fabian Gardin
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Julia-Tatjana Maul
- Department of Dermatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Reinhard Dummer
- Department of Dermatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
| | - Laurence Imhof
- Department of Dermatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Medical Faculty, University of Zurich, Zurich, Switzerland
- Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
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Yang L, Li X, Wang Y. Ferrostatin-1 inhibits fibroblast fibrosis in keloid by inhibiting ferroptosis. PeerJ 2024; 12:e17551. [PMID: 38887622 PMCID: PMC11182022 DOI: 10.7717/peerj.17551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/20/2024] [Indexed: 06/20/2024] Open
Abstract
Background Keloid is a chronic proliferative fibrotic disease caused by abnormal fibroblasts proliferation and excessive extracellular matrix (ECM) production. Numerous fibrotic disorders are significantly influenced by ferroptosis, and targeting ferroptosis can effectively mitigate fibrosis development. This study aimed to investigate the role and mechanism of ferroptosis in keloid development. Methods Keloid tissues from keloid patients and normal skin tissues from healthy controls were collected. Iron content, lipid peroxidation (LPO) level, and the mRNA and protein expression of ferroptosis-related genes including solute carrier family 7 member 11 (SLC7A11), glutathione peroxidase 4 (GPX4), transferrin receptor (TFRC), and nuclear factor erythroid 2-related factor 2 (Nrf2) were determined. Mitochondrial morphology was observed using transmission electron microscopy (TEM). Keloid fibroblasts (KFs) were isolated from keloid tissues, and treated with ferroptosis inhibitor ferrostatin-1 (fer-1) or ferroptosis activator erastin. Iron content, ferroptosis-related marker levels, LPO level, mitochondrial membrane potential, ATP content, and mitochondrial morphology in KFs were detected. Furthermore, the protein levels of α-smooth muscle actin (α-SMA), collagen I, and collagen III were measured to investigate whether ferroptosis affect fibrosis in KFs. Results We found that iron content and LPO level were substantially elevated in keloid tissues and KFs. SLC7A11, GPX4, and Nrf2 were downregulated and TFRC was upregulated in keloid tissues and KFs. Mitochondria in keloid tissues and KFs exhibited ferroptosis-related pathology. Fer-1 treatment reduced iron content, restrained ferroptosis and mitochondrial dysfunction in KFs, Moreover, ferrostatin-1 restrained the protein expression of α-SMA, collagen I, and collagen III in KFs. Whereas erastin treatment showed the opposite results. Conclusion Ferroptosis exists in keloid. Ferrostatin-1 restrained ECM deposition and fibrosis in keloid through inhibiting ferroptosis, and erastin induced ECM deposition and fibrosis through intensifying ferroptosis.
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Affiliation(s)
- Liu Yang
- Plastic & Cosmetics Surgery Department, Zibo Central Hospital, Zibo, China
| | - Xiuli Li
- Plastic & Cosmetics Surgery Department, Zibo Central Hospital, Zibo, China
| | - Yanli Wang
- Plastic & Cosmetics Surgery Department, Zibo Central Hospital, Zibo, China
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Işık H, Yaşar EK, Alagöz MŞ. A Novel Method for Patients With Ear Keloid: Enucleation and Fat Grafting. Ann Plast Surg 2024; 92:635-641. [PMID: 38747571 DOI: 10.1097/sap.0000000000004003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND Keloid is a dermal fibroproliferative disease unique to humans. Due to the ambiguity in its pathophysiology and the frequent recurrence of keloid, there is no clear consensus on the treatment of keloid and there are many treatment methods defined. In order to benefit from the positive effects of fat grafting on pathological scars, we applied fat grafting to patients who underwent keloid enucleation. METHODS Fifteen ear keloid patients included in the study. All patients underwent the same surgical procedure by the same surgeon. Routine follow-ups and examinations were performed to evaluate the results and in addition, the Patient and Observer Scar Assessment Scale (POSAS) survey was used. RESULTS In the study, 15 patients were followed for a median (IQR) period of 21 (13-28) months. No recurrence was observed in any patient during follow-up, which occurred for a median of 21 (13-28) months. In the questionnaire filled out by the patients, the preoperative median value was found to be 48 (IQR: 12), whereas the postoperative median value was found to be 14 (IQR: 8). According to the patients, there was a statistically significant ( P < 0.05) positive improvement after surgery. CONCLUSIONS Historically, surgical procedures were avoided because the surgical recurrence rate was very high, but today, recurrence rates are decreasing with combined treatments. These treatment combinations may require more than one intervention and require frequent clinical follow-ups. With our technique of fat grafting after enucleation, the treatment was completed with a single operation and no additional intervention was required.
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Affiliation(s)
- Halil Işık
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
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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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Ma QY, Yang YT, Chen ZA, Xie CH, Wang WB, Lin X, Xia LL, Zhao Q, Gao Z, Wu XL. Laser Combined with Radiotherapy for Keloid Treatment: A Novel and Efficient Comprehensive Therapy with a Lower Recurrence Rate. Plast Reconstr Surg 2023; 152:1022e-1029e. [PMID: 36877761 DOI: 10.1097/prs.0000000000010376] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Keloids are a fibroproliferative skin disorder with a high recurrence rate. Combined therapies are often used in clinical treatment, but, in addition to the relatively high risk of relapse and complexity of the treatment process, side effects remain unknown for combination therapies. METHODS A total of 99 patients with keloids in 131 positions were included in this retrospective study. Fractional CO 2 laser therapy was first applied with energy ranging from 360 to 1008 mJ; then, 6-Mev, 900-cGy electron beam irradiation was applied twice. The first pass was initiated within 24 hours after the laser therapy, and the second pass was performed on the seventh day after laser therapy. The Patient and Observer Scar Scale evaluated the lesions before the treatment and at 6, 12, and 18 months after treatment. At each follow-up visit, the patients filled out a questionnaire on recurrence, side effects, and satisfaction. RESULTS The authors found a significant decrease in total Patient and Observer Scar Scale score [29 (23, 39) versus 61.2 ± 13.4; P < 0.001] at the 18-month follow-up compared with the baseline value (before the therapy). A total of 12.1% of the patients had recurrences during the 18-month follow-up period (11.1% partial recurrence and 1.0% complete recurrence). The total satisfaction rate was 97.0%. No severe adverse effects were observed during the follow-up period. CONCLUSIONS Laser combined with radiotherapy is a new comprehensive therapy comprising ablative lasers and radiotherapy for keloids. It had excellent clinical efficacy, low recurrence rate, and no serious adverse effects. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Qian-Yu Ma
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Ya-Ting Yang
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Zong-An Chen
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Chun-Hui Xie
- Department of Burns Surgery, The First Hospital of Jilin University
| | - Wen-Bo Wang
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Xiang Lin
- Department of Burn and Plastic Surgery, Shandong Heze Municipal Hospital
| | - Ling-Ling Xia
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Qiong Zhao
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Zhen Gao
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
| | - Xiao-Li Wu
- From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine
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Liu J, Zhang Z, Wang X, Li J, Zhang W, Wang Y. Rare Complication of Massive Depigmentation After Postoperative Treatment of Giant Keloid Combined With Strontium-90. J Craniofac Surg 2023; 34:e556-e558. [PMID: 37259191 DOI: 10.1097/scs.0000000000009413] [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: 03/16/2023] [Accepted: 03/23/2023] [Indexed: 06/02/2023] Open
Abstract
Post-acne keloids have become a serious problem affecting the physical and mental health of adolescents. However, traditional single-treatment methods have a high recurrence rate and are highly susceptible to a variety of complications. Postoperative radiotherapy has rapidly become a popular choice for comprehensive postoperative treatment because of its painlessness, non-invasiveness, convenience, low recurrence rate, and few complications. 1 In the available literature, no serious complications have been reported. Here we introduce a case of keloid after acne with isotope strontium-90 as a comprehensive treatment regimen, which leads to extensive depigmentation in the maxillofacial region. Combined with knowledge of the relevant literature, the mechanisms, types, and timing and dose, and reflect on balancing of recurrence rates and complications to deepen our understanding of the disease.
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Affiliation(s)
- Jingyi Liu
- Plastic Surgery Institute, Weifang Medical University
| | - Zheng Zhang
- Plastic Surgery Institute, Weifang Medical University
| | - Xueying Wang
- Plastic Surgery Institute, Weifang Medical University
| | - Jisen Li
- School of Clinical Medicine, Weifang Medical University, Weifang, China
| | - Wei Zhang
- Department of Aesthetic and Plastic Surgery, Weifang People's Hospital, Weifang, China
| | - Yanhua Wang
- Department of Aesthetic and Plastic Surgery, Weifang People's Hospital, Weifang, China
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Non-Oncological Radiotherapy: A Review of Modern Approaches. J Pers Med 2022; 12:jpm12101677. [PMID: 36294816 PMCID: PMC9605240 DOI: 10.3390/jpm12101677] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/05/2022] Open
Abstract
Despite being usually delivered in oncological patients, radiotherapy can be used as a successful treatment for several non-malignant disorders. Even though this use of radiotherapy has been scarcely investigated since the 1950s, more recent interest has actually shed the light on this approach. Thus, the aim of this narrative review is to analyze the applications of non-oncological radiotherapy in different disorders. Key references were derived from a PubMed query. Hand searching and clinicaltrials.gov were also used. This review contains a narrative report and a critical discussion of non-oncological radiotherapy approaches. In conclusion, non-oncological radiotherapy is a safe and efficacious approach to treat several disorders that needs to be further investigated and used in clinical practice.
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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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Dzul S, Jaenisch H, Nagle C, Joiner M, Miller S. Radiation induced mucoepidermoid carcinoma of the parotid gland following post-operative radiotherapy to the earlobe for keloid prophylaxis. EAR, NOSE & THROAT JOURNAL 2022:1455613221099998. [PMID: 35503458 DOI: 10.1177/01455613221099998] [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: 11/17/2022] Open
Abstract
Radiation-induced malignancies (RIMs) are rare but well-documented late toxicities associated with exposure to radiation or radiotherapy. A keloid scar is a common benign proliferation of scar tissue which commonly develops at the site of an injury, such as on the earlobe after ear-piercing. While typically reserved for management of malignancies, radiotherapy is often utilized in the management of some benign conditions, including keloids. Given the benign nature of keloids, any theoretical late toxicity from radiotherapy, particularly a life-threatening toxicity such as a RIM, is particularly concerning. Here, we report a case of a 34-year-old male who presented with a radiation induced mucoepidermoid carcinoma of the parotid gland which developed in a previously irradiated field ten years after the patient received electron radiotherapy for a keloid of the earlobe. Using available literature, we estimate the risk of a RIM of the parotid gland from a typical course of radiotherapy to the earlobe as 0.007% per year.
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Affiliation(s)
- Stephen Dzul
- Department of Radiation Oncology, 2954Wayne State University, Detroit, MI, USA
| | - Harriett Jaenisch
- Department of Radiation Oncology, 2954Wayne State University, Detroit, MI, USA
| | - Chris Nagle
- Department of Radiation Oncology, 2954Wayne State University, Detroit, MI, USA
| | - Michael Joiner
- Department of Radiation Oncology, 2954Wayne State University, Detroit, MI, USA
| | - Steven Miller
- Department of Radiation Oncology, 2954Wayne State University, Detroit, MI, USA
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