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Taneja S, Barbee DL, Cohen RF, Malin M. Implementation of a Stereoscopic Camera System for Clinical Electron Simulation and Treatment Planning. Pract Radiat Oncol 2024; 14:e291-e300. [PMID: 38325547 DOI: 10.1016/j.prro.2024.01.005] [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: 05/10/2023] [Revised: 12/14/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024]
Abstract
PURPOSE A 3-dimensinal (3D) stereoscopic camera system developed by .decimal was commissioned and implemented into the clinic to improve the efficiency of clinical electron simulations. Capabilities of the camera allowed simulations to be moved from the treatment vault into any room with a flat surface that could accommodate patient positioning devices, eliminating the need for clinical patient setup timeslots on the treatment machine. This work describes the process used for these simulations and compares the treatment parameters determined by the system to those used in delivery. METHODS AND MATERIALS The Decimal3D scanner workflow consisted of: scanning the patient surface; contouring the treatment area; determining gantry, couch, collimator, and source-to-surface distance (SSD) parameters for en face entry of the beam with sufficient clearance at the machine; and ordering custom electron cutouts when needed. Transparencies showing the projection of in-house library cutouts at various clinical SSDs were created to assist in choosing an appropriate library cutout. Data from 73 treatment sites were analyzed to evaluate the accuracy of the scanner-determined beam parameters for each treatment delivery. RESULTS Clinical electron simulations for 73 treatment sites, predominately keloids, were transitioned out of the linear accelerator (LINAC) vault using the new workflow. For all patients, gantry, collimator, and couch parameters, along with SSD and cone size, were determined using the Decimal3D scanner with 57% of simulations using library cutouts. Tolerance tables for patient setup were updated to allow differences of 10, 20, and 5° for gantry, collimator, and couch, respectively. Approximately 7% of fractions (N = 181 total fractions) were set up outside of the tolerance table based on physician direction during treatment. This reflects physician preference to adjust the LINAC rather than patient position during treatment setup. No scanner-derived plan was untreatable because of cutout shape inaccuracy or clearance issues. CONCLUSIONS Clinical electron simulations were successfully transitioned out of the LINAC vault using the Decimal3D scanner without loss of setup accuracy, as measured through machine parameter determination and electron cutout shape.
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Affiliation(s)
- Sameer Taneja
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York.
| | - David L Barbee
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York
| | - Richard F Cohen
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York
| | - Martha Malin
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York
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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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Huang Y, Ren S, Yang Q. Efficacy and Safety of Excision Combination Therapies for Earlobe Keloids: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024:10.1007/s00266-024-04092-0. [PMID: 38789810 DOI: 10.1007/s00266-024-04092-0] [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: 12/22/2023] [Accepted: 04/15/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Different combinations of excision and adjuvant therapies have been applied to improve outcomes for earlobe keloids, though evidence in this field is still lacking. OBJECTIVES This study sought to systematically investigate efficacy and safety of these treatments. METHODS We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane Library to find all relevant studies. Meta-analysis of recurrence rates (RRs) and adverse event rates with 95% confidence intervals, and individual participants data (IPD) were calculated for each intervention when possible. Otherwise, narrative syntheses were performed. RESULTS A total of 85 articles, covering 23 treatments for earlobe keloids, were included, indicating a preference for multiple combination therapy. The estimated RRs for 6 interventions (i.e., excision monotherapy, combinations of excision with imiquimod, pressure therapy, radiotherapy, steroids, and steroids with pressure therapy) appeared to be comparable. Electron radiotherapy was found to have potential advantages over X-ray treatment, contributing to the observed heterogeneity. Further meta-analysis using IPD revealed that both combination therapies of excision plus steroid therapy (p=0.003) and excision plus radiotherapy (p=0.003) yielded better recurrence-free survival compared to excision alone. The median recurrence-free interval for combination therapy was 10 months. Adverse event rates were similar among different intervention groups. CONCLUSIONS This study suggests that combining excision with radiotherapy or perioperative steroid therapy has the potential to improve prognosis of earlobe keloids without increasing the risk of adverse events. Overall evaluation of patients' conditions and further studies with sufficient follow-up are warranted for clinical practice. LEVEL OF EVIDENCE IV 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)
- Ying Huang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China
| | - Shuofang Ren
- Department of Cardiac Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Qinghua Yang
- Department of Comprehensive Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Badachu Road 33, Beijing, People's Republic of China.
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Yu GB, Kwon J, Chae S, Lee SY, Jung S. Evaluations of patient-specific bolus fabricated by mold-and-cast method using computer numerical control machine tools†. JOURNAL OF RADIATION RESEARCH 2023; 64:973-981. [PMID: 37839093 PMCID: PMC10665306 DOI: 10.1093/jrr/rrad075] [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: 12/20/2022] [Revised: 01/19/2023] [Indexed: 10/17/2023]
Abstract
The patient-specific bolus fabricated by a mold-and-cast method using a 3D printer (3DP) and silicon rubber has been adopted in clinical practices. Manufacturing a mold using 3DP, however, can cause time delays due to failures during the 3D printing process. Thereby, we investigated an alternative method of the mold fabrication using computer numerical control (CNC) machine tools. Treatment plans were conducted concerning a keloid scar formed on the ear and nose. The bolus structures were determined in a treatment planning system (TPS), and the molds were fabricated using the same structure file but with 3DP and CNC independently. Boluses were then manufactured using each mold with silicone rubbers. We compared the geometrical difference between the boluses and the planned structure using computed tomography (CT) images of the boluses. In addition, dosimetric differences between the two measurements using each bolus and the differences between the measured and calculated dose from TPS were evaluated using an anthropomorphic head phantom. Geometrically, the CT images of the boluses fabricated by the 3DP mold and the CNC mold showed differences compared to the planned structure within 2.6 mm of Hausdorff distance. The relative dose difference between the measurements using either bolus was within 2.3%. In conclusion, the bolus made by the CNC mold benefits from a stable fabricating process, retaining the performance of the bolus made by the 3DP mold.
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Affiliation(s)
- Geum Bong Yu
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 03080, Republic of Korea
| | - Jimin Kwon
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto M5S 3G8, Ontario, Canada
| | - Seunghoon Chae
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Sung Young Lee
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
| | - Seongmoon Jung
- Department of Radiation Oncology, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Institute of Radiation Medicine, Seoul National University Medical Research Center, Seoul 03080, Republic of Korea
- Biomedical Research Institute, Seoul National University Hospital, Seoul 03080, Republic of Korea
- Department of Nuclear Engineering, Ulsan National Institute of Science and Technology, Ulsan 44919, Republic of Korea
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Fu S, Duan L, Zhong Y, Zeng Y. Comparison of surgical excision followed by adjuvant radiotherapy and laser combined with steroids for the treatment of keloids: A systematic review and meta-analysis. Int Wound J 2023; 21:e14449. [PMID: 37967571 PMCID: PMC10895202 DOI: 10.1111/iwj.14449] [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: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/17/2023] Open
Abstract
This meta-analysis aims to evaluate and compare the effect of surgical excision followed by adjuvant radiotherapy and laser combined with steroids on keloids. Relevant studies reporting the recurrence rate or incidence of adverse events (AEs) were retrieved from the PubMed, Web of Science, Embase and Cochrane Library databases through August 2023. The quality of noncomparative single-arm clinical trials was evaluated using the methodological index for nonrandomised studies (MINORS) Methodological items. This meta-analysis was conducted utilizing Stata 12.0 statistical software. 26 studies involving 989 patients were included in the analysis. The recurrence rate in the laser combined with steroids therapy group (12.2%, 95% confidence interval [CI]: 5.9%-18.5%) was lower than that of the surgical excision combined with radiotherapy group (13.5%, 95% CI: 6.6%-22.2%). For the incidence of AEs, relatively low incidence of atrophy (0.0%, 95% CI: 0.0%-1.2%), telangiectasia (3.2%, 95% CI: 0.4%-7.6%), erythema (2.3%, 95% CI: 0.0%-10.6%), infection (0.2%, 95% CI: 0.0%-1.6%) and high hyperpigmentation rate (8.3%, 95% CI: 4.2%-13.4%) were obtained in the surgical excision combined with radiotherapy group. Compared with surgical resection followed by radiotherapy, the combination of laser and steroids for keloids showed a lower hyperpigmentation rate (6.5%), as well as a higher incidence of atrophy (22.7%), telangiectasia (6.4%), erythema (3.3%) and infection (3.3%). Only a hypopigmentation rate of 2.9% was obtained in patients treated with surgical excision plus radiotherapy. Current evidence revealed that surgical excision followed by adjuvant radiotherapy and laser combined with steroids therapy were effective and safe treatments for keloids, with relatively low recurrence rate and complication rate. Comparative studies are needed to further compare the effects of these two combination therapies on keloids.
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Affiliation(s)
- Siqi Fu
- Department of DermatologySecond Xiangya Hospital, Central South UniversityChangshaChina
| | - Liu Duan
- Department of DermatologyThe Third Hospital of ChangshaChangshaChina
| | - Yan Zhong
- Department of Preventive MedicineSchool of Medicine, Hunan Normal UniversityChangshaChina
| | - Yu Zeng
- Hunan Provincial University Key Laboratory of the Fundamental and Clinical Research on Neurodegenerative DiseasesChangsha Medical UniversityChangshaChina
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Ahmednaji NM, Wu XY, Wang YX, Chen XD. Surgical Core Excision With Tongue Flap Closure in Combination With Electron Beam Radiotherapy in the Treatment of Ear Keloids. Dermatol Surg 2023; 49:S58-S63. [PMID: 37116002 DOI: 10.1097/dss.0000000000003778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND Ear keloids are disfiguring disorders resistant to various treatments. OBJECTIVE The authors aimed to assess the efficacy of surgical treatment of ear keloids in a Chinese population using a tongue flap with electron beam radiotherapy. METHODS The authors conducted a retrospective analysis of 41 patients treated at the Affiliated Hospital of Nantong University between January 2018 and May 2021. Core excision with a tongue flap was performed, followed by 3 days of electron beam radiotherapy and 3 to 6 months of pressure clip application. The Vancouver Scar Scale (VSS) and the Visual Analog Scale (VAS) were used to assess the results. RESULTS The mean age of the patients was 28.10 years (9-61 years). Postoperative follow-up ranged from 5 to 32 months (mean:12.07). The patients underwent 3 days of postoperative radiotherapy followed by pressure clips for 2 to 6 months. Thirty-seven patients had no recurrence, whereas 4 had a mild recurrence (<3 mm in height) with redness and itchiness. The VSS and VASscores significantly decreased. (p < .05). CONCLUSION Excision with a tongue flap and radiotherapy can be used as the primary treatment for ear keloids considering the good outcome and long-term management.
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Affiliation(s)
- Nebil Mahamoud Ahmednaji
- All authors are affiliated with the Department of Dermatology, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
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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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Keloid treatments: an evidence-based systematic review of recent advances. Syst Rev 2023; 12:42. [PMID: 36918908 PMCID: PMC10012475 DOI: 10.1186/s13643-023-02192-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/15/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Keloids are pathologic scars that pose a significant functional and cosmetic burden. They are challenging to treat, despite the multitude of treatment modalities currently available. OBJECTIVE The aim of this study was to conduct an evidence-based review of all prospective data regarding keloid treatments published between 2010 and 2020. METHODS A systematic literature search of PubMed (National Library of Medicine), Embase (Elsevier), and Cochrane Library (Wiley) was performed in November of 2020. Search strategies with the keywords "keloid" and "treatment" were performed by a medical librarian. The search was limited to prospective studies that were peer-reviewed, reported on clinical outcomes of keloid therapies, and were published in the English language between January 1, 2010, and November 24, 2020. RESULTS A total of 3462 unique citations were identified, of which 108 studies met inclusion criteria. Current literature supports silicone gel or sheeting with corticosteroid injections as first-line therapy for keloids. Adjuvant intralesional 5-fluorouracil (5-FU), bleomycin, or verapamil can be considered, although mixed results have been reported with each. Laser therapy can be used in combination with intralesional corticosteroids or topical steroids with occlusion to improve drug penetration. Excision of keloids with immediate post-excision radiation therapy is an effective option for recalcitrant lesions. Finally, silicone sheeting and pressure therapy have evidence for reducing keloid recurrence. CONCLUSIONS This review was limited by heterogeneity of subject characteristics and study outcome measures, small sample sizes, and inconsistent study designs. Larger and more robust controlled studies are necessary to further understand the variety of existing and emerging keloid treatments, including corticosteroids, cryotherapy, intralesional injections, lasers, photodynamic therapy, excision and radiation, pressure dressings, and others.
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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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Intralesional Keloid Excision Followed by Single Fraction Electron Beam Radiotherapy and Postoperative Local Steroids: a Non-randomized Open Study on Recurrence Rate. Indian J Surg 2022. [DOI: 10.1007/s12262-022-03511-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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12
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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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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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Yang S, Luo YJ, Luo C. Network Meta-Analysis of Different Clinical Commonly Used Drugs for the Treatment of Hypertrophic Scar and Keloid. Front Med (Lausanne) 2021; 8:691628. [PMID: 34568361 PMCID: PMC8458741 DOI: 10.3389/fmed.2021.691628] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/29/2021] [Indexed: 11/24/2022] Open
Abstract
Background: There is no uniform treatment for pathological scars, including keloids and hypertrophic scars, in clinic currently. Previously, multiple randomized controlled trials have examined the clinical efficacy of different treatments. Nonetheless, the results are inconsistent, and many treatments have not been directly compared. This makes it difficult to conclude which approach is more favorable, in terms of efficacy and safety, for the treatment of pathological scarring. This study aimed at evaluating the efficacy of different injection and topical treatment strategies for hypertrophic scar and keloid. Methods: Relevant literature from PubMed, Medline, Embase, Scopus, the Cochrane Central Register of Controlled Trials (CCRCT), and WHO International Clinical Trials Registry Platform (WHO-ICTRP) were searched, from database inception through November 2020. Randomized clinical trials evaluating different treatment strategies of pathological scars, including triamcinolone acetonide (TAC), verapamil (VER), 5-fluorouracil (5-FU), botulinum toxin A (BTA), bleomycin (BLM), and silicone gels were included in the study. Results: The network meta-analysis included a total of 2,009 patients from 29 studies. A network meta-analysis of injection and topical treatment strategies showed that the efficacy of TAC combined with BTA was best in the treatment of pathological scars. Combination therapies of TAC with 5-FU and TAC with BTA significantly improved the clinical efficiency. However, there was no statistically significant difference between other treatment strategies. The order of efficacy predicted by the surface under the cumulative ranking (SUCRA) curve was as follows: TAC+BTA (82.2%) > TAC+5-FU (69.8%) > BTA (67.3%) > 5-FU+silicone (59.4%) > TAC+silicone (58.3%) > 5-FU (49.8%) > BLM (42.0%) > TAC (26.7%) > VER (26.2%) > silicone (18.3%). There was no publication bias revealed based on the funnel diagram. Conclusion: This study recommends intralesional injection of TAC-BTA and TAC-5-FU combined therapies. But for patients who cannot tolerate the side effects, the use of silicone gels in combination with TAC is recommended. However, these conclusions need to be further confirmed by more randomized controlled trials.
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Affiliation(s)
- Sha Yang
- Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yujia J Luo
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurosurgeons, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Cong Luo
- Department of Orthopaedics, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Engineering Research Center of Stem Cell Therapy, Children's Hospital of Chongqing Medical University, Chongqing, China
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15
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Barone N, Safran T, Vorstenbosch J, Davison PG, Cugno S, Murphy AM. Current Advances in Hypertrophic Scar and Keloid Management. Semin Plast Surg 2021; 35:145-152. [PMID: 34526861 PMCID: PMC8432993 DOI: 10.1055/s-0041-1731461] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hypertrophic scars and keloids are caused by excessive tissue response to dermal injury due to local fibroblast proliferation and collagen overproduction. This response occurs because of pathologic wound healing due to dysregulation in the inflammatory, proliferative, and/or remodeling phase. Patients with hypertrophic scars or keloids report reduced quality of life, physical status, and psychological health. Hypertrophic scars or keloids will develop in 30 to 90% of individuals, and despite their prevalence, treatment remains a challenge. Of the treatments currently available for hypertrophic scars and keloids few have been adequately supported by studies with appropriate experimental design. Here, we aim to review the available literature to provide up-to-date information on the etiology, epidemiology, histology, pathophysiology, prevention, and management options available for the treatment of hypertrophic scars and keloids and highlight areas where further research is required.
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Affiliation(s)
- Natasha Barone
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Tyler Safran
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | - Joshua Vorstenbosch
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | - Peter G. Davison
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | - Sabrina Cugno
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
| | - Amanda M. Murphy
- Division of Plastic and Reconstructive Surgery, McGill University Health Centre, Montreal, Canada
- Division of Plastic and Reconstructive Surgery, Jewish General Hospital, Montreal, Canada
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16
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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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Zhao LT, Gao LM, Chen XD, Wu XY. A massive mandibular keloid with severe infection: What is your treatment? Photodiagnosis Photodyn Ther 2021; 33:102200. [PMID: 33516945 DOI: 10.1016/j.pdpdt.2021.102200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/06/2021] [Accepted: 01/08/2021] [Indexed: 10/22/2022]
Abstract
A case report of massive mandibular keloid with severe infection induced by acne achieved resolution of skin lesions after combined treatment with surgery and high concentration single-dose 5-aminolevulinic acid photodynamic therapy (5-ALA PDT). The patient achieved satisfactory effects, after receiving combined treatment with radiotherapy, secondary healing, intralesional injection of glucocorticoids, and other treatments. The scar didn't exhibit growth in a follow-up check after a year. This case provides evidence that photodynamic therapy is effective in the treatment of massive mandibular keloid with severe infection.
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Affiliation(s)
- Li-Tian Zhao
- 7, Department of Dermatology and Venereology, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Li-Mu Gao
- 7, Department of Dermatology and Venereology, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Xiao-Dong Chen
- 7, Department of Dermatology and Venereology, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China
| | - Xiao-Yan Wu
- 7, Department of Dermatology and Venereology, Affiliated Hospital of Nantong University, No 20 Xisi Road, Nantong, 226001, Jiangsu, China.
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18
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Miles OJ, Zhou J, Paleri S, Fua T, Ramakrishnan A. Chest keloids: effect of surgical excision and adjuvant radiotherapy on recurrence, a systematic review and meta-analysis. ANZ J Surg 2021; 91:1104-1109. [PMID: 33438368 DOI: 10.1111/ans.16561] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 12/07/2020] [Accepted: 12/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chest keloids are a difficult sub-group of scars to treat, likely secondary to the high wound tension in the area that promotes excessive fibroblast proliferation and collagen deposition. Excision and adjuvant radiotherapy has been demonstrated as an efficacious treatment for keloids in general, but no meta-analysis exists to support the claims for chest keloids. This study aims to identify the rate of recurrence after surgical resection and radiotherapy on patients with chest keloids. METHODS A search was performed using Embase, MEDLINE, Pubmed and Cochrane database on 22 December 2018 for terms 'radiotherapy', 'keloid' and 'chest'. Papers included met a prospectively designed inclusion criteria assessed by multiple investigators. RESULTS Twelve studies, including 1 randomized controlled trial, were included for a total of 400 patients with a chest keloid scar managed with surgical excision and adjuvant radiotherapy. Overall pooled-estimate of recurrence rate was 22% (95% CI 12-32%). Meta-regression did not demonstrate a significant effect for method of wound closure, type of radiotherapy, radiotherapy dose (BED10 ) and study type. CONCLUSION Excision and adjuvant radiotherapy represents an effective method of treatment for chest keloids, however sufficient prospective data, including randomized controlled trials, did not yet exist to support these findings. Further studies with sufficient sub-group analysis for keloid location are required to add to the pool of literature that can be added to this meta-analysis.
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Affiliation(s)
- Oliver J Miles
- Department of Plastic and Reconstructive Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Jieyun Zhou
- Department of Plastic and Reconstructive Surgery, The Alfred Hospital Melbourne, Melbourne, Victoria, Australia
| | - Sarang Paleri
- Department of Cardiology, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - Tsien Fua
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Anand Ramakrishnan
- Department of Plastic and Reconstructive Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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19
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The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis. Dermatol Surg 2021; 46:1054-1059. [PMID: 32224709 DOI: 10.1097/dss.0000000000002362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective. OBJECTIVE To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy). MATERIALS AND METHODS Systematic literature review and meta-analysis of combination treatment for keloids. RESULTS After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099). CONCLUSION Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.
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20
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Kim JH, Shin CH, Kim DC, Paik SY, Lee CK. Solitary sclerotic fibroma on the thigh. Arch Craniofac Surg 2020; 21:323-325. [PMID: 33143403 PMCID: PMC7644342 DOI: 10.7181/acfs.2020.00360] [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] [Received: 07/18/2020] [Accepted: 10/06/2020] [Indexed: 11/25/2022] Open
Abstract
Sclerotic fibroma is a rare fibrous tumor of the skin associated with Cowden’s disease. In 1989, Rapini described sclerotic fibroma without Cowden’s disease as solitary sclerotic fibroma of the skin. It is a solid, well-circumscribed, slow-growing nodular tumor and it looks similar to a keloid scar. Consequently, it is extremely difficult to make a differential diagnosis of solitary sclerotic fibroma with keloid scar based on clinical findings only. The authors report a case of solitary sclerotic fibroma arising at the left lateral thigh of a 25-year-old man.
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Affiliation(s)
- Ji Hoon Kim
- Department of Plastic and Reconstructive Surgery, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Chi Ho Shin
- Department of Plastic and Reconstructive Surgery, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Dong Chul Kim
- Department of Plastic and Reconstructive Surgery, Bundang Jesaeng Hospital, Seongnam, Korea
| | - So Ya Paik
- Department of Pathology, Bundang Jesaeng Hospital, Seongnam, Korea
| | - Chong Kun Lee
- Department of Plastic and Reconstructive Surgery, Bundang Jesaeng Hospital, Seongnam, Korea
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21
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Jiang ZY, Liao XC, Liu MZ, Fu ZH, Min DH, Yu XT, Guo GH. Efficacy and Safety of Intralesional Triamcinolone Versus Combination of Triamcinolone with 5-Fluorouracil in the Treatment of Keloids and Hypertrophic Scars: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2020; 44:1859-1868. [PMID: 32342167 DOI: 10.1007/s00266-020-01721-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although keloids and hypertrophic scars are common benign hyperproliferative growths of dermal fibroblasts, the clinical problems including physical and psychological problems are significant and impairing, with few proven treatments. Intralesional triamcinolone acetonide (TAC) and combination of TAC with 5-fluorouracil (5-FU) are widely used to treat keloids and hypertrophic scars, but their efficacy and safety remain controversial. METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, and CNKI for relevant trials. RESULTS The mean scar height and the erythema score in the TAC + 5-FU group were lower than those in the TAC group after treatment (P < 0.05). The effectiveness based on observer assessment after treatment in the TAC + 5-FU group was superior than that in the TAC group (P < 0.05); further, the subgroup analysis showed the TAC + 5-FU group was also superior than the TAC group in the treatment of hypertrophic scars (P = 0.01), and there were no significant differences in the treatment of keloid (P = 0.12). The effectiveness based on patient self-assessment after treatment in the TAC + 5-FU group was also superior than the TAC group (P < 0.05). The overall complication rate in the TAC + 5-FU group was lower than the TAC group (P < 0.05). CONCLUSIONS Combination of TAC with 5-FU is more effective and safer than TAC alone therapy in the treatment of keloids and hypertrophic scars. Data on keloids alone or hypertrophic scars alone are, however, limited. A better understanding of effective after intralesional combination of TAC with 5-FU in the treatment of keloids alone or hypertrophic scars alone is imperative. LEVEL OF EVIDENCE IV 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)
- Zheng-Ying Jiang
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xin-Cheng Liao
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Ming-Zhuo Liu
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Zhong-Hua Fu
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Ding-Hong Min
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Xiao-Ting Yu
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Guang-Hua Guo
- The Department of Burn, The First Affiliated Hospital of Nanchang University, No.17 Yong Wai Street, Nanchang, 330006, Jiangxi, People's Republic of China.
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22
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Akinbiyi T, Kozak GM, Davis HD, Barrette LX, Rios-Diaz AJ, Maxwell R, Tilahun ED, Jones JA, Broach RB, Butler PD. Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy. Am J Surg 2020; 221:689-696. [PMID: 32878694 DOI: 10.1016/j.amjsurg.2020.07.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/29/2020] [Accepted: 07/27/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). STUDY DESIGN Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. RESULTS 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group. CONCLUSIONS MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.
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Affiliation(s)
- Takintope Akinbiyi
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Geoffrey M Kozak
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Harrison D Davis
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Louis-Xavier Barrette
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Arturo J Rios-Diaz
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA; Department of Surgery, Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Russell Maxwell
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Estifanos D Tilahun
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Joshua A Jones
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Robyn B Broach
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Paris D Butler
- Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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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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24
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Treatment of keloids with a single dose of low-energy superficial X-ray radiation to prevent recurrence after surgical excision: An in vitro and in vivo study. J Am Acad Dermatol 2020; 83:1304-1314. [PMID: 32540415 DOI: 10.1016/j.jaad.2020.06.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Although keloids have been empirically treated with steroids and radiation, evidence-based radiation parameters for keloid therapy are lacking. OBJECTIVE To determine evidence-based radiation parameters for blocking keloid fibroblast proliferation in vitro and apply them to patients. METHODS The effects of various radiation parameters and steroids on cell proliferation, cell death, and collagen production in keloid explants and fibroblasts were evaluated with standard assays. Effective radiation parameters were then tested on patients. RESULTS No differences were observed between the effects of 50 and 320 kV radiation or between single and fractionated radiation doses on keloid fibroblasts. A 3 Gy, 50 kV dose inhibited keloid fibroblast proliferation in culture, whereas 9 Gy completely blocked their outgrowth from explants by inducing multiple cell death pathways and reducing collagen levels. Thirteen of 14 keloids treated with a single 8 Gy, 50 kV dose of radiation did not recur, although 4 patients with 6 keloids were lost to follow-up. LIMITATIONS Seventy-five percent of patients received steroids for pruritus, whereas approximately 25% of patients were lost to follow-up. CONCLUSIONS A single 8 Gy dose of superficial 50 kV radiation delivered an average of 34 days after keloid excision maybe sufficient to minimize recurrence, including in individuals resistant to steroids. Higher radiation energies, doses, or fractions may be unnecessary for keloid therapy.
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25
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Smith KA, Kingdom TT, Gray ST, Poetker DM, Orlandi RR. Drug‐eluting implants in chronic rhinosinusitis: an evidence‐based review with recommendations. Int Forum Allergy Rhinol 2020; 10:856-870. [DOI: 10.1002/alr.22565] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 02/28/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Kristine A. Smith
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Manitoba Winnipeg MB Canada
| | - Todd T. Kingdom
- Department of Otolaryngology–Head and Neck SurgeryUniversity of Colorado Denver CO
| | - Stacey T. Gray
- Department of Otolaryngology–Head and Neck SurgeryHarvard Medical School Boston MA
| | - David M. Poetker
- Division of Otolaryngology, Department of SurgeryZablocki VA Medical Center Milwaukee WI
| | - Richard R. Orlandi
- Division of Otolaryngology–Head and Neck SurgeryUniversity of Utah Salt Lake City UT
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26
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Tripathi S, Soni K, Agrawal P, Gour V, Mondal R, Soni V. Hypertrophic scars and keloids: a review and current treatment modalities. BIOMEDICAL DERMATOLOGY 2020. [DOI: 10.1186/s41702-020-00063-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AbstractHypertrophic scars (HTS) are raised, red, rigid, inflexible cell-like, and cosmetic problems precipitated due to multiple underlying dermal injuries such as burn, surgery, and trauma during which aberrant wound healing with more pathological deposition of the extracellular matrix than degradation leads to their spawning. Till date, well established and specific treatments for HTS have not been reported; hence, the need of recent developments is thrusted with novel drug delivery vision. This review will try to encompass all the agogs to HTS, definition, pathophysiology, mechanism of hypertrophic scar formation, the role of growth factors in hypertrophic scarring, and their difference with keloids. Further, it will illuminate the available medicaments and recent advances in novel topical drug delivery systems such as ethosomes, transethosomes, liposomes, solid lipid nanoparticles, and microsponges for treatment of HTS.
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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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Adjuvant Radiotherapy After Keloid Excision: Preliminary Experience in Taiwan. Ann Plast Surg 2019; 83:607-608. [PMID: 31246673 DOI: 10.1097/sap.0000000000001956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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30
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Khalid FA, Mehrose MY, Saleem M, Yousaf MA, Mujahid AM, Rehman SU, Ahmad S, Tarar MN. Comparison of efficacy and safety of intralesional triamcinolone and combination of triamcinolone with 5-fluorouracil in the treatment of keloids and hypertrophic scars: Randomised control trial. Burns 2019; 45:69-75. [DOI: 10.1016/j.burns.2018.08.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 06/20/2018] [Accepted: 08/07/2018] [Indexed: 11/25/2022]
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Renz P, Hasan S, Gresswell S, Hajjar RT, Trombetta M, Fontanesi J. Dose Effect in Adjuvant Radiation Therapy for the Treatment of Resected Keloids. Int J Radiat Oncol Biol Phys 2018; 102:149-154. [PMID: 29970316 DOI: 10.1016/j.ijrobp.2018.05.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 03/21/2018] [Accepted: 05/08/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Surgical excision of keloids can result in an insidious cycle of tissue injury and repeat keloid formation unless combined with adjuvant therapy to halt this cycle. We present our results of postoperative radiation therapy for keloids with various dose regimens. METHODS AND MATERIALS A retrospective review of 124 patients with 250 keloid lesions treated with postoperative radiation therapy was analyzed. In this institutional review board-approved study, 125 keloids were treated to 20 Gy in 5 fractions and 125 keloids were treated to 12 to 16 Gy in 3 to 4 fractions. Local failure was defined as redevelopment of any clinically apparent keloid at the treated site. The median age was 34 years (14-84 years). Keloids were located on the ear (34%), neck/shoulder (19%), abdomen (13%), chest (10%), face (9%), breast (7%), extremities (4%), and back (3%). Median keloid size was 4 cm (0.5-20 cm). RESULTS At a median follow-up of 40 months, the recurrence rate for all lesions was 5.6%. Lesions treated to 20 Gy had a recurrence rate of 1.6% compared with 9.6% with <20 Gy and an odds ratio of 0.16 (P = .02). Upon univariate and multivariate analysis there were no differences in recurrence rate with respect to location, race, gender, age, previously treated lesions, and presence of multiple keloids. The lone predictor for improved control rate was the dose of 20 Gy in 5 fractions compared with less than that. Control rate for lesions treated to a biologically equivalent dose2 of 35 to 36 Gy2, 48 to 52.5 Gy2, and 60 to 72 Gy2 were 10% (P = .007), 8.9% (P = .16), and 1.6% (P = .02), respectively. CONCLUSIONS Surgical excision followed by immediate adjuvant radiation therapy for keloids provides excellent local control and cosmesis. Treatment with a biologically equivalent dose2 > 60 (20 Gy in 5 fractions) yielded superior local control over lower dose regimens.
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Affiliation(s)
- Paul Renz
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania.
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Steven Gresswell
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - Raymond T Hajjar
- Department of Plastic Surgery, Beaumont Hospital, Farmington Hills, Michigan
| | - Mark Trombetta
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, Pennsylvania
| | - James Fontanesi
- Department of Radiation Oncology, Oakland University William Beaumont School of Medicine, Botsford Cancer Center, Farmington Hills, Michigan
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Hoang D, Reznik R, Orgel M, Li Q, Mirhadi A, Kulber DA. Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis. Aesthet Surg J 2017; 37:212-225. [PMID: 27553611 DOI: 10.1093/asj/sjw124] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities. OBJECTIVES We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy. METHODS One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05. RESULTS Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01). CONCLUSIONS Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Don Hoang
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
| | - Robert Reznik
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
| | - Matt Orgel
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
| | - Quanlin Li
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
| | - Amin Mirhadi
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
| | - David A Kulber
- From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA
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Shin JY, Yun SK, Roh SG, Lee NH, Yang KM. Efficacy of 2 Representative Topical Agents to Prevent Keloid Recurrence After Surgical Excision. J Oral Maxillofac Surg 2016; 75:401.e1-401.e6. [PMID: 27865791 DOI: 10.1016/j.joms.2016.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/08/2016] [Accepted: 10/06/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE Keloids are difficult to remove successfully and there is no universally accepted treatment. After surgical excision of the keloid, there are various management methods for prevention of keloid recurrence, such as intralesional injection, radiation, and topical agents. A few studies have compared topical agents with other treatments. The aim of this study was to investigate effective topical agents for the prevention of recurrent keloid after surgical excision. MATERIALS AND METHODS Eligible articles were sought using core databases, including Medline, Embase, and Cochrane databases, up to April 2016. The predictor variables were mitomycin C (MC) and imiquimod cream treatment after keloid excision. The outcome variable was keloid recurrence rate. RESULTS The search strategy identified 120 publications. After screening, 9 articles were selected for review. Articles were divided into 2 groups: MC and imiquimod cream. The recurrence rate after surgical excision in the MC group was estimated to be 16.5%, and that in the imiquimod cream group was estimated to be 24.7%. CONCLUSION If intralesional injection or radiation is not available, then MC or imiquimod 5% cream could be an effective alternative in preventing keloid recurrence.
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Affiliation(s)
- Jin Yong Shin
- Professor, Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, Korea
| | - Seok-Kweon Yun
- Professor, Department of Dermatology, Chonbuk National University Hospital, Jeonju, Korea
| | - Si-Gyun Roh
- Professor, Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, Korea
| | - Nae-Ho Lee
- Professor, Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, Korea.
| | - Kyung-Moo Yang
- Professor, Department of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Jeonju, Korea
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A Comparison of the Effectiveness of Triamcinolone and Radiation Therapy for Ear Keloids after Surgical Excision. Plast Reconstr Surg 2016; 137:1718-1725. [DOI: 10.1097/prs.0000000000002165] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Jannati P, Aref S, Jannati AA, Jannati F, Moravvej H. Comparison of Therapeutic Response of Keloids to Cryotherapy Plus Intralesional Triamcinolone Acetonide or Verapamil Hydrochloride. ACTA ACUST UNITED AC 2015. [DOI: 10.17795/jssc2928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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