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Katano A, Minamitani M, Yamashita H. Risk factors for local recurrence of keloids and hypertrophic scars after postoperative electron beam radiotherapy. J Cancer Res Ther 2024; 20:163-166. [PMID: 38554315 DOI: 10.4103/jcrt.jcrt_1861_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/10/2022] [Indexed: 04/01/2024]
Abstract
OBJECTIVE Keloids and hypertrophic scars are benign fibroproliferative lesions that occur as a result of skin injury. Postoperative radiation therapy is used to reduce the recurrence rate because of the high recurrence rate with surgical treatment alone. This study aimed to identify the risk factors for recurrence after postoperative electron beam radiotherapy. MATERIALS AND METHODS Patients with keloid or hypertrophic scars with at least one lesion and who underwent postoperative electron beam radiotherapy at our institution from June 2013 to March 2022 were included in the study, while patients with a follow-up period of fewer than three months were excluded. RESULTS A retrospective analysis was performed on 94 lesions in 81 patients. Exactly two years after the treatment, the actuarial local control rate was 86.4%. The chest wall, shoulder, and suprapubic area were identified as high-risk recurrence sites. Compared to other body sites, these sites had significantly lower local control rates (two-year local control rates: 75.5% vs. 95.2%, P = 0.005). After multivariate analysis, treatment site (P = 0.014), male gender (P = 0.019), and younger age (P = 0.029) were revealed to be statistically significant risk factors for local recurrence. Risk factors for keloid recurrence after postoperative electron beam radiotherapy were therefore identified. CONCLUSION This result could be used for follow-up and as a determinant for the optimal dose/fractionation of postoperative radiotherapy.
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Affiliation(s)
- Atsuto Katano
- Department of Radiology, University of Tokyo Hospital, Tokyo, Japan
| | - Masanari Minamitani
- Department of Comprehensive Radiation Oncology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Significance: Hypertrophic scarring is a challenging issue for patients and clinicians. The prevalence of hypertrophic scarring can be up to 70% after burns, and patients suffer from pain, itching, and loss of joint mobility. To date, the exact mechanisms underlying hypertrophic scar formation are unclear, and clinical options remain limited. Recent Advances: Several studies have demonstrated that pathological scars are a type of hyperactive vascular response to wounding. Scar regression has been found to be accompanied by microvessel occlusion, which causes severe hypoxia, malnutrition, and endothelial dysfunction, suggesting the essential roles of microvessels in scar regression. Therefore, interventions that target the vasculature, such as intense pulsed light, pulsed dye lasers, vascular endothelial growth factor antibodies, and Endostar, represent potential treatments. In addition, the mass of scar-associated collagen is usually not considered by current treatments. However, collagen-targeted therapies such as fractional CO2 laser and collagenase have shown promising outcomes in scar treatment. Critical Issues: Traditional modalities used in current clinical practice only partially target scar-associated microvessels or collagen. As a result, the effectiveness of current treatments is limited and is too often accompanied by undesirable side effects. The formation of scars in the early stage is mainly affected by microvessels, whereas the scars in later stages are mostly composed of residual collagen. Traditional therapies do not utilize specific targets for scars at different stages. Therefore, more precise treatment strategies are needed. Future Directions: Scars should be classified as either "vascular-dominant" or "collagen-dominant" before selecting a treatment. In this way, strategies that are vascular-targeted, collagen-targeted, or a combination thereof could be recommended to treat scars at different stages.
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Affiliation(s)
- Bo Yuan
- Burns and Plastic Surgery Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Zee Upton
- Institute of Medical Biology, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - David Leavesley
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
| | - Chen Fan
- Skin Research Institute of Singapore, Agency for Science, Technology and Research (A*STAR), Singapore, Singapore
- Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, China
- Correspondence: Chen Fan, Wenzhou Institute, University of Chinese Academy of Sciences, Wenzhou, Zhejiang 325000, China
| | - Xi-Qiao Wang
- Burns and Plastic Surgery Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
- Correspondence: Xi-Qiao Wang, Burns and Plastic Surgery Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai, P.R. China
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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] [What about the content of this article? (0)] [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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Liu EK, Cohen RF, Chiu ES. Radiation therapy modalities for keloid management: a critical review. J Plast Reconstr Aesthet Surg 2022. [DOI: 10.1016/j.bjps.2022.04.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
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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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Ogawa R. The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago. Plast Reconstr Surg 2022; 149:79e-94e. [PMID: 34813576 PMCID: PMC8687618 DOI: 10.1097/prs.0000000000008667] [Citation(s) in RCA: 97] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 05/12/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review. METHODS All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available. RESULTS Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis. CONCLUSIONS Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
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Affiliation(s)
- Rei Ogawa
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
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Wang K, Hu J, Chen T, Tang J, Zhai Y, Feng Y, Zhao Z, Fan H, Wang K. Radiation shielding properties of flexible liquid metal-GaIn alloy. Progress in Nuclear Energy 2021. [DOI: 10.1016/j.pnucene.2021.103696] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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10
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Ellis MM, Jones LR, Siddiqui F, Sunkara PR, Ozog DM. The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis. Dermatol Surg 2020; 46:1054-9. [PMID: 32224709 DOI: 10.1097/DSS.0000000000002362] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Gold MH, Nestor MS, Berman B, Goldberg D. Assessing keloid recurrence following surgical excision and radiation. Burns Trauma 2020; 8:tkaa031. [PMID: 33225004 PMCID: PMC7666880 DOI: 10.1093/burnst/tkaa031] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 04/02/2020] [Accepted: 06/28/2020] [Indexed: 01/01/2023]
Abstract
Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.
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Affiliation(s)
- Michael H Gold
- Gold Skin Care Center, 2000 Richard Jones Road, Suite 220, Nashville, TN 37215
| | - Mark S Nestor
- Center for Clinical and Cosmetic Research, 2925 NE 199th St, Suite 205, Aventura, FL 33180
| | - Brian Berman
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - David Goldberg
- Skin Laser & Surgery Specialists of NY/NJ, 110 E. 55th Street, 13th floor, New York, NY 10022
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Maemoto H, Iraha S, Arashiro K, Ishigami K, Ganaha F, Murayama S. Risk factors of recurrence after postoperative electron beam radiation therapy for keloid: Comparison of long-term local control rate. Rep Pract Oncol Radiother 2020; 25:606-611. [PMID: 32523428 DOI: 10.1016/j.rpor.2020.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/25/2020] [Accepted: 05/06/2020] [Indexed: 11/17/2022] Open
Abstract
Aim To investigate the new risk factors for keloid recurrence after postoperative electron beam radiotherapy (RT) and evaluate the effectiveness of tranilast in combination with electron beam RT by comparing the local control rate. Background Identifying patients at high risk of recurrence after postoperative RT for keloids remains a challenge. Besides, no study examined the effectiveness of tranilast in combination with RT after surgery for the prevention of keloids recurrence. Materials and Methods This study included 75 lesions in 59 consecutive patients who had undergone postoperative RT at our institute. The follow-up period and prescription of tranilast were examined beside several potential risk factors, such as multiple lesions, size, and shape. Results The median follow-up was 72 months (range, 6-147 months). Twenty-one lesions in 17 patients recurred in a median of 12 months after treatment (range, 1-60 months). Local control rates of all 75 lesions were estimated as 93%, 78%, 70%, and 68% at 1, 2, 5, and 10 years. Multiple lesions constituted a significant risk of recurrence (P = 0.03). A larger long axis was significantly related to the recurrence (P < 0.01). Irregular shape was associated with a significantly worse local control rate (P = 0.02). There was no significant difference in the local control rate between patients receiving tranilast and those who did not (P = 0.52). Conclusions Multiple lesions and irregular shape were risk factors of keloid recurrence after postoperative electron beam RT. The effectiveness of tranilast was not demonstrated in the study.
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Affiliation(s)
- Hitoshi Maemoto
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
| | - Shiro Iraha
- Department of Radiology, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, Okinawa, Japan
| | | | - Kousei Ishigami
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
| | - Fumikiyo Ganaha
- Department of Radiology, Okinawa Prefectural Nanbu Medical Center & Children's Medical Center, Okinawa, Japan
| | - Sadayuki Murayama
- Department of Radiology, Graduate School of Medical Science, University of the Ryukyus, Okinawa, Japan
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Bautista Hernandez Y, Villavicencio Queijero MA, Quezada Bautista AA, Vazquez Tinajero A. Surface brachytherapy in the treatment of keloid scars in Mexico. Rep Pract Oncol Radiother 2020; 25:133-138. [PMID: 31920465 PMCID: PMC6948234 DOI: 10.1016/j.rpor.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 07/20/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To demonstrate that superficial high-dose-rate (HDR) brachytherapy by means of Leipzig applicators or moulds with catheters is an adjuvant treatment with impact on local control and low toxicity. BACKGROUND Keloid scars occur in 5-15 % of cases, secondary to an uncontrolled proliferation of fibroblasts and reduction in the inhibition of growth factors. MATERIAL AND METHODS Retrospective, longitudinal and descriptive study in patients with keloid scars who were treated with superficial HDR brachytherapy in the General Hospital of Mexico between November 2009 and December 2013. RESULTS Eighty patients were evaluated, and the mean follow-up was 22.18 months (range 8-48). The anatomic site treated was the ear in 72 patients (90.0 %), anterior thorax in 5 patients, retroauricular region in 2, and abdomen region in 1 patient. The application was performed 24 h after surgery; the dose for 79 patients (99 %) was 1500 cGy/3 fractions, and 1 received 500 cGy in 1 fraction. Adequate healing occurred in 76 patients (95 %), and the local failure was 5 % (95 % CI). Acute toxicity occurred in 15 % (12 patients) with grade 1 radioepithelitis. Chronic toxicity occurred in 22 patients (27.5 %) with grade 1 hypopigmentation and 18 patients (22.5 %) with grade 1 fibrosis. The cosmetic result was good in 72 patients (90 %). During follow-up, 2 patients presented recurrence, and 2 patients persisted. CONCLUSIONS Treatment with superficial brachytherapy in keloid scars using a mould with catheters or a Leipzig applicator is a therapeutic option that results in 95 % local control and low toxicity.
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Affiliation(s)
- Yicel Bautista Hernandez
- Hospital General de México “Dr. Eduardo Liceaga”, 148 Balmis Street, Doctores Colony, Mexico City 06720, Mexico
| | - Michelle Aline Villavicencio Queijero
- Centro Médico Nacional 20 de Noviembre, Issste (Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado), 540 Felix Cuevas Street, del Valle Sur Colony, Mexico City 03100, Mexico
- ISSSTE and ABC Medical Center, 136 116 South, Las Americas, Alvaro Obregon, 01120, Mexico City, Mexico
| | - Abril Antonia Quezada Bautista
- Fucam (Fundación de Cáncer de Mama), 100 El Bordo Avenue, El Vergel de Coyoacán Colony, México City 04980, Mexico
- Fucam and Hospital Juarez de Mexico, 5160 Politecnico Nacional Avenue, Magdalena de las Salinas Colony, Mexico City 07760, Mexico
| | - Azcary Vazquez Tinajero
- Hospital General de México “Dr. Eduardo Liceaga”, 148 Balmis Street, Doctores Colony, Mexico City 06720, Mexico
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Ogawa R, Akita S, Akaishi S, Aramaki-Hattori N, Dohi T, Hayashi T, Kishi K, Kono T, Matsumura H, Muneuchi G, Murao N, Nagao M, Okabe K, Shimizu F, Tosa M, Tosa Y, Yamawaki S, Ansai S, Inazu N, Kamo T, Kazki R, Kuribayashi S. Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018. Burns Trauma 2019; 7:39. [PMID: 31890718 PMCID: PMC6933735 DOI: 10.1186/s41038-019-0175-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 10/14/2019] [Indexed: 01/05/2023]
Abstract
There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.
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Affiliation(s)
- Rei Ogawa
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Sadanori Akita
- 2Department of Plastic Surgery, Wound Repair and Regeneration, Fukuoka University, Fukuoka, 814-0180 Japan
| | - Satoshi Akaishi
- 3Department of Plastic Surgery, Nippon Medical School Musashikosugi Hospital, 1-396 Kosugicho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533 Japan
| | - Noriko Aramaki-Hattori
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Teruyuki Dohi
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Toshihiko Hayashi
- 5Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638 Japan
| | - Kazuo Kishi
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Taro Kono
- 6Department of Plastic Surgery, Tokai University School of Medicine, 4-1-1 Kitakaname, Hiratsuka, Kanagawa 259-1292 Japan
| | - Hajime Matsumura
- 7Department of Plastic and Reconstructive Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023 Japan
| | - Gan Muneuchi
- 8Department of Plastic and Reconstructive Surgery, Osaka Saiseikai Nakatsu Hospital, 2-10-39 Shibata, Kita-ku, Osaka, 530-0012 Japan
| | - Naoki Murao
- 5Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, Sapporo, 060-8638 Japan
| | - Munetomo Nagao
- 9Department of Plastic, Reconstructive and Aesthetic Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate 020-8505 Japan
| | - Keisuke Okabe
- 4Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Fumiaki Shimizu
- 10Department of Plastic Surgery, Oita University Hospital, 1-1 Idaigaoka, Hasamamachi, Yufu-shi, Oita 879-5503 Japan
| | - Mamiko Tosa
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Yasuyoshi Tosa
- 11Department of Plastic Surgery, Showa University Fujigaoka Hospital, 1-30 Fujigaoka, Aoba-ku, Yokohama, Kanagawa Japan
| | - Satoko Yamawaki
- Department of Plastic and Reconstructive Surgery, Japanese Red Cross Fukui Hospital, 2-4-1 Tsukimi, Fukui, 918-8501 Japan
| | - Shinichi Ansai
- 13Division of Dermatology and Dermatopathology, Nippon Medical School Musashikosugi Hospital, 1-396, Kosugicho, Nakahara-ku, Kawasaki-shi, Kanagawa 211-8533 Japan
| | - Norihisa Inazu
- 14Faculty of Pharmaceutical Sciences, Teikyo Heisei University, 4-21-2 Nakano, Nakano-ku, Tokyo, 164-8530 Japan
| | - Toshiko Kamo
- Wakamatsu-cho Mental and Skin Clinic, 9-4 Wakamatsu-cho, Shinjyuku-ku, Tokyo, 162-0056 Japan
| | - Reiko Kazki
- 1Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, 1-1-5 Sendagi Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Shigehiko Kuribayashi
- 16Department of Radiation Oncology, Nippon Medical School Hospital, Tokyo, 113-8603 Japan
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Yang X, Shao Y, Yu W, Zhang X, Sun Y, Zhang L, Li H, Yang X, Fu J. A Novel Radiotherapy Approach for Keloids with Intrabeam. Biomed Res Int 2019; 2019:4693528. [PMID: 31428636 DOI: 10.1155/2019/4693528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/10/2019] [Accepted: 07/14/2019] [Indexed: 01/05/2023]
Abstract
Background Keloids are hard nodules or plaques formed by excessive proliferation of connective tissue. Radiotherapy, widely used in various benign and malignant skin diseases, is an effective treatment for keloids. This work evaluates Intrabeam photon radiotherapy in the management of keloids. Methods Fourteen patients who have undergone Intrabeam radiotherapy for a total of 15 sites of keloids were followed up. Twelve cases were first onset and the other two had recurrent diseases. Thirteen patients underwent surgical resection of keloids before radiotherapy. One relapsing patient received only 2 rounds of radiation therapy as she could not be reoperated. Radiotherapy was divided into 2 sessions on days 0 and 3 after surgery. The dose was 4 or 5 Gy each time for 3 min 14 s to 12 min 1 s. In addition, we compared our data to the recurrence of keloids in fourteen patients who had previously been exposed to electron beam using conventional accelerators. Results We analyzed the treatment for adverse reactions and recurrence. In the Intrabeam group, one patient developed superficial skin ulcers a month after treatment. No one experienced wound rupture, bleeding, infection, skin contractures, or obvious hyperpigmentation. None of the fourteen cases showed any recurrence so far after on median 22.5 months of follow-up. Five patients in the electron beam group relapsed 3 to 10 months after treatment. Conclusion Here, Intrabeam photon radiotherapy was shown to be an effective treatment for keloid scars and it is therefore recommended for management of this disease.
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Huang C, Liu L, You Z, Du Y, Ogawa R. Managing keloid scars: From radiation therapy to actual and potential drug deliveries. Int Wound J 2019; 16:852-859. [PMID: 30864269 DOI: 10.1111/iwj.13104] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/07/2019] [Accepted: 02/10/2019] [Indexed: 12/19/2022] Open
Abstract
The aetiology of keloids is becoming clearer, but many questions remain, including about the most optimal treatment. Current therapies include surgical excision, radiotherapy, and various pharmaceutical drugs. However, none of these drugs are keloid-specific. Moreover, all current interventions are associated with high recurrence rates. Here, we review the pharmaceutical interventions that are currently available. All are based on the fact that keloids are an expanding solid mass with intense chronic inflammation at its advancing edges. Consequently, current pharmaceuticals aim to reduce the mass and/or symptoms of keloids, similar to surgery and radiotherapy. They include chemotherapies, immunotherapies, volume-reducing therapies, and anti-inflammatory therapies. We also describe new advances in keloid pharmaceuticals. They include drugs that were designed to treat systemic diseases such as hypertension or breast cancer but were found to also treat keloids. Furthermore, recent progress in genetic, epigenetic, and stem cell therapies suggests that they could become useful in the keloid field. This review of pharmaceutical advances will hopefully promote additional research and the development of effective and specific pharmaceuticals for keloids.
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Affiliation(s)
- Chenyu Huang
- Department of Dermatology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Longwei Liu
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Zhifeng You
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Yanan Du
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, China
| | - Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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17
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Abstract
Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.
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Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Mamiko Tosa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
| | - Satoshi Akaishi
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School Hospital, Tokyo, Japan
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Jiang P, Geenen M, Siebert FA, Bertolini J, Poppe B, Luetzen U, Dunst J, Druecke D. Efficacy and the toxicity of the interstitial high-dose-rate brachytherapy in the management of recurrent keloids: 5-year outcomes. Brachytherapy 2018; 17:597-600. [PMID: 29305151 DOI: 10.1016/j.brachy.2017.12.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/03/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Recurring keloids are a clinical challenge. Interdisciplinary treatments are required in most cases. Owing to the wide variety of concepts, the optimal treatment regime remains unclear. Our clinic established a protocol of perioperative interstitial high-dose-rate brachytherapy with three fractions of 6 Gy and achieved an excellent 2-year local control rate of 94% (In search of the optimal treatment of keloids: Report of a series and a review of the literature). This report is an update on our long-term results of prospective study. Twenty-nine patients were included with a median followup of 5 years. METHODS AND MATERIALS From 2009 to 2015, 29 patients with 37 recurrent keloids were treated with perioperative interstitial high-dose-rate brachytherapy; 3 patients had been previously treated with adjuvant external beam radiotherapy and presented with recurrences in the pretreated area. Brachytherapy was given in three fractions with a single dose of 6 Gy in 5-mm tissue depth and covered the scar in total length. Followup visits were scheduled at 6 weeks, 3 months, 6 months, 1 year, and annually thereafter. Therapeutic outcome was assessed in terms of recurrence, acute and late complications, and cosmetic results. RESULTS No procedure-related complications occurred. Improvement of keloid-related symptoms was noticed in all patients after treatment. After a median followup of 49.7 months (range: 7.9-91.9 months), three keloid recurrences and two hypertrophied scars were observed. CONCLUSIONS Our results suggest that brachytherapy may be advantageous in the management of high-risk keloids, even after failure of external beam radiotherapy and other treatment procedures. Our three-fraction treatment schedule reduces the treatment period to 2 days and is therefore convenient for the patients.
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Affiliation(s)
- Ping Jiang
- Department of Radiation Oncology, University Clinic Schleswig-Holstein, Campus Kiel, Kiel, Germany.
| | - Matthias Geenen
- Department of Reconstructive Surgery, Lubinus Clinic Kiel, Kiel, Germany
| | - Frank-André Siebert
- Department of Radiation Oncology, University Clinic Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Julia Bertolini
- Department of Reconstructive Surgery, University Clinic Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bjoern Poppe
- University Clinic for Medical Radiation Physics, Medical Campus Pius-Hospital, Carl von Ossietzky University, Oldenburg, Germany
| | - Ulf Luetzen
- Department of Nuclear Medicine, University Clinic Schleswig-Holstein, Campus Kiel, Germany
| | - Juergen Dunst
- Department of Radiation Oncology, University Clinic Schleswig-Holstein, Campus Kiel, Kiel, Germany; Department of Radiation Oncology, University of Copenhagen, Denmark
| | - Daniel Druecke
- Department of Reconstructive Surgery, University Clinic Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Bijlard E, Verduijn GM, Harmeling JX, Dehnad H, Niessen FB, Meijer OWM, Mureau MAM. Optimal High-Dose-Rate Brachytherapy Fractionation Scheme After Keloid Excision: A Retrospective Multicenter Comparison of Recurrence Rates and Complications. Int J Radiat Oncol Biol Phys 2017; 100:679-686. [PMID: 29249529 DOI: 10.1016/j.ijrobp.2017.10.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/24/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To determine the optimal brachytherapy dose and fractionation scheme for keloid treatment. METHODS AND MATERIALS Patient cohorts from 3 centers treated with keloid excision followed by 2 × 9 Gy, 3 × 6 Gy, or 2 × 6 Gy high-dose-rate brachytherapy were retrospectively compared regarding recurrence (after at least 12 months' follow-up) and complications (after at least 1 month's follow-up), using logistic regression analyses. RESULTS A total of 238 keloids were treated. An overall full recurrence rate of 8.3% was found. After correction for confounders (sex, skin color, keloid location, keloid duration) no statistically significant differences in recurrence rates could be discerned between fractionation schemes. There were 12.8% major and 45.6% minor complication rates. Lower radiation dose resulted in significantly fewer complications (odds ratio 0.35, P=.015). CONCLUSIONS After excision of resistant keloids, high-dose-rate brachytherapy with a biological equivalent dose of approximately 20 Gy is recommended, on the basis of low recurrence and complication rates.
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Affiliation(s)
- Eveline Bijlard
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Gerda M Verduijn
- Department of Radiation Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J X Harmeling
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Homan Dehnad
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank B Niessen
- Department of Plastic and Reconstructive Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Otto W M Meijer
- Department of Radiation Oncology, VU Medical Center, Amsterdam, The Netherlands
| | - Marc A M Mureau
- Department of Plastic and Reconstructive Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ahmad M, Ahmad H, Khattak MR, Shah KA, Javed N, Shah SJA, Shaheen W, Mansoor K. Postoperative single versus multiple fractions high-dose rate iridium-192 surface mould brachytherapy for keloid treatment: a comparative study. J Radiother Pract 2018; 17:60-5. [DOI: 10.1017/s1460396917000395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractBackground and purposeIn developing countries like Pakistan the cost effectiveness and patient convenience in any treatment modality is a question of major concern. The purpose of this study was two-fold; first to report our experience with a high-dose rate Iridium-192 surface mould brachytherapy of keloid scars after surgical excision, using different radiation treatment regimen and second to establish the most convenient and cost effective treatment protocol having no compromise on the treatment outcomes.Materials and methodsFrom January 2012 to April 2015 a total 51 patients with 65 keloid lesions underwent postoperative Iridium-192 high-dose rate surface mould brachytherapy. The dose regimen used was: 8 Gy in a single fraction, 10 Gy in a single fraction, 15 Gy in three fractions and 18 Gy in three fractions. The median follow-up period was 33 months (range 15–53 months).ResultsThe success rates were 57·2, 89·5, 85 and 89·5% for the treatment regimen of 8 Gy/F×1, 10 Gy/F×1, 5 Gy/F×3 and 6 Gy/F×3, respectively. Grade 2 or above radiation induced toxicity was not observed.FindingsThe results of this study show that a dose regimen of 10 Gy (biological effective dose=20 Gy) in a single fraction have comparable results with a dose regimen of 15 Gy in three fractions or 18 Gy in three fractions. 10 Gy in a single fraction is therefore the most convenient and cost effective dose regimen for the management of keloid scars in developing countries like Pakistan, while 8 Gy in a single fraction is considered suboptimal and discouraged in practice.
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Ogawa R, Akaishi S, Kuribayashi S, Miyashita T. Keloids and Hypertrophic Scars Can Now Be Cured Completely: Recent Progress in Our Understanding of the Pathogenesis of Keloids and Hypertrophic Scars and the Most Promising Current Therapeutic Strategy. J NIPPON MED SCH 2017; 83:46-53. [PMID: 27180789 DOI: 10.1272/jnms.83.46] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Keloids and hypertrophic scars are fibroproliferative disorders of the skin that are caused by abnormal healing of injured or irritated skin. It is possible that they are both manifestations of the same fibroproliferative skin disorder and just differ in terms of the intensity and duration of inflammation. These features may in turn be influenced by genetic, systemic, and local risk factors. Genetic factors may include single nucleotide polymorphisms, while systemic factors may include hypertension, pregnancy, hormones, and cytokines. The most important local factor is tension on the scar. Over the past 10 years, our understanding of the pathogenesis of keloids and hypertrophic scars has improved markedly. As a result, these previously intractable scars are now regarded as being treatable. There are many therapeutic options, including surgery, radiation, corticosteroids, 5-fluorouracil, cryotherapy, laser therapy, anti-allergy agents, anti-inflammatory agents, bleaching creams and make-up therapies. However, at present, we believe that the following combination of three therapies most reliably achieves a complete cure: surgery, followed by radiation and the use of steroid tape/plaster.
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Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School
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22
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Mankowski P, Kanevsky J, Tomlinson J, Dyachenko A, Luc M. Optimizing Radiotherapy for Keloids: A Meta-Analysis Systematic Review Comparing Recurrence Rates Between Different Radiation Modalities. Ann Plast Surg 2017; 78:403-11. [DOI: 10.1097/sap.0000000000000989] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Hafkamp C, Lapid O, Dávila Fajardo R, van de Kar A, Koedooder C, Stalpers L, Pieters B. Postoperative single-dose interstitial high-dose-rate brachytherapy in therapy-resistant keloids. Brachytherapy 2017; 16:415-420. [DOI: 10.1016/j.brachy.2016.12.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/12/2016] [Indexed: 11/26/2022]
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24
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
INTRODUCTION Radiation therapy is a well-recognised modality for the adjuvant treatment of keloid scars. It can be conventionally delivered as external beam using a large apparatus at a distance from the lesion or as brachytherapy with specialised equipment to enable the delivery of treatment in the immediate vicinity of the keloidal tissue. METHODS An English literature review was performed with keywords 'brachytherapy' and 'keloid' using the databases PubMed, Embase and Web of Science from their individual dates of inception until June 2017. Studies pertinent to the field are presented in a chronological manner to depict the evolution of different brachytherapy strategies over the last decades. We also discuss considerations relating to the risk of secondary carcinogenesis, which are relevant to shared decision-making in the clinical setting. DISCUSSION Low dose rate interstitial brachytherapy was first introduced in the English literature in 1976 and currently appears to have been superseded by more modern approaches, including high dose rate interstitial brachytherapy. This modality compares favourably to more traditional modes of radiotherapy in terms of recurrence as well as rates of symptomatic relief from keloidal symptoms. Superficial brachytherapy was introduced more recently in the relevant literature and appears to be associated with favourable therapeutic outcomes compared to external beam radiation therapy. CONCLUSION Brachytherapy is a valid modality of radiotherapy for the adjuvant treatment of keloid scars, with high dose rate interstitial and surface regimens gaining in popularity over recent years. Further research needs to focus on randomised controlled trials to further establish the role of different radiotherapy modalities in keloid scar management.
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Affiliation(s)
- Ioannis Goutos
- Centre for Cutaneous Research, Blizard
Institute, London, UK
| | - Rei Ogawa
- Department of Plastic, Reconstructive
and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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Abstract
Background The high recurrence rate following keloid resection has generated interest in adjuvant treatments for this disease. Objective This study assesses keloid recurrence when treated with surgery and adjuvant radiotherapy. Methods Retrospective analysis of resected keloids in patients referred to a Chilean radiation oncology centre between 2006 and 2013. Local recurrence was defined as new tissue growth on the surgical scar margin. Results Around103 keloids were analysed in 63 patients treated with 15 Gy in three fraction radiotherapy which was initiated on the same day as the surgery (75% of cases). The median keloid diameter was 6 cm; the most common site was thoracic (22%); the most common cause was prior surgery (35%); 37% caused symptoms, and several (47%) had received prior treatment with corticosteroids (32%), or surgery (30%). The median follow-up was three years, and 94% of recurrences occurred during the first year following treatment. Uni and multivariate analyses showed that an absence of symptoms was a protective factor for recurrence (OR: 0.24), while the time interval from onset to treatment with surgery plus radiotherapy >4.2 years was a risk factor (OR: 2.23). The first year recurrence rate was 32% and stabilised at 32% by the second year with no recurrences after 15 months. Conclusions The combination of surgery and radiotherapy proved to be a good therapeutic alternative in the management of keloids. Our results are similar to those described in the literature for a dose of 15 Gy. Given these results, our centre will implement a new dose escalation protocol to improve future outcomes.
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Affiliation(s)
| | - Carla M Ibarra
- Servicio de Cirugía General, Hospital Militar, Santiago, Chile
| | | | - Moisés N Russo
- Servicio de Radioterapia, Clínica IRAM, Santiago 7630595, Chile
| | - Claudio P Solé
- Service de Radiothérapie, Institut Gustave Roussy, París 94805, France
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Ogawa R, Ono S, Akaishi S, Dohi T, Iimura T, Nakao J. Reconstruction after Anterior Chest Wall Keloid Resection Using Internal Mammary Artery Perforator Propeller Flaps. Plast Reconstr Surg Glob Open 2016; 4:e1049. [PMID: 27757357 PMCID: PMC5055023 DOI: 10.1097/gox.0000000000001049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/03/2016] [Indexed: 11/30/2022]
Abstract
It is difficult to completely resect huge anterior chest wall keloids and then close the wound directly. We report here our retrospective analysis of our case series of patients with such keloids who underwent reconstruction with internal mammary artery perforator (IMAP) pedicled propeller flaps and then received postoperative high-dose-rate superficial brachytherapy.
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Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Shimpei Ono
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Satoshi Akaishi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Teruyuki Dohi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Takeshi Iimura
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
| | - Junichi Nakao
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan
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28
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Jiang P, Baumann R, Dunst J, Geenen M, Siebert F, Niehoff P, Bertolini J, Druecke D. Perioperative Interstitial High-Dose-Rate Brachytherapy for the Treatment of Recurrent Keloids: Feasibility and Early Results. Int J Radiat Oncol Biol Phys 2016; 94:532-6. [DOI: 10.1016/j.ijrobp.2015.11.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/04/2015] [Indexed: 11/23/2022]
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Ogawa R, Akaishi S, Dohi T, Kuribayashi S, Miyashita T, Hyakusoku H. Analysis of the Surgical Treatments of 63 Keloids on the Cartilaginous Part of the Auricle: Effectiveness of the Core Excision Method. Plast Reconstr Surg 2015; 135:868-75. [DOI: 10.1097/prs.0000000000000962] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Leeuwen MCE, Stokmans SC, Bulstra AJ, Meijer OWM, van Leeuwen PAM, Niessen FB. High-dose-rate brachytherapy for the treatment of recalcitrant keloids: a unique, effective treatment protocol. Plast Reconstr Surg 2014; 134:527-34. [PMID: 25158710 DOI: 10.1097/PRS.0000000000000415] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature. METHODS This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale. RESULTS The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals. CONCLUSIONS The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Abstract
BACKGROUND Following injury, Asian skin has a tendency towards hyper-pigmentation and scar formation, and therefore the prevention of scarring is particularly important in Asian patients. Since publication of an International Clinical Recommendation on Scar Management in 2002, there have been numerous publications in the field of scar management. Advances in understanding scar formation have also led to the introduction of new treatments as well as a better understanding of established therapeutic options. METHODS A literature search for abstracts, clinical trials and meta-analyses evaluating scar prevention and treatment was performed using PubMed and the Cochrane Database of Systematic Reviews. Based on this data a panel of experts formulated treatment recommendations for Asian patients. RESULTS Following surgery, scar prevention should be initiated in all Asian patients due to the high risk of poor scars. There is strong evidence for the efficacy of silicone based products, and due to their ease of use, they can be considered first-line therapy. Silicone gel (versus silicone gel sheets) products have demonstrated efficacy. For patients who fail to respond to first-line therapy, intralesional steroid injections, radiation therapy, and intralesional 5-flourouracil injections have achieved widespread acceptance. Laser treatments have been increasingly used, although the evidence remains largely anecdotal without a clear consensus on optimal wavelength, or amount of energy. Surgical approaches have increased in sophistication with recognition of the impact that tension has on scar formation. CONCLUSION Updated scar management recommendations will benefit practitioners making decisions regarding optimal, evidence-based treatment strategies for their patients.
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Ogawa R, Huang C, Akaishi S, Dohi T, Sugimoto A, Kuribayashi S, Miyashita T, Hyakusoku H. Analysis of Surgical Treatments for Earlobe Keloids. Plast Reconstr Surg 2013; 132:818e-825e. [DOI: 10.1097/prs.0b013e3182a4c35e] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Keloids are defined as excessive scar tissue formation extending beyond the area of the original skin injury and occurring in predisposed individuals. While no single treatment has proven widely effective, several series report excellent outcomes for keloids with post-surgery radiation therapy as described in the literature. We present a patient with recurrent giant keloid of left buttock after several surgical removals, that at physical examination shows the size of 40×22×10 cm in the largest dimension. Patient underwent a surgical excision of gluteal lesion and postoperative radiotherapy using photons at 8 MV of linear accelerator: the total dose delivered was 22 Gy in 11 days, with a daily fraction of 2 Gy. No relapse was showed at 36 months post-therapy. Several methods seem unsatisfactory for preventing keloid recurrence. The combination of surgery and adjuvant radiotherapy seems an excellent strategy to prevent recurrent disease.
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Affiliation(s)
- Michele Troiano
- Department of Oncology, Scientific Institute Hospital Casa Sollievo della Sofferenza, San Giovanni Rotondo (FG), Italy
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