Treatment of keloids by high-dose-rate brachytherapy: A seven-year study

Purpose: To analyze the results obtained in a prospective group of patients with keloid scars treated by high-dose-rate (HDR) brachytherapy with or wi thout surgery. Methods and Materials: One hundred and sixty-nine patients with keloid scar s were treated with HDR brachytherapy between December 1991 and December 19 98. One hundred and thirty-four patients were females, and 35 were males. T he distribution of keloid scars was as follows: face, 77; trunk, 73; and ex tremities, 19. The mean length was 4.2 cm (range 2-22 cm), and the mean wid th 1.8 cm (range 1.0-2.8 cm). In 147 patients keloid tissues were removed b efore HDR brachytherapy treatment, and in 22 HDR brachytherapy was used as definitive treatment. In patients who underwent prior surgery, a flexible p lastic tube was put in place during the surgical procedure. Bottoms were us ed to fix the plastic tubes, and the surgical wound was repaired by absorba ble suture. HDR brachytherapy was administered within 30-60 min of surgery. A total dose of 12 Gy (at 1 cm from the center of the catheter) was given in four fractions of 300 cGy in 24 h (at 09.00 am, 15.00 pm, 21.00 pm, and 09.00 am next day). Treatment was optimized using standard geometric optimi zation. In patients who did not undergo surgery, standard brachytherapy was performed, and plastic tubes were placed through the skin to cover the who le scar. Local anesthesia was used in all procedures. In these patients a t otal dose of 18 Gy was given in 6 fractions of 300 cGy in one and a half da ys (at 9.00 am, 3.00 pm, and 9.00 pm; and at 9.00 am, 3.00 pm, and 9.00 pm next day). No further treatment was given to any patient. Patients were see n in follow-up visits every 3 months during the first year, every 6 months in the second year, and yearly thereafter. No patient was lost to follow-up . Particular attention was paid to keloid recurrence, late skin effects, an d cosmetic results. Results: All patients completed the treatment. After a follow-up of seven y ears, 8 patients (4.7%) had keloid recurrences. Five of these had undergone prior surgery (local failure rate 3.4%), and 3 had received only HDR brach ytherapy (local persistence fate 13.6%), Cosmetic results were considered t o be good or excellent in 130/147 patients treated with prior surgery and i n 17/22 patients without surgery. Skin pigmentation changes were observed i n 10 patients, and tetangiectasias in 12 patients. No late effects such as skin atrophy or skin fibrosis were observed during the 7 years of follow-up . Conclusions: HDR brachytherapy is an effective treatment for keloid scars. It is well tolerated and does not present significant side effects. The bra chytherapy results were more successful in patients who underwent previous surgical excision of keloid scar than in patients without surgery. We favor HDR brachytherapy rather than superficial X-rays or low energy electron be ams in keloid scars, because HDR provides a better selective deposit of rad iation in tissues and a lower degree of normal tissue irradiation. Other ad vantages of high-dose-rate brachytherapy over low-dose-rate brachytherapy a re its low cost, the fact that it can be performed on an outpatient basis, its excellent radiation protection, and the better dose distribution obtain ed. From the clinical perspective, the technique provides a high local cont rol rate without significant sequelae or complications. (C) 2001 Elsevier S cience Inc.