Ear lobe keloids, surgical excision followed by radiation therapy: a 10-year experience.

Chaudhry MR, Akhtar S, Duvalsaint F, Garner L, Lucente FE.   Ear Nose Throat J 1994 Oct;73(10):779-81

Department of Otolaryngology and Radiation Oncology, State University of New York Health Science Center at Brooklyn.

This retrospective study was conducted to analyze the recurrence of ear lobe keloids in 36 patients after surgical excision followed by radiation therapy. In all the cases keloids were excised and the surgical wound closed primarily. Following surgery, patients underwent 1800 cGy of radiation therapy in three equally divided doses over five to seven days. Most of our patients were young black females who developed keloids secondary to ear lobe piercing. Of the 36 patients followed for a mean period of 5.6 years, we noted only one (2.8%) recurrence. All the patients were followed for a minimum of two years. No serious complications were observed in our series. However, one patient developed radiation dermatitis followed by patchy hypopigmentation. We conclude that surgical excision followed by radiation therapy is a safe and effective method to control keloid recurrence in the ear lobe region.

Evaluation of various methods of treating keloids and hypertrophic scars: a 10-year follow-up study.

Darzi MA, Chowdri NA, Kaul SK, Khan M.   Br J Plast Surg 1992 Jul;45(5):374-9

Department of Plastic and Reconstructive Surgery, Sher-i-Kashmir Institute of Medical Sciences, India.

An attempt was made to assess the value of beta radiation alone or in combination with surgery, and of intralesional triamcinolone acetonide in treating 100 keloids and hypertrophic scars in 65 patients. Beta radiation alone was found to be effective in the eradication of symptoms (55% symptomatic relief), while results in the reduction of size of lesions have been poor (11% success rate). Surgery combined with postoperative beta radiation therapy yielded a 67% success rate. The success rate was 75% when radiation was delivered within 48 h of surgery. Preoperative radiation was found to be of no advantage. Intralesional triamcinolone acetonide produced symptomatic relief in 72% and complete flattening in 64% of the lesions.

The role of kilovoltage irradiation in the treatment of keloids.

Doornbos JF, Stoffel TJ, Hass AC, Hussey DH, Vigliotti AP, Wen BC, Zahra MK, Sundeen V.    Int J Radiat Oncol Biol Phys 1990 Apr;18(4):833-9

Department of Radiology, University of Iowa College of Medicine, Iowa City 52242-1059.

This is a retrospective analysis of the results of kilovoltage irradiation given to prevent the regrowth of 203 keloids excised at the University of Iowa Hospitals and Clinics, Iowa City, Iowa, Lutheran Hospital in Moline, Illinois, and Mercy Hospital in Cedar Rapids, Iowa. We found that a minimum follow-up of 1 year is needed to evaluate the results of post-excisional kilovoltage x-ray therapy. A dose versus response effect was also observed. Although it is desirable to use the lowest possible dose of radiation that is likely to be effective, the likelihood of failure is too great to justify the routine use of doses of less than 900 cGy regardless of how they are fractionated or when they are given. It appears that the total dose of irradiation that is given to prevent the regrowth of an excised keloid is more important than when irradiation is started, the size of the largest fraction given, whether the irradiation is completed in 1 week or 3, or where the keloid has grown. When a small number of keloids were irradiated less than 1 year after they first appeared greater than or equal to 1500 cGy were sufficient to control 90% of them without re-excision.

Keloids treated with excision followed by radiation therapy.

Klumpar DI, Murray JC, Anscher M.  J Am Acad Dermatol 1994 Aug;31(2 Pt 1):225-31

Division of Dermatology, Duke University Medical Center, Durham, NC 27710.

BACKGROUND: In the treatment of keloids surgical excision followed by radiation therapy provides the highest reported control rates of 72% to 92%. OBJECTIVE: We evaluated the effectiveness of excision followed by radiation therapy in the treatment of keloids and compared the efficacy of orthovoltage and electron beam radiation. METHODS: One hundred twenty-six keloids were treated with radiation therapy after surgical excision. Median follow-up period was 12 years. Recurrence rate, side effects, and effectiveness of therapy were assessed. Data were analyzed with multivariate analysis for significant objective and subjective factors. RESULTS: Higher posttreatment recurrence rates were noted with keloids forming at infected sites and in patients with a family history. No increased likelihood of recurrence was noted with respect to patient age, sex, or ethnicity; keloid size or location; individual keloid history; or prior therapy or radiation type used. CONCLUSION: Excision followed by radiation therapy is a useful and effective method of keloid eradication, particularly in cases in which lesions are disfiguring or refractory. Electron beam radiation offers no advantage over orthovoltage as a treatment.

Radiation therapy following keloidectomy: a 20-year experience.

Kovalic JJ, Perez CA.   Int J Radiat Oncol Biol Phys 1989 Jul;17(1):77-80

Radiation Oncology Center, Mallinckrodt Institute of Radiology, St. Louis, MO 63110.

Radiation therapy following excision for keloids has been shown to decrease the recurrence rate by about 50%. We followed 75 patients with 113 keloids for a mean time of 9.75 years. Seventy-four percent of the lesions involved the earlobe. Superficial X ray therapy was used in 89% of the cases. The most frequent dose schedule was 12 Gy in three fractions over 3 days. The overall control rate was 73%. There was no advantage to starting radiation within 1 day of surgery. Keloids greater than 2 cm in size, those that had previous therapy, and those occurring in men were found to indicate a high likelihood of recurrence. The mean time to recurrence was 12.8 months. There were no complications from this low dose treatment. Radiotherapy following excision is an effective and safe adjuvant treatment for keloids.

Radiotherapy in the management of keloids. Clinical experience with electron beam irradiation and comparison with X-ray therapy.

Maarouf M, Schleicher U, Schmachtenberg A, Ammon J.   Strahlenther Onkol 2002 Jun;178(6):330-5

Department of Radiotherapy, University of Technology (RWTH), Aachen, Germany. m.maarouf@uni-koeln.de

BACKGROUND: Aim of this study was to evaluate the advantages of electron beam irradiation compared to kilovoltage X-ray therapy in the treatment of keloids. Furthermore, the risk of developing malignancy following keloid radiotherapy was assessed. PATIENTS AND METHODS: An automatic water phantom was used to evaluate the dose distribution in tissue. Furthermore, a series of measurements was done on the patients using thermoluminescence dosimeters (TLD) to estimate the doses absorbed by the organs at risk. We also report our clinical experience with electron beam radiation of 134 keloids following surgical excision. RESULTS: Electron beam irradiation offers a high control rate (84%) with minimal side effects for keloids. Electron irradiation provides better dose distribution in tissue, and therefore less radiation burden to the organs at risk. After a mean follow-up period of 7.2 years, no severe side effects or malignancies were observed after keloid radiotherapy. CONCLUSIONS: Electron radiation therapy is superior to kilovoltage irradiation for treating keloids due to better dose distribution in tissue. In agreement with the literature, no cases of malignancy were observed after keloid irradiation.

Treatment of so-called keloid with excision and postoperative electron irradiation

Mitsuhashi K, Miyashita T.  Nippon Ika Daigaku Zasshi 1995 Apr;62(2):186-95

Department of Plastic and Reconstructive Surgery, Nippon Medical School, Tokyo, Japan.

Between 1988 and 1994, 110 patients with 139 so-called keloids site, which had been treated with conservative therapy were treated with excision, suture, and postoperative irradiation with a 4 MeV electron beam. They were irradiated within one or two days after surgery, for three consecutive days. The total doses were 15 Gy or 18 Gy per fractions for the most part. Control rates of true keloids and hypertrophic scars were 76.0% (57/75) and 93.8% (60/64), respectively, and the overall effectiveness rate was 84.2%. No remarkable side effects were observed. Transient hyperpigmentation was found in 44.6%. No carcinogenesis have been found in our series of patients. Considering the possibility of recurrence, side effects, and carcinogenesis, the indication of our treatment was decided. The result of our treatment using a low-megavolt electron beam was similar to that of published series using a low-energy X-ray. The advantages of the use of electron beam are that the peak of dose is the layer of the occurrence of keloid, and that the depth of penetration of radiation is limited without appreciable effect on the deeper structures. At present, the equipments of low-energy X-ray have been disposed. Our treatment using a electron beam will be an effective treatment.

Superficial x-ray therapy in keloid management: a retrospective study of 24 cases and literature review.

Norris JE.   Plast Reconstr Surg 1995 May;95(6):1051-5

St. Luke's/Roosevelt Hospital Center, New York, N.Y., USA.

Radiotherapy for the management of keloids was introduced in 1906. Eighty-eight years later there is no consensus among physicians who treat keloids that radiotherapy is safe, although it is generally accepted that radiotherapy is effective in reducing the recurrence of keloids following excision. There has been only one case report of a carcinoma occurring subsequent to the treatment of a keloid postexcisional site with radiotherapy, and the causal relation was questionable. A system for long-term follow-up of patients who receive superficial x-ray therapy is proposed.

Treatment of keloids with surgical excision and postoperative X-ray radiation.

Sallstrom KO, Larson O, Heden P, Eriksson G, Glas JE, Ringborg U.   Scand J Plast Reconstr Surg Hand Surg 1989;23(3):211-5

Department of Plastic Surgery, Sabbatsberg Hospital, Stockholm, Sweden.

124 patients with keloids were treated with surgical excision followed by postoperative X-ray radiation, begun within 24 hours after surgery. Only patients with a two-year keloid history were included in this study. The treatment results were evaluated 6 and 24 months after treatment. There was good correlation agreement between subjective and objective evaluations. Good or excellent results were observed in 92% of the patients. Side effects were moderate. Slight hyperpigmentation was found in 31% of the patients and telangiectasis in 15%. It was concluded that excision and early postoperative irradiation constitute effective keloid treatment.

Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature.

Sclafani AP, Gordon L, Chadha M, Romo T 3rd.   Dermatol Surg 1996 Jun;22(6):569-74

Department of Otolaryngology-Head & Neck Surgery, Beth Israel Medical Center, New York, USA.

BACKGROUND. Simple excision of earlobe keloids can result in recurrence rates approaching 80%. Many modalities have been suggested to reduce the risk of recurrence postoperatively, including intralesional steroids and radiotherapy. OBJECTIVE. In order to determine the most reliable method to prevent keloid recurrence, we have conducted the first randomized, prospective trial comparing corticosteroid injections versus radiation therapy. RESULTS. Thirty-one keloids were treated and followed for a minimum of 12.0 months. Two of 16 keloids (12.5%) recurred after surgery and radiation therapy, while 4 of 12 (33%) recurred after surgery and steroid injections. No alteration of skin pigmentation, wound dehiscence, chronic dermatitis, or neoplastic changes was observed in any patient in either group. Although a statistically significant difference was not observed, radiotherapy appeared to be more effective than steroid injections in preventing keloid recurrence. CONCLUSIONS. Radiotherapy is a simpler treatment modality with better patient compliance, and patients were much more likely to complete treatment than with corticosteroid injections. We believe that radiotherapy can play an important role in the prevention of earlobe keloid recurrences, and that with current techniques, complications can be minimized. Further randomized study with additional patients is needed to compare the effectiveness of corticosteroid injections and radiotherapy in preventing keloid recurrence

Sternal keloids: successful treatment employing surgery and adjunctive radiation.

Ship AG, Weiss PR, Mincer FR, Wolkstein W.   Ann Plast Surg 1993 Dec;31(6):481-7

Department of Plastic and Reconstructive Surgery, Albert Einstein College of Medicine, Bronx, NY.

Traditional treatment of keloids by surgery or surgery combined with other techniques has met with limited success. Successful treatment of sternal keloids by surgical excision and skin grafting, followed by radiation therapy is reported. Eleven patients, ranging in age from 14 to 66 years, were so treated. The groin was used as a donor site in all patients. Postoperative radiotherapy was administered to suture lines only, using three doses of 500 cGy each, such that 1,500 cGy was delivered within 7 to 14 days of surgery. The protocol was followed without variation in all patients. Follow-up ranged from 1 to 24 years. Only 1 patient demonstrated recurrence. Six patients received postoperative, episodic steroid injections for localized itching or nodule formation. None of these patients demonstrated recurrence of their keloids.

Results of prophylactic irradiation in patients with resected keloids--a retrospective analysis.

Wagner W, Alfrink M, Micke O, Schafer U, Schuller P, Willich N.   Acta Oncol 2000;39(2):217-20

Paracelsus-Strahlenklinik, Osnabruck, Germany.

The data of 139 patients with 166 keloids treated postoperatively between 1962 and 1996 were evaluated for prognostic factors and outcomes. Treatment commenced within 48 h after surgery. Radiotherapy was carried out as brachytherapy, using an integrated radionuclide 90 Sr-90Y surface applicator. The median dose delivered to the subcutis amounted to 14 Gy (range 7.5-28.5 Gy). The overall recurrence-free response rate was calculated to be 80% for all keloids. Response rates differed significantly (p < 0.001) between the different anatomical regions. The recurrence rate was lowest (2%) with keloids of the face and neck and highest with keloids of the thorax (49%). Outcome also differed significantly, depending on the etiology. Keloids following burns had a poorer success rate than those developing after surgery or mechanical trauma (p < 0.001). We were unable to demonstrate any significance in outcome related to gender, age or size. No direct correlation was found between total doses and response rates. In our patients there were no signs of secondary malignancies in the irradiation area within a median follow-up period of 12 years. Two new prognostic factors have been identified: keloid etiology and localization of the disorder.

Role of adjuvant radiotherapy in recurrent earlobe keloids.

Dinh Q, Veness M, Richards S.   Australas J Dermatol. 2004 Aug;45(3):162-6.

Department of Radiation Oncology, Westmead Hospital, Westmead, New South Wales, Australia.

Earlobe keloids are commonly encountered in dermatological practice and often prove to be recurrent, despite a variety of treatment options. Recurrent keloids, particularly in the head and neck, are associated with unsightly cosmetic consequences, particularly in younger patients. There is no consensus regarding the optimal treatment for recurrent keloids. However, re-excision accompanied by adjuvant treatment is often recommended. Low-dose fractionated radiotherapy (12 Gy in three fractions) delivered within 24 hours of excision remains an effective adjuvant option

Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature.

Sclafani AP, Gordon L, Chadha M, Romo T 3rd.   Dermatol Surg. 1996 Jun;22(6):569-74.

Department of Otolaryngology-Head & Neck Surgery, Beth Israel Medical Center, New York, USA.

BACKGROUND. Simple excision of earlobe keloids can result in recurrence rates approaching 80%. Many modalities have been suggested to reduce the risk of recurrence postoperatively, including intralesional steroids and radiotherapy. OBJECTIVE. In order to determine the most reliable method to prevent keloid recurrence, we have conducted the first randomized, prospective trial comparing corticosteroid injections versus radiation therapy. RESULTS. Thirty-one keloids were treated and followed for a minimum of 12.0 months. Two of 16 keloids (12.5%) recurred after surgery and radiation therapy, while 4 of 12 (33%) recurred after surgery and steroid injections. No alteration of skin pigmentation, wound dehiscence, chronic dermatitis, or neoplastic changes was observed in any patient in either group. Although a statistically significant difference was not observed, radiotherapy appeared to be more effective than steroid injections in preventing keloid recurrence. CONCLUSIONS. Radiotherapy is a simpler treatment modality with better patient compliance, and patients were much more likely to complete treatment than with corticosteroid injections. We believe that radiotherapy can play an important role in the prevention of earlobe keloid recurrences, and that with current techniques, complications can be minimized.

Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy.

Ragoowansi R, Cornes PG, Moss AL, Glees JP.  Plast Reconstr Surg. 2003 May;111(6):1853-9.

Department of Plastic and Reconstructive Surgery, St. George's Hospital, UK. pragowans@aol.com

The authors report the outcomes of patients with keloid scars treated with a protocol of extralesional excision and immediate single-fraction adjuvant radiotherapy. The design of the study was a retrospective analysis with up to 5-year outcome data. The setting was a single treatment team, University Teaching Hospital in London, United Kingdom. Participants (n = 80) were treated for 80 keloid scars (59 percent female patients, 76 percent nonwhite), and 44 percent of keloids were located on earlobes. For all patients, prior treatment without radiotherapy had failed. The salvage treatment reported in this article is combined extralesional excision and immediate postoperative external-beam radiotherapy. A 10-Gy dose of superficial 60-kV or 100-kV photon irradiation was given within 24 hours of the operation. The main outcome measure was freedom from recurrence of keloid scars. Results were that all keloid scars were controlled at 4-week follow-up. Probability of relapse at 1 year was 9 percent; at 5 years, probability of relapse was 16 percent. The earlobe showed no greater chance of relapse than other sites on the body.