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LETTERS

Long-Term Follow-Up in the Treatment of Keloids by Combined Surgical Excision and Immediate Postoperative Adjuvant Irradiation

Annacontini, Luigi M.D.; Parisi, Domenico M.D.; Maiorella, Arianna M.D.; Campanale, Antonella M.D.; Gozzo, Giuseppe M.D.; Portincasa, Aurelio M.D.

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Plastic and Reconstructive Surgery: January 2008 - Volume 121 - Issue 1 - p 338-339
doi: 10.1097/01.prs.0000294955.58502.2f
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Sir:

A prospective study on the result of surgical excision and adjuvant irradiation for therapy-resistant keloids was conducted by van de Kar et al. (Plast. Reconstr. Surg. 119: 2248, 2007). This approach to keloids follows the International Clinical Recommendations on Scar Management based on retrospective studies that do not define recurrence. Moreover, the significant variations in methodology of most of the studies is well highlighted; many of them, being retrospective, refer to a treatment that is not standardized, and inclusion/exclusion criteria were set afterward (subjecting the study to bias), making it difficult to compare results. What is really clear is that there is still no consensus on the optimal treatment of keloids. After a mean follow-up of 19 months, van de Kar et al. had a cure rate of 28 percent, compared with the 78 percent average of previous studies. They ascribed their low rate to the “long” follow-up and the strict inclusion criteria of their study.

A few other considerations are necessary. Radiation therapy, commonly used for malignancy, has both acute and chronic effects on the skin. Acute effects include erythema, inflammation, edema, desquamation, and ulceration. Late effects include change in pigmentation, atrophy of the epithelium and dermis, decreased local vascularity associated with fibrosis, teleangiectasia, sebaceous and sweat gland dysfunction, necrosis, and, above all, neoplasia.1 The late effects are challenging to treat; treatment ranges from simple intervention, such as protection of hypopigmented areas, to grafting or flaps (local or microvascular) for tumors.

Many epidemiological studies have demonstrated that ionizing radiation carries a risk of carcinogenesis. Radiotherapy for the treatment of keloids was first introduced in 1906,2 yet 101 years later there is still debate about its safety. The optimal dosage schedule for radiotherapy is unclear, since authors disagree about total dose, fractionation, the time interval between surgery and radiotherapy, and whether electrons are preferable to photons. A number of large studies report a 0 percent carcinogenicity rate, although there is some concern regarding length of follow-up as short as 2 years.3

A review of the literature shows that, despite the potential risks, very few malignancies arise from treating keloids with radiotherapy after 8 years (keloid on thyroid), 23 years (keloid on breast and lung), and 30 years (keloid on breast).4–6

New retrospective or, better, prospective studies (with a new pinpoint schedule) should focus on the effect of combined surgical excision and immediate postoperative adjuvant irradiation, looking at the long-term follow-up (up to 30 years) of the use of radiation as a therapeutic modality to control keloids with respect to the precept of primum non nocere. Regardless, radiation should always be prohibited in children, young adults, pregnant women, and patients with keloids close to the thyroid or breast. In the meantime, in strictly selected cases, when other treatments (such as steroids, pressure therapy, silicone gel sheeting, laser therapy, and previous surgery) have failed, we agree with literature reports that advocate radiotherapy as the mainstay of treatment.

Luigi Annacontini, M.D.

Domenico Parisi, M.D.

Arianna Maiorella, M.D.

Antonella Campanale, M.D.

Giuseppe Gozzo, M.D.

Aurelio Portincasa, M.D.

Department of Plastic and Reconstructive Surgery

University of Foggia

Foggia, Italy

REFERENCES

1. Mustoe, T. A., and Porras-Reyes, B. H. Modulation of wound healing in chronic irradiated tissues. Clin. Plast. Surg. 20: 465, 1993.
2. De Bearman, R., and Gougerot, H. Cheloides des maqueuses. Ann. Dermatol. Syphilol. (Paris) 7: 151, 1906.
3. Borok, T. L., Bray, M., Sinclair, I., Plafker, J., LaBirth, L., and Rollins, M. D. Role of ionizing irradiation for 393 keloids. J. Radiat. Oncol. Biol. Phys. 15: 865, 1988.
4. Botwood, N., Lewanski, C., and Lowdell, C. The risk of treating keloids with radiotherapy. Br. J. Radiol. 72: 1222, 1999.
5. Hoffman, S. Radiotherapy for keloids. Ann. Plast. Surg. 9: 265, 1982.
6. Bilbey, J. H., Muller, N. L., Miller, R. R., and Nelemus, B. Localized fibrous mesothelioma of pleura following external ionizing radiation therapy. Chest 94: 1291, 1988.

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