We would like to make critical comments on an article by van de Kar and colleagues entitled “The Results of Surgical Excision and Adjuvant Irradiation for Therapy-Resistant Keloids” (Plast. Reconstr. Surg. 119: 2248, 2007).
First, they used “Gy” as the scale of radiation absorption dose in the abstract, body, and Table 4 of their article. This is a clear mistake. They must have meant “cGy” (centigray). If they meant 1200 cGy, this means 12 Gy. Second, they indicated that “superficial 250-kV electron beam irradiation was used.” If 250 kV were correct, an electron beam would be impossible. They must have used x-rays. From these basic errors, we consider that no competent radiation oncologist participated in the radiation therapies. Moreover, it is doubtful that appropriate irradiation was performed on the appropriate area.
Third, they cited our article1 and commented that “some authors did not even report their minimum follow-up period.” However, in the article they cited, we indicated that “only cases that were followed for more than 18 months were selected for this study.” In fact, the median follow-up period was 24 months (range, 18 to 128 months) in our article.1
Fourth, they claimed that “some authors did not describe whether or not they performed histologic tissue analysis.” However, we clearly stated that “pathological discrimination of hypertrophic scars from keloids is difficult except for typical keloids.”1 In our experience, the history of the keloid and the clinical findings are much more important factors when it comes to distinguishing keloids from hypertrophic scars. If they insist on the importance of a histological examination, they must cite some articles2,3 that describe the pathological differences between keloid and hypertrophic scars.
Fifth, 18 of 21 patients (85.7 percent) in their study were of the black race. It is considered that keloid prevalence is five to 15 times higher in African-Americans than in Caucasians.4 Logically, therefore, their conclusions should be limited to people of the black race, admitting that appropriate radiation therapy was administered. However, they did not even describe the differences in prevalence or recurrence rates by race. Moreover, the number of patients by keloid site was too small. Recurrence rate by keloid site is a very useful indicator, as we have indicated previously.1 In our facility, keloids of Asian people are treated with dose protocols that are customized for each site: (1) 20 Gy in four fractions over 4 days for the anterior chest wall, scapular region, and suprapubic region, (2) 10 Gy in two fractions over 2 days for the earlobes, and (3) 15 Gy in three fractions over 3 days for other sites.
In conclusion, they should reconsider the cause of the abnormally high recurrence rates in their results. In addition, they should review and discuss whether or not their prescription and delineation of the target volume were appropriate. We think they should cast an eye on our facility, where we have tried to calculate the absorbed dose, even in irregular and complicated irradiation fields, on a case-by-case basis. Moreover, we have used a self-management program for postoperative patient care.
Rei Ogawa, M.D., Ph.D.
Tsuguhiro Miyashita, M.D., Ph.D.
Hiko Hyakusoku, M.D., Ph.D.
Department of Plastic and Reconstructive Surgery
Nippon Medical School
1. Ogawa, R., Mitsuhashi, K., Hyakusoku, H., and Miyashita, T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: Retrospective study of 147 cases followed for more than 18 months. Plast. Reconstr. Surg.
111: 547, 2003.
2. Ehrlich, H. P., Desmouliere, A., Diegelmann, R., et al. Morphological and immunochemical differences between keloid and hypertrophic scar. Am. J. Pathol.
145: 105, 1994.
3. Lee, J. Y., Yang, C. C., Chao, S. C., et al. Histopathological differential diagnosis of keloid and hypertrophic scar. Am. J. Dermatopathol.
26: 379, 2004.
4. Slemp, A. E., and Kirschner, R. E. Keloids and scars: A review of keloids and scars, their pathogenesis, risk factors, and management. Curr. Opin. Pediatr.
18: 396, 2006.
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