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High-Dose-Rate Brachytherapy for the Treatment of Recalcitrant Keloids: A Unique, Effective Treatment Protocol RECONSTRUCTIVE Reprinted by permission of Plast Reconstr Surg. 2014; 134(3):527-534.

Michiel C. E. van Leeuwen, M.D. Suzanne C. Stokmans, B.Sc. Anne-Eva J. Bulstra, B.Sc. Otto W. M. Meijer, M.D. Paul A. M. van Leeuwen, M.D., Ph.D. Frank B. Niessen, M.D., Ph.D. Amsterdam, The Netherlands

Background: Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recur- rence rates forming the main issue. Surgical excision with adjuvant radio- therapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy proce- dure 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 mea- sured ( 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 prob- lems 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 out- come with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the impor- tance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience. ( Plast. Reconstr. Surg. 134: 527, 2014.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

K eloids are benign fibrous cutaneous tumors that arise as a result of abnormal healing of the dermis. 1 Besides aesthetic disfig- urement, keloids can cause major physical com- plaints of pain and pruritus, thus impairing the quality of life of the patient. 2–5 Men and women are equally affected regarding incidence, but From the Departments of Plastic and Reconstructive Surgery, Radiation Oncology, and Surgery, VU University Medical Center. Received for publication December 10, 2013; accepted March 17, 2014. This trial is registered under the name “High Dose Rate Brachytherapy for Treatment of Keloids,” Clinicaltrials.gov identification number NCT02005055 (http://clinicaltri- als.gov/show/NCT02005055). Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000415

the incidence is five to 15 times higher in dark- skinned individuals. 1,6–8 Treatment of keloids is a significant challenge for the clinician, because no single treatment modality has proven widely effec- tive in preventing recurrence. 1 According to the international advisory panel on scar management, surgical excision with postoperative radiation therapy is considered the most efficacious treat- ment. 4 Radiation is applied through traditional external beam radiation therapy, low-dose-rate brachytherapy, or high-dose-rate brachytherapy. Brachytherapy, also known as internal irradiation, is a form of radiotherapy in which a radiation

Disclosure: The authors have no financial interest to declare in relation to the content of this article. No external funds were received.

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