2017-18 HSC Section 4 Green Book

Plastic and Reconstructive Surgery • September 2014

consulted by both surgeon and radiotherapist, gave informed consent, and agreed to radiation therapy treatment and follow-up. The study was approved by the Medical Ethical Council of the VU University, Amsterdam, The Netherlands. Treatment Protocol The keloid was marked and excised extrale- sionally under local anaesthesia (Fig. 1). Hemosta- sis was achieved with electrocautery. Subsequently, a metal-tipped Varisource catheter (external diameter, 1.6 mm; length, 150 cm; Varian Medical Systems, Palo Alto, Calif.) was positioned between the dermal edges of the entire wound, 5 mm below the surface of the skin and extending out of the skin beyond the wound at both sides. The catheter followed the shape of the scar, and was kept intact without kinking. The wound was closed primarily using Monocryl 4-0 or 5-0 (Ethicon, Inc., Somer- ville, N.J.) intracutaneously and subcutaneously, thereby also fixating the catheter against the der- mis. Postoperatively, patients were transferred immediately to the radiation department, where the catheter was connected to the iridium-192 remote control afterloader (Varisource). The planning target volume was defined as a cylinder along the axis of the scar, with a central diameter of 5 mm. Patients received two fractions of high- dose-rate brachytherapy. Within 4 hours after the resection, the first brachytherapy fraction of 6 Gy at 5 mm of the source axis was given. This dose was prescribed at the middle of the catheter and continuous dwell positions were used from the skin entry point to the skin exit point of the catheter. Equal dwell times were used for all dwell positions. Within 24 hours after the first fraction, a second fraction of 6 Gy was administered to a total dose of 12 Gy in 2 days. The typical radiation time was 100 seconds, depending on the decay of the source. After the second fraction, the catheter was gently removed. Patients received no other adjunct treatment for their keloids, such as sili- cone gel sheeting, scar cream, pressure clothing, or steroids. Follow-Up Before surgery, age, sex, date of treatment, original scar size, scar cause, scar duration, pre- vious treatments, Fitzpatrick skin type score, 19 anatomical localization, clinical aspects, and brachytherapy parameters were scored and pho- tographs were taken. Patients were seen at post- operative consultations for long-term follow-up at the VU Medical Center. During consultation, the

source is placed inside the target area. It offers several practical advantages over external beam radiation therapy, including improved dose opti- mization, better radioprotection to surrounding healthy tissue, and a more focused radiation dis- tribution and delivery. 9 In addition, brachytherapy shows lower recurrence rates (3.4 to 23.6 percent) compared with external beam irradiation (12 to 27 percent). 10–12 Low-dose-rate brachytherapy, in which a radioactive seed is implanted in the target area for a certain period, requires patients to be hospitalized for several days, because of the rela- tively long treatment time. In contrast, with high- dose-rate brachytherapy, a radioactive source is directed through a hollow catheter into the target site, reducing treatment time to typically only sev- eral minutes. This process can be repeated several times in an outpatient clinical setting. Therefore, there is no need for hospitalization in lead-coated radioprotection chambers, as is required with low- dose-rate brachytherapy. At our institution, we have been treating keloids with a high-dose-rate brachytherapy outpatient procedure for over 10 years. The treatment protocol uses a unique radia- tion schedule with a total dose of 12 Gy. This is the lowest dosage known in the literature for the treatment of keloids. This long-term prospective study evaluated the effectiveness of this radiation schedule in a large population including patients of all Fitzpatrick skin types. Scars were evaluated with respect to local recurrence and cosmesis. In addition, scar evaluation was performed with the Patient and Observer Scar Assessment Scale. 13–15 PATIENTS AND METHODS All patients who presented with keloids in the period 2003 to 2009 were included in a prospective study according to the following inclusion criteria. First, a keloid was defined as excessive scar tissue raised above skin level and proliferating beyond the confines of the original lesion. 1,16,17 Keloids were distinguished from hypertrophic scars based on the clinical judgment of experienced plastic surgeons and on the age of the scar (>1 year). 18 Second, the keloid had proven insensitive to at least one other treatment modality. Lastly, patients had to be older than 10 years of age. Exclusion criteria included keloids not suitable for excision with primary closure because of size or anatomi- cal location, pregnancy, or diabetes. All patients were treated at the Department of Plastic Surgery and the Department of Radiation Oncology of the VU University Medical Center, Amsterdam, The Netherlands. Before treatment, all patients were

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