2017-18 HSC Section 4 Green Book

Volume 134, Number 3 • Treatment of Recalcitrant Keloids

(Fitzpatrick V to VI) than in Fitzpatrick I to IV skin type patients. 22,36 Although physical complaints improved in the majority of the patients, a per- centage of the patients still experienced (some) physical complaints of pain and itching at long- term follow-up. This is consistent with most other studies, and it is unclear whether this is the result of residual scar tissue or recurrence, because these complaints are also known as side effects from skin irradiation. 18,29,34,37 Two- or Three-Dimensional Treatment Plans Other groups described the use of two- or three-dimensional treatment plans to locate the source and to achieve dose optimization. 9 In our opinion, pretreatment radiographs or even com- puted tomographic scanning would make the procedure very time consuming and expensive. In addition, it was found that in experienced hands, catheter placement and fixation would ensure good coverage of the target volume by radiation. Limitations Although the loss to follow-up is comparable to that of other studies, we acknowledge that failure of follow-up could imply a bias, because patients with good results may be less motivated to return for fol- low-up. 3,18,34,37 Another limitation of this study is the lack of randomization. On this account, our group is currently performing a multicenter randomized study including brachytherapy, intralesional cryo- therapy, and intralesional corticosteroids. 38 CONCLUSIONS In conclusion, the results of this study show that high-dose-rate brachytherapy with a 2 × 6-Gy dosage yields good cosmetic outcomes with low recurrence rates. The unique schedule confirms the efficacy and safety of high-dose-rate brachy- therapy and suggests the importance of immedi- ate postoperative irradiation. In addition, only one outpatient treatment is required after sur- gery, enhancing patient convenience. 39–41 Michiel C. E. van Leeuwen, M.D. Department of Plastic, Reconstructive and Hand Surgery VU University Medical Center

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Postbus 7057, Van der Boechorststraat 7 1081 BT Amsterdam, The Netherlands mc.vanleeuwen@vumc.nl

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