Brian Berman, M.D., Ph.D. Brian Berman, M.D., Ph.D. Center for - - PowerPoint PPT Presentation
Superficial Radiation Thera Superficial Radiation Therapy py (SRT) in the Treatment of Keloids (SRT) in the Treatment of Keloids Brian Berman, M.D., Ph.D. Brian Berman, M.D., Ph.D. Center for Clinical and Cosmetic Research & University
Center for Clinical and Cosmetic Research & University of Miami School of Medicine
Disclosure of Industry Relationships Disclosure of Industry Relationships
Radiation Treatment of Keloids Radiation Treatment of Keloids
Brian Berman, MD, PhD
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Weighted Average Recurrence = 71.2 % Weighted Average Recurrence = 71.2 %
Ionizing Radiation on Wound Healing Ionizing Radiation on Wound Healing
without prior local irradiation with 521 rad, was excised
Control wounds contained:
Irradiated wounds had:
fewer BrdU-positive proliferating cells proliferating cells and
significant TUNEL-positive apoptotic cells apoptotic cells at days 3
lower proportion of G2/M G2/M phase cells
inactive cell proliferation , greater greater apoptosis apoptosis, and cell cycle arrest cell cycle arrest at days 3-9 post-wounding may be cellular mechanisms responsible for delayed wound delayed wound healing healing
Liu, X et al. J Trauma. 2005 Sep;59(3):682-90.
RagoowansiR, Cornes PG, Moss AL, Glees JP. Plast Reconstruct Surg 2003; 111: 1853 –9.
retrospective study of 80 80 keloidectomy keloidectomy patients treated with postoperative postoperative single-fraction 10Gy radiotherapy radiotherapy
9% of keloids relapsed after 1 year
16%of keloids relapsed after 5 years
Post Post-Excision Radiation of Auricular Kelo Excision Radiation of Auricular Keloids ids
Recalcati S et al. J Dermatol Treatment 2011; 22: 38
Retrospective study of suturing lines of 60 60 keloidectomy keloidectomy patients (76 76 ear ear keloids keloids )
post-operatively
superficial radiotherapy radiotherapy
year relapse relapse -free free rate of 79.84% 79.84%
No pigmentation or telangiectasias telangiectasias
BL BL 3 Years 3 Years
Relapse Relapse-Free Rate Following Free Rate Following Post Post-Operative Radiotherapy (n=76) Operative Radiotherapy (n=76)
A BED value of 30
Gy can be obtained with
–a single acute dose of 13 Gy –two fractions of 8 Gy –three fractions of 6 three fractions of 6 Gy Gy –a single dose of 27 Gy at low dose rate
The radiation treatment should be
administered within 1-2 days after surgery
Kal HB, Veen RE
. Keloid Dose and Fractionation Schemes
297
297 keloids were surgically completely excised
Starting on post-operative day 1 the suture
closure line, with a 5 mm margin, received a BED 30 of superficial radiation 70 or 100 kV
Almost all, three 6 Gy fractions on POD 1, 2 & 3 Follow-up: 3m to >3 yrs (majority >6m)
9/297
Berman et al. SKIN 2: 402, 2018
BL Post BL Post-Excision Excision 6 m 12 m 6 m 12 m
Schmieder, EADV Geneva, 2017
12.7 cm diameter at 25 cm SSD 18 cm x 8 cm at 30 cm SSD
Retrospective, chart review study of 96
96 excised keloids + SRT (61 patients) with > 1 year 1 year followup followup (or recurrence noted prior to 1 year), at 4 US sites
Usually 3, 6-Gy fractions, on POD 1, 2 & 3 (BED 30 SRT 70 or 100 kV) to the
suture closure line, with a 5 mm margin
10
10/96, 10.4% 10.4%treated keloids noted to recur within 12 12 months - 5/10 5/10 were clinically significant; 1 additional recurrence by 18 18 months f/u
8/11 recurred within the first 6 months; 2/11 within 6 to 12 months and 1/11
within 12 to 18 months; Kaplan-Meier Survival Probability Estimate cure rate cure rate
85.6%from 24 months 24 months post-SRT treatment end onwards
Greater rate of recurrence if keloid had previously recurred or was on chest If 1 recurred, not all keloids recurred in patients with multiple treated keloids
Chart Review
Clinically Significant Recurrence Clinically Significant Recurrence
Prior to Excision/SRT (left) and Prior to Excision/SRT (left) and 6-month follow month follow -up Post up Post-SRT (right) SRT (right) Silicon scar gel was recommended at Silicon scar gel was recommended at the 6 the 6-month follow month follow -up visit up visit Prior to Excision and SRT (left) and Prior to Excision and SRT (left) and 19 months Post 19 months Post-SRT (right) SRT (right) Patient received an intralesional Patient received an intralesional corticosteroid and topical silicone gel at corticosteroid and topical silicone gel at the last follow the last follow -up visit up visit
Non Non-Clinically Significant Recurrence Clinically Significant Recurrence
Consensus Guidelines on the Use Consensus Guidelines on the Use of
Superficial Radiation Therapy for T Superficial Radiation Therapy for Treating reating Nonmelanoma Skin Cancers and Ke Nonmelanoma Skin Cancers and Keloids loids
11.1 …Post-surgical treatment of keloid excision suture lines with several
fractions of SRT significantly reduces keloid recurrence rates. …
11.2 …Fractionation of the SRT dose
reduces the risk of hyperpigmentation and other adverse events . The optimal treatment protocol is a biologically effective dose of 3000 cGy in three fractions of 600 cGy on post-operative days 1, 2 and 3. …
11.3 There is little evidence that exposing keloid or surrounding healthy
skin to SRT at a 3000 cGy dosing causes skin cancer.
Nestor, Berman, Goldberg, Cognetta, Gold, Roth, Cockerell , Glick: J Clin Aesthet Dermatol. 2019;12(2):12–18
Radiation Treatment of Keloids Literature Radiation Treatment of Keloids Literature Review for Associated Malignancy Review for Associated Malignancy
A computerized literature search of MEDLINE and PubMed
Central between 1901 and March of 2009 located 5 cases
carcinogenesis that were associated with radiation therapy for keloids
Basal cell carcinoma, thyroid carcinoma, breast carcinoma
and fibrosarcoma
However, it was unclear whether an appropriate dose of
radiation or sufficient protection were used
The authors conclude radiation therapy is acceptable as a
keloid treatment modality
Ogawa et al. Plast Reconstr Surg. 2009 Oct;124(4):1196
Surgical Keloid Excision With/Without Surgical Keloid Excision With/Without External Beam Radiation vs Brachytherapy External Beam Radiation vs Brachytherapy
Hoang et al: Aesthetic Surgery Journal 2016, 1 –14. DOI: 10.1093/ asj/sjw124
+/ +/ - OR OR
28 28 excised alone, 197 197 received post-excision EBRT (9-30 Gy over 1-10 daily doses) and 39 39 received post-excision HDR (8-12 Gy) interstitial Iridium-192brachytherapy, all but 1 within 36 hrs post excision
54% recurred post-excision alone (9m f/u)
19% recurred post-excision + EBRT(42m f/u, p< .01)
23% recurred post-excision + brachytherapy (12m f/u, p< .01)
than after brachytherapy (mean difference of 2.5 years , p< .01)
No development of malignancy
36
36 keloidectomy keloidectomy scars scars were treated with high-dose- rate superficial brachytherapy superficial brachytherapy after keloidectomy
– 20 Gy delivered in 3 or 4 daily fractions to 2 mm below from skin surface
9.7%
(3/32) [19.4% 19.4%ITT ITT] keloid recurrence recurrence rate at a median follow-up period of 18 18 months (range, 9 to 29 months)
Kuribayashi S, Miyashita T, Ozawa Y, Iwano M, Ogawa R, et al. J
Treated 91 keloids with by a combination of surgical
excision and postoperative electron beam radiation 20 Gy: 5 Fractions (Ear: 16 Gy: 4 Fractions)
44%
44%keloid recurrence recurrence rate (include symptoms)
Y amawaki S, Naitoh M, Ishiko T, Muneuchi G, Suzuki S. Ann Plast Surg. 2011;67(4):402-6
SRT Post SRT Post-Keloidectomy Keloidectomy
Baseline Intraoperative Post- Operative Immediately Post SRT 2 Months Courtesy of Michael H. Gold, MD