Perioperative Interstitial Brachytherapy for Recurrent Keloid Scars

Sir: At the CRLCC (Centre régional de lutte contre le cancer) of Nantes-Atlantique-France, we performed a retrospective analysis of 73 keloids (from 58 patients) resistant to medical and surgical treatments, retreated by excision plus early perioperative interstitial brachytherapy with low-dose iridium-192. Our objective was to evaluate local control and functional and cosmetic results. All keloids were recurrences after one or more surgical excisions and/or intracicatricial corticoid injections and presented functional disorders (pruritus, pain, or inflammation). Local control was evaluated by clinical evaluation. Functional and cosmetic results were assessed in terms of patient responses to a self-administered questionnaire. After excision, plastic tubes were implanted at the dermohypodermic junction and cutaneous closure was achieved by intradermal overcasting or suture. Median length of the iridium-192 wire was 6 cm (range, 1 to 14.5 cm), and the mean postoperative afterloading was 4 hours (range, 1 to 6 hours). The median dose delivered was 20 Gy (range, 15 to 40 Gy). Lesions were located as follows: 30 percent (22 of 73) on the retroauricular groove, 32 percent (23 of 73) on the trunk or the abdomen, 16 percent (12 of 73) on the neck, and 22 percent (16 of 73) others. Sixty-six lesions were from white patients, and the seven remaining were from black patients. Five patients were lost to follow-up. Local control for the remaining 64 keloids was 86 percent (55 of 64) (i.e., 53 patients; median follow-up, 44.5 months; range, 14 to 150 months). All nine relapses (two of seven black with skin) occurred early in the first 2 years postoperatively, mostly on skin traction areas (four on the neck and three on the trunk). The only patient who developed a postoperative local infection (retroauricular groove) had relapsed. There is no statistical difference in the risk of recurrence between black and white races. The influence of treated length (>6 cm) on risk of recurrence was statistically significant (p = 0.038). Our results confirm the effectiveness of treatment early (within 6 hours) postoperatively after loading brachytherapy at 20 Gy.1 Recurrence risk factors include initial scar size, anatomical picture, and local trophic complications, but not skin color.1–4 Relapses generally occur early in the year following treatment, which underscores the need for strict monitoring during the first 2 years.1,3,4 Eighty-six percent of patients (24 of 28) (35 scars) whose results were reassessed were satisfied. Six scars remained symptomatic, and the aesthetic results were considered to be good in 51 percent (18 of 35) and average in 37 percent (13 of 35) (median follow-up, 70 months; range, 16 to 181 months). Best results were obtained for retroauricular scars, with 83 percent (15 of 18) good and only 12 percent (two of 17) average or poor results. Perioperative brachytherapy with low-dose-rate iridium-192 and early after-loading delivering 20 Gy 5 mm from the source reduced the rate of recurrence of keloids. Among the 86 percent of controlled scars, the regression of functional signs largely compensated for less good aesthetic results. This simple technique requires only short hospitalization and is the treatment of choice in the authors’ institution for keloid scars resistant to other approaches, especially for retroauricular keloids. Emmanuel Rio, M.D. Etienne Bardet, M.D. Patrick Peuvrel, M.D. Radiotherapy Department CRLCC-Nantes-Atlantique St. Herblain Michel Pannier, M.D. Plastic Surgery Department Brigitte Dreno, Ph.D. Dermatology Department CHU Hôtel Dieu Nantes, France