Therapeutic effects of adjuvant brachytherapy in patients with resectable keloids

Background: Keloid treatment can be divided into two categories: resectable and unresectable. For resectable keloids, the treatment typically involves surgical excision followed by adjuvant therapies, such as radiotherapy (RT) or silicone gel sheeting. Various RT techniques have been developed for keloid treatment, including electron beam, orthovoltage X-ray, megavoltage X-ray, and brachytherapy. However, there is no universally established approach for postoperative RT following keloid excision. This study aims to report our institution’s experience with postoperative keloid treatment using brachytherapy. Methods: This case series study retrospectively reviewed the medical records of patients treated for keloids at National Cheng-Kung University Hospital, who received brachytherapy (20 Gy in 4 fractions) as adjuvant treatment after surgical excision. The severity of keloids was assessed using the Japan Scar Workshop (JSW) Score, Vancouver Scar Scale (VSS), and Visual Analogue Scale (VAS). The differences in scores before and after RT, along with the recurrence rates, were evaluated. Radiation side effects were assessed according to CTCAE 4.0 criteria. Results: From January 2015 to December 2022, a total of 10 keloid lesions in six patients were treated with surgical excision followed by superficial mould brachytherapy. RT was initiated 1 to 6 weeks post-surgery, with 5 out of 6 patients receiving RT within 2 weeks of surgery. All patients achieved good local control and satisfactory cosmesis, with no observed recurrence of keloids. A significant reduction was observed in the median VSS scores (from 11 to 1, P=0.002), VAS scores (from 5 to 0, P=0.002), and JSW scores (from 11 to 1, P=0.002), indicating improvements in both pain levels and scar severity post-RT. The only side effect noted was Grade 1 acute radiation dermatitis in all patients, with no Grade 3 or higher acute or late toxicity observed. Conclusions: Brachytherapy is an effective modality for postoperative keloid treatment. A dosage of 20 Gy in 4 fractions provides excellent local control with minimal side effects, yielding no Grade 3 or higher toxicity.