32. Keloids - The GEC-ESTRO Handbook of Brachyterapy

Keloids

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THE GEC ESTRO HANDBOOK OF BRACHYTHERAPY | Part II Clinical Practice Version 1 - 11/04/2025

4. PATHOLOGY

5. WORK UP

The pathogenesis of keloids has not yet been conclusively explained. The classical model of wound healing distinguishes 3 overlapping phases. In the inflammatory phase (days 1-3), growth factors, macrophages and inflammatory processes are activated. The proliferation phase begins on day 2-3 and can last up to 6 weeks. In this phase, fibroblasts are formed and angiogenesis is activated. In the late proliferation or granulation phase from day 8 onwards, granulation tissue is formed by myofibroblasts and collagen bundles. The processes in the inflammatory phase should be influenced at an early stage. The first irradiation fraction should be given within 24 hours after excision of the keloid [3, 5]. In one extensive overview of the literature van Leeuwen et al. [6] suggested however that better outcome was observed for external beam radiotherapy when started within 7 hours as compared to longer duration. Conversely, this was not seen in series treated with LDR or HDR brachytherapy.

Because of the increased risk of long-term side effects and cancer induction, keloids should only in extreme conditions be treated in children. In adolescents completion of growth should be documented by measuring length. Further there is no specific work up except general examination to determine if there is no contra indication for local excision. A complete skin examination is recommended to detect other potential lesions.

6. INDICATIONS, CONTRA-INDICATIONS

The main indication for treatment is in patients with recurrence of a keloid and patients with large keloids. Active skin infections present a contraindication. Because of the different pathogenesis of keloids occurring after a burn, it is generally not recommended to treat them with radiotherapy.

Figure 32.1 Keloid of the right ear lobe pre and 15 months post treatment

Figure 32.2 : Keloid after breast reconstruction before and after treatment