title: Surgical Excision and Adjuvant Brachytherapy vs External Beam Radiation for the Effective Treatment of Keloids: 10-Year Institutional Retrospective Analysis.
abstract: BACKGROUND
  Surgically excised keloids reportedly recur at a rate of >45%. Post-excision radiation (RT) has been delivered via external beam radiotherapy (EBRT) or interstitial high dose rate (HDR) brachytherapy. Despite historical data showing 10% to 20% keloid recurrences with post-excision RT, there is a paucity of high-quality evidence comparing keloid recurrences between the two RT modalities.
  
  
  OBJECTIVE
  We performed the largest single-institution case-control retrospective study (2004-2014) of keloid recurrence rates and complications between post-excision EBRT and HDR brachytherapy.
  
  
  METHODS
  One-hundred and twenty-eight patients, with 264 keloid lesions, were treated by excision alone (n = 28), post-excision EBRT (n = 197), or post-excision HDR brachytherapy (n = 39). Patient and keloid recurrence data were analyzed using mixed effect Cox regression modeling with a statistical threshold of P < .05.
  
  
  RESULTS
  Fifty-four percent of keloids recurred after surgical excision alone (9-month median follow up); 19% of keloids recurred with post-excision EBRT (42-month median follow up); 23% of keloids recurred with post-excision brachytherapy (12-month median follow up). Adjuvant EBRT and brachytherapy each showed significant control of keloid recurrence compared to excision alone (P < .01). EBRT significantly delayed the time of keloid recurrence over brachytherapy by a mean difference of 2.5 years (P < .01).
  
  
  CONCLUSIONS
  Post-excision RT shows significant reduction in keloid recurrence compared to excision alone. While the recurrence control rates are not statistically different between EBRT and brachytherapy, keloids treated with EBRT recurred significantly later than those treated by HDR brachytherapy by a mean of 2.5 years. Further workup with a randomized control study will help to refine optimal adjuvant RT treatment. LEVEL OF EVIDENCE 3.
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Don
authors.initials: D
authors.lastname: Hoang
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Robert
authors.initials: R
authors.lastname: Reznik
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Matt
authors.initials: M
authors.lastname: Orgel
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Quanlin
authors.initials: Q
authors.lastname: Li
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Amin
authors.initials: A
authors.lastname: Mirhadi
authors.affiliation: From the Keck School of Medicine, University of Southern California, and Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: David A
authors.initials: DA
authors.lastname: Kulber
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001918:Brachytherapy / Q000009:adverse effects; D002648:Child; D062109:Dermatologic Surgical Procedures / Q000009:adverse effects; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D007627:Keloid / Q000175:diagnosis / Q000628:therapy*; D015141:Los Angeles; D008297:Male; D008875:Middle Aged; D010781:Photography; D011183:Postoperative Complications / Q000209:etiology; D011879:Radiotherapy Dosage; D018714:Radiotherapy, Adjuvant; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult