J. Tello

Treatment of keloids by high-dose-rate brachytherapy: A seven-year study.

PURPOSE To analyze the results obtained in a prospective group of patients with keloid scars treated by high-dose-rate (HDR) brachytherapy with or without surgery. METHODS AND MATERIALS One hundred and sixty-nine patients with keloid scars were treated with HDR brachytherapy between December 1991 and December 1998. One hundred and thirty-four patients were females, and 35 were males. The distribution of keloid scars was as follows: face, 77; trunk, 73; and extremities, 19. The mean length was 4.2 cm (range 2-22 cm), and the mean width 1.8 cm (range 1.0-2.8 cm). In 147 patients keloid tissues were removed before HDR brachytherapy treatment, and in 22 HDR brachytherapy was used as definitive treatment. In patients who underwent prior surgery, a flexible plastic tube was put in place during the surgical procedure. Bottoms were used to fix the plastic tubes, and the surgical wound was repaired by absorbable suture. HDR brachytherapy was administered within 30-60 min of surgery. A total dose of 12 Gy (at 1 cm from the center of the catheter) was given in four fractions of 300 cGy in 24 h (at 09.00 am, 15.00 pm, 21.00 pm, and 09.00 am next day). Treatment was optimized using standard geometric optimization. In patients who did not undergo surgery, standard brachytherapy was performed, and plastic tubes were placed through the skin to cover the whole scar. Local anesthesia was used in all procedures. In these patients a total dose of 18 Gy was given in 6 fractions of 300 cGy in one and a half days (at 9.00 am, 3.00 pm, and 9.00 pm; and at 9.00 am, 3.00 pm, and 9.00 pm next day). No further treatment was given to any patient. Patients were seen in follow-up visits every 3 months during the first year, every 6 months in the second year, and yearly thereafter. No patient was lost to follow-up. Particular attention was paid to keloid recurrence, late skin effects, and cosmetic results. RESULTS All patients completed the treatment. After a follow-up of seven years, 8 patients (4.7%) had keloid recurrences. Five of these had undergone prior surgery (local failure rate 3.4%), and 3 had received only HDR brachytherapy (local persistence rate 13.6%). Cosmetic results were considered to be good or excellent in 130/147 patients treated with prior surgery and in 17/22 patients without surgery. Skin pigmentation changes were observed in 10 patients, and telangiectasias in 12 patients. No late effects such as skin atrophy or skin fibrosis were observed during the 7 years of follow-up. CONCLUSIONS HDR brachytherapy is an effective treatment for keloid scars. It is well tolerated and does not present significant side effects. The brachytherapy results were more successful in patients who underwent previous surgical excision of keloid scar than in patients without surgery. We favor HDR brachytherapy rather than superficial X-rays or low energy electron beams in keloid scars, because HDR provides a better selective deposit of radiation in tissues and a lower degree of normal tissue irradiation. Other advantages of high-dose-rate brachytherapy over low-dose-rate brachytherapy are its low cost, the fact that it can be performed on an outpatient basis, its excellent radiation protection, and the better dose distribution obtained. From the clinical perspective, the technique provides a high local control rate without significant sequelae or complications.

Exeresis and Brachytherapy as Salvage Treatment for Local Recurrence After Conservative Treatment for Breast Cancer: Results of a Ten-Year Pilot Study

PURPOSE To analyze the long-term results of a pilot study assessing excision and brachytherapy as salvage treatment for local recurrence after conservative treatment of breast cancer. METHODS AND MATERIALS Between December 1990 and March 2001, 36 patients with breast-only recurrence less than 3 cm in diameter after conservative treatment for Stage I or II breast carcinoma were treated with local excision followed by high-dose rate brachytherapy implants (30 Gy in 12 fractions over a period of 5 days). No patient was lost to follow-up. Special attention was paid to local, regional, or distant recurrences; survival; cosmesis; and early and late side effects. RESULTS All patients completed treatment. During follow-up (range, 1-13 years), 8 patients presented metastases (2 regional and 6 distant) as their first site of failure, 1 had a differed local recurrence, and 1 died of the disease. Actuarial results at 10 years were as follows: local control, 89.4%; disease-free survival, 64.4%; and survival, 96.7%. Cosmetic results were satisfactory in 90.4%. No patient had Grade 3 or 4 early or late complications. Of the 11 patients followed up for at least 10 years, all but 1 still had their breast in place at the 10-year stage. CONCLUSIONS High-dose rate brachytherapy is a safe, effective treatment for small-size, low-risk local recurrence after local excision in conservatively treated patients. The dose of 30 Gy of high-dose rate brachytherapy (12 fractions over a period of 5 days twice daily) was well tolerated. The excellent results support the use of breast preservation as salvage treatment in selected patients with local recurrence after conservative treatment for breast cancer.

Keloids and Hypertrophie Scars

Abnormal skin scarring was first described in the Smith papyrus between 2500 and 3000 BC [7]. In 1817, Alibert proposed the word “cheloide” (keloid) to differentiate these lesions from malignant neoplasms [2]. Today, keloids and hypertrophie scars are recognized as uncontrolled proliferations of fibrous tissue after injury or trauma to the skin [15]. However, meanwhile hypertrophie scars are confined to the extent of the original wound; in contrast, keloids invade the surrounding skin [15].

Whole-breast hypofractionated IMRT and brachytherapy boost after conservative surgery for breast cancer: Early results of a prospective non-randomised trial.

46 Background: To report early results obtained in a prospective group of patients (pts) treated with whole breast IMRT radiotherapy plus a brachytherapy boost to the tumor bed after conservative surgery, given either with hypofractionated or normofractionated radiotherapy. METHODS Between 12/2008 and 06/2014, 829 pts with <4cm, N0-2 breast cancers treated with conservative surgery were assigned to enter the study. Pts were offered to be treated either with IMRT hypofrationated whole breast and lymphnode areas (if needed) radiotherapy 42.6 Gy (266cGyx16 fractions) plus a 7 Gy boost to the tumor bed, (hypofractionated group) or IMRT normofractionated 50 Gy (200cGyx25) to the whole breast and lymphatic areas (when needed) plus 16 Gy brachytherapy boost (200cGyx8 fractions) (normofractionated group). Treatment assignation was done according to the patients preference or, if none, were randomly assigned to have both groups uniformly balanced. During treatment and follow-up special attention was taken to early and late side-effects, breast fibrosis, arm lymphedema, skin reaction, patient satisfaction and local, regional and distant disease control. RESULTS A total of 309 pts were included in the hypofractionated group and 520 in the normofractionated group. All patients completed treatment. Pts were evaluated weekly during treatment and every 3 months for the first 2 years of follow-up and in a yearly basis after. Photographs were taken at each visit. SOMA-LENT scales were used in every visit. For quality of life EORTC QLQ-C30 plus the BR-15 module were used. No pts had adverse side-effect that required treatment ending in any group. In the hypofractionated group, there were 1 LR, 1 M1 and 1 death due to the disease. In the normofractionated group there were 12 LR, 7 M1 and 4 patients died due to the disease. CONCLUSIONS Hypofractionated IMRT to the whole breast followed by a 1 fraction HDR breast implant was a safe and effective method of treatment for early breast cancer treated with conservative surgery, even in those patients N+ in which the supraclavicular fossa was included in the treatment fields. Pts satisfaction was greater in the hypofractionated group.

Accelerated partial breast brachytherapy after lumpectomy as salvage treatment for local recurrences after conservative treatment of breast cancer: Eighteen-year results of a nonrandomized comparison with mastectomy.

109 Background: To report the long-term results in a prospective group of patients (pts) treated for local recurrence after conservative treatment of breast cancer by a second conservative surgery or by total mastectomy. METHODS Between 12/1990 and 10/2004, 85 pts with <3 cm, low-risk local recurrence after conservative treatment for breast cancer were offered total mastectomy. 48 of them refused it and were treated by a second lumpectomy followed by HDR brachytherapy implant to the tumor bed+margin. 30 Gy in 12 fractions in 5 days were given. Pts treated by mastectomy had no further radiotherapy. Postmenopausal pts with negative receptors had no systemic tx. The rest of the pts had chemo or hormones. No pts were lost for follow-up. RESULTS All pts completed treatment. During the 17-year, 1-year minimum follow-up, in the second conservative group there were 8 pts who had regional (2 pts) or distant metastases (6 pts) as their first site of failure. Three of them experienced a differed local recurrence and 1 died from the disease. In the total mastectomy group, there were 2 local recurrences, 1 regional recurrence, and 5 distant metastases as first site of failure. One patient died from the disease. Actuarial results at 17-year for second conservative and total mastectomy were respectively: local control 84.2%-71.7%; disease free survival 65.4%-63.8%; and survival 90.7% and 88.2%. Cosmetic results were satisfactory in 89.4% treated conservatively. No patient experienced arm edema or grade 3-4 early or late complications. Between the 14 pts that were followed-up for at least 10-years, 13 of them were with their breast still in place. CONCLUSIONS Second conservative treatment by HDR brachytherapy was a safe and effective method of treatment for small-size, low-risk, local recurrence after local excision in conservatively treated pts. APBI with wide margins probed to be enough treatment, without significant side-effects in previously intesively irradiated patients. Lumpectomy and partial breast brachytherapy can be conidered the treatment of choice in selected patients with low-risk recurrent breast tumors.

Partial Breast Brachytherapy after Lumpectomy as Salvage Treatment of Local Recurrences after Conservative Treatment of Breast Cancer: Eighteen-year Results of a Non-randomized Comparison with Mastectomy

Purpose/Objective(s): To report the long term results obtained in a prospective group of patients (pts) treated for local recurrence after conservative treatment of breast cancer treated by a second conservative surgery or by total mastectomy. Materials/Methods: Between 12/1990 and 10/2004, 85 patients with <3cm, low-risk local recurrence after conservative treatment for breast cancer were offered total mastectomy. 48 of them refused it and were treated by a second lumpectomy followed by HDR brachytherapy implant to the tumor bed plus a 3 cm margin. 30 Gy in 12 fractions in 5 days were given. Patients treated by mastectomy had no further radiotherapy treatment. Postmenopausal patients with negative receptors had no systemic treatment. The rest of the patients had chemo or hormonal treatment. No patient was lost for follow-up. Results: All patients completed treatment. During the 17-year, 1-year minimum follow-up, in the 2nd conservative group there were 8 pts who had regional (2 pts) or distant metastases (6 pts) as their first site of failure. 3 of them experienced a differed local recurrence and 1 died from the disease. In the total mastectomy group, there were 2 local recurrences, 1 regional recurrence and 5 distant metastases as first site of failure. One patient died from the disease. Actuarial results at 17-year for 2nd conservative and total mastectomy were respectively: local control 84.2% 71.7%; disease free survival 65.4%-63.8%; and survival 90.7% and 88.2%. Cosmetic results were satisfactory in 89.4 % treated conservatively. No patient experienced arm edema or grade 3-4 early or late complications. Between the 14 pts that were followed-up for at least 10-years, 13 of them were with their breast still in place. Conclusions: Second conservative treatment by HDR brachytherapy was a safe and effective method of treatment for small-size, lowrisk, local recurrence after local excision in conservatively treated patients. Partial breast irradiation with wide margins probed to be enough treatment, without significant side-effects in previously intesively irradiated patients. Lumpectomy and partial breast brachytherapy can be conidered the treatment of choice in selected patients with low-risk recurrent breast tumors.

2299 Treatment of skin carcinomas of the face by high dose rate brachytherapy and custom made surface molds

PURPOSE To analyze the results obtained in a prospective group of patients with basal or squamous cell skin carcinomas of the face treated by high-dose-rate (HDR) brachytherapy via custom-made surface molds. METHODS AND MATERIALS A total of 136 patients with basal or squamous cell carcinomas of the face were treated between March 1992 and March 1997 by surface molds and HDR brachytherapy with iridium-192. Nineteen patients were treated with standard Brock applicators and 117 patients with custom-made polymethyl methacrylate applicators, built over a plaster mold obtained of the patients face. Minimum dose administered to the tumor was 6000 to 6500 cGy in 33 to 36 fractions at 180 cGy/fraction in lesions of up to 4 cm. Lesions greater than 4 cm were boosted up to 7500-8000 cGy after a 3-week pause. RESULTS With the custom-made surface molds, the dose distribution was uniform in the surface of the skin and at 5 mm depth in the whole area of the applicator. Differences between the areas of maximum and minimum dose at this depth never reached values higher than 5% of the prescribed dose. At the edges of the custom-made molds dose gradient was sharp, with the detected dose at 5 mm from the applicator being negligible. All the patients were complete responders. There were 3 local recurrences, 1/73 patients treated for primary tumor and 2/63 patients treated for recurrent tumor. Actuarial local control at 5 years for all patients was 98%, for those patients with primary tumors 99%, and for recurrent patients 87%. The treatment tolerance was excellent in all cases. No severe, early, or late, complications were detected. CONCLUSIONS Radiotherapy is a highly effective treatment of skin carcinomas of the face. Custom-made molds, to be used in conjunction with HDR brachytherapy equipment, make possible a uniform dose distribution, with a sharp dose gradient in the limits of applicators. Custom-made surface molds are easy and safe to use, and they fit very accurately for daily treatment. Local control is excellent with minimal sequelae or complications. Probably they will become the standard way of treatment of face skin carcinomas in the near future.