Background
Retrospective single-institution study. 234 patients with keloids at 426 anatomic sites treated with postoperative RT after surgical excision at a major academic center. Evaluated recurrence rates by site, dose/fractionation, RT timing after excision, and predictors of keloid recurrence. Garg MK et al — one of the largest institutional series of keloid RT.
Interventions and follow up
Arm A: Post-excision RT: 15–20 Gy in 3–4 fractions (5 Gy/fraction) initiated within 24–48 hours of surgical excision; superficial X-rays (100–250 kV) or electro
Primary endpoint: Keloid recurrence rate by anatomic site and dose
mFollow up: 3.0 year
Primary endpoint: Keloid recurrence rate by anatomic site and dose
mFollow up: 3.0 year
Results
Overall recurrence rate: 21% at 3 years
Recurrence by site: Ear 8% vs sternal 34% vs shoulder 28% vs scalp 20%
RT within 24 hr: Recurrence 18% vs >48 hr 41%, P=.003
Dose <15 Gy: Recurrence 38% vs ≥15 Gy 18%, P=.02
Recurrence by site: Ear 8% vs sternal 34% vs shoulder 28% vs scalp 20%
RT within 24 hr: Recurrence 18% vs >48 hr 41%, P=.003
Dose <15 Gy: Recurrence 38% vs ≥15 Gy 18%, P=.02
Adverse events
Main adverse events: Acute: erythema grade 1–2 (48%), dry desquamation 12%. Late: hyperpigmentation 25% (dark skin phototypes). Telangiectasia grade 1: 8% at 3 years. No grade ≥3 toxicity. No secondary malignancies in this follow-up period.
Conclusions
Post-excision RT within 24–48 hours at 15–20 Gy effectively reduces keloid recurrence. Site-specific recurrence rates are substantially higher for sternal and shoulder keloids, warranting consideration of higher doses or more aggressive techniques at these locations. Early RT timing is critical.
Key Limitations
Key Limitations: Retrospective; no randomized comparator. Keloid staging not standardized. Excision technique (shave vs full excision) varied. Long-term secondary malignancy risk, particularly for young patients with multiple keloids, requires follow-up beyond 3 years. Skin phototype impact on late toxicity not fully characterized.
Clinical Context
Keloid excision + postoperative RT is the standard treatment for large or recurrent keloids. Key principles: RT within 24–48 hours of excision, minimum 15 Gy/3 fractions. Superficial X-rays (100–250 kV) or low-energy electrons are appropriate. Ear keloids have the best outcomes; sternal and shoulder require higher vigilance. Compression garment use is adjunctive.
References
References: Garg MK et al, IJROBP 2004 (keloid RT outcomes)