428J Med Assoc Thai Vol. 89 No. 4 2006
Correspondence to : Narkwong L, Radiation Oncology Divi-
sion, Ramathibodi Hospital, Rama 6 Rd, Bangkok 10400,
Thailand. Phone: 0-2201-1140, 0-2201-2295 , Fax: 0-2201-
1191, E-mail: email@example.com
J Med Assoc Thai 2006; 89 (4): 428-33
Full text. e-Journal: http://www.medassocthai.org/journal
Keloid is an excessive proliferation of con-
nective tissue of the skin that frequently develops
secondary to a skin wound. Clinically, it presents as a
reddish tumor that extends beyond a surgical or
traumatic scar and generally increases in dimension
over time. Surgical resection of the keloids results in
recurrence in 50- 80% of the cases(1,2). This has led to
the use of adjuvant treatments, such as postoperative
radiation(3,4), intralesional steroid injections(5), cryo-
therapy(6,7), laser excision(8), and topical silicon(9) to
reduce the rate of recurrence of keloids. The results
reported are highly variable. Keloids have occurred
frequently after earlobe piercing (Fig. 1A) and caused
cosmetic deformity and functional symptoms such as
pain, pruritus or numbness. The incidence of earlobe
keloids has been estimated at 2.5% from a survey of
1,000 nurses at an American teaching hospital(10).
Postoperative radiation is one of the treatment moda-
lities that have been demonstrated to be effective in
preventing recurrence of the keloids in the earlobe
In the present report, the authors described
their experience with adjuvant high dose rate Iridium
192 mould in earlobe keloids patients.
Material and Method
From March1999 to March 2003, 22 patients
with 24 earlobe keloids underwent surgical excision
followed by radiation. There were 8 males and 14
females. The mean age at treatment was 20.7 years,
ranging from 14 to 43 years. The etiology of keloids
was ear piercing in 20 cases and trauma in 2 cases.
Keloid size ranged from 1-4.3 cm in diameter. Pregnant
or breast feeding women were excluded. Two patients
were previously treated by surgical excision. Two
patients had recurrence after surgical excision and
steroid injection. Four patients had recurrence after
steroid injection. None of them received radiation.
Postoperative Radiotherapy with High Dose Rate
Iridium 192 Mould for Prevention of Earlobe Keloids
Ladawan Narkwong MD*,
Poth Thirakhupt MD**
* Radiation Oncology Division, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University
** Department of Surgery, BMA Medical Collage and Vajira Hospital
Background: A 50% to 80% recurrence rate of earlobe keloids can occur following a simple excision. Many
modalities, including radiotherapy, have been suggested to reduce the postoperation recurrence.
Objective: The aim of the present study was to determine the efficacy of postoperative radiotherapy by a high
dose rate Iridium 192 mould in the prevention of earlobe keloids recurrence.
Material and Method: Between March 1999 and March 2003, 22 patients with 24 earlobe keloids were
treated by radiotherapy immediately following surgical excision. A dose of 15 Gray in 3 fractions was delivered
at a point placed 5 mm from the axis of the Iridium sources.
Results: From the 22 patients with 24 keloids who were treated, 15 patients with 16 keloids were followed for
a minimum of 6 months. Recurrence occurred in two keloids (12.5%). There were no severe adverse effects.
Conclusion: Postoperative radiotherapy by high dose rate Iridium 192 mould was an effective prevention of
earlobe keloids recurrence. It was well tolerated and did not present any significant side effects.
Keywords: Keloids, Earlobe, High dose rate, Iridium 192, Mould
J Med Assoc Thai Vol. 89 No. 4 2006429
In the first step, the surgical excision of all
earlobe keloids was performed under local anesthesia.
The surgical wound was primarily closed (Fig. 1B).
Postoperative adjuvant radiation was given within
24 hours after surgery. The dose was 15 Gray at 5 mm
from the axis of the Iridium sources, divided in 3
fractions (5 Gray/fraction) in 3 consecutive days. The
high dose rate Iridium 192 mould was made of flaps
or catheters attached to plastic tubes for Iridium
192 loading (Fig. 2). The margin of prescribed dose
at the proximal and distal end was about 0.5 cm.
During Iridium 192 loading, shielding to protect normal
tissues with lead shield was performed whenever
Patients were seen at day 7-10 of surgical
excision to evaluate the wound and to remove the
suture. In each follow up, the presence or absence of
keloid recurrence and sequelae of treatment were
observed. Recurrence was defined as evidence of
mass or obvious return of keloid. Late effects were
evaluated according to SOMA-LENT (Somatic Late
Effects on Normal Tissue) scale of the EORTC(15).
A) Earlobe keloid occurred after ear piercing
B) After surgical excision and primarily closure was performed
High dose rate Iridium 192 mould, made of flaps attached to plastic tubes
430 J Med Assoc Thai Vol. 89 No. 4 2006
Twenty two patients with twenty four earlobe
keloids were entered into the present study. Seven
patients with 8 keloids were unavailable for follow-up,
the remaining 15 patients with 16 keloids were the
basis of this report. The median follow-up was14.8
months (range 6-36 months). Two keloids (2/16 = 12.5%)
developed recurrence within 6 and 15 months after
treatment. One patient had residual keloid after treat-
ment, one had grade 1 hypopigmentation and one
developed grade 1 fibrosis. No patient experienced
grade 3 or 4 toxicity.
The efficiency of radiation as an adjuvant
treatment in the management of keloid has been con-
vincing. Following surgical excision, radiotherapy was
more effective, independently of the modality used,
superficial X-ray, electrons or beta ray. Table 1 reports
the results of 9 series with recurrent rate ranging from
Experience with brachytherapy has demon-
strated that it can substitute for external beam radia-
tion (EBRT) as adjuvant treatment of keloids in some
situations. Malaker et al(23) have reported a recurrence
rate of 20% in 30 linear keloids after surgery followed
by Iridium 192 wire low dose rate. Experience with
Iridium 192 brachytherapy treated keloids has been
reported by Escarmant et al(24) They treated 855 keloids
with surgical excision followed by immediate intersti-
tial implantation of Iridium 192 wire low dose rate, with
a recurrence rate of 21%. Quix et al(25) have reported
169 keloids treated by high dose rate brachytherapy.
A total dose of 12 Gy as postoperative radiation and
18 Gy were given to patients who did not undergo
surgery. They found 4.7% recurrence after a follow
up of 7 years. The results of brachytherapy are rather
similar to superficial X-rays or low energy electron
beams in keloid recurrence. The advantages of high
dose rate brachy-therapy include: 1) it can be performed
on an out patient basis; and 2) it provides a better
selective deposite of radiation in tissues and lower
degree of normal tissue radiation.
Keloids of the earlobes are more difficult to
treat than those at other sites(11,19), and different treat-
ment modalities have been reported with highly
variable results (Table 2). Chaudhry MR et al(11), who
reported postoperative radiation by 100 KV radiation
Table 1. Postoperative radiotherapy modality of keloids review of the literatures
Author Number of keloidsRadiation modality Dose (Gy)Recurrent rate (%)
β-ray 90 Sr-90Y
β-ray 90 Sr-90Y
Table 2. Earlobe keloids: the range of reported outcome for treatment options
Author TreatmentRecurrence rate (%)
Surgery + steroid
Surgery + steroid
Surgery + Verapamil + Pressure
Steroid + splint
Surgery + steroid + silicone gel sheet and pressure
J Med Assoc Thai Vol. 89 No. 4 2006431
to 36 earlobe keloids, with a mean follow up period of
5.6 years, show a recurrence rate of only 2- 8%. A
randomized controlled trial of earlobe keloids excision
followed by either intralesional steroid injection or
radiation(12), using either superficial 100 KV X-rays or
electron beam, has shown that radiation has better
patient compliance and lower recurrence rate than
steroid injection. Ragoowansi R et al(13) have reported
35 patients for high risk ear lobe keloids, who failed to
respond to prior treatment with massage, silicone, and
corticosteroid injection. Patients have been treated
by surgical excision, followed by one fraction of
superficial x-ray 10 Gy. The cumulative probability of
control at 5 years was 79.4%. There was no case of
serious radiation toxicity.
The present study has shown a recurrence
of 12.5% without severe complication, and this was
comparable to other reports. However, there are only a
few reports of earlobe keloids that compared recur-
rence rates. Besides, there are variable qualities of
treatment series such as surgical techniques, timing
between surgery and radiation, radiation dose frac-
tionation and techniques, and follow up period. One
of the difficulties that the present study and others(8,12)
have encountered is poor compliance with follow up
after treatment; in the present study, 7/22 patients
were unavailable for the 6 months follow up, even
though the authors had given preoperative education
about the likelihood of keloid recurrence and the need
for close follow up and early treatment of recurrence.
The potential toxicity of radiation in treatment
of benign disease has been reviewed(30). Although no
radiation-induced cancer was found in the preceding
studies, the long term follow up is necessary as well as
discussion about this issue to inform the patients of
these possible risks before treatment.
Postoperative radiotherapy by high dose
rate Iridium 192 mould was an effective prevention of
earlobe keloids. It was well tolerated and did not present
any significant side effects. Further study with a larger
number of patients and longer follow-up time are
needed to further confirm the efficacy and safety of
this technique as an adjuvant treatment in prevention
of earlobe keloids.
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