Optimizing Radiotherapy for Keloids

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Dear Sir,
Thank you for the opportunity to comment on the article written by Mankowski et al.1 The authors undertook a systematic review and meta-analysis of the literature, from more than 70 years of data, to determine the influence of different radiation modalities on recurrence rates of keloid scars. They determined that brachytherapy is likely the optimal form of radiotherapy, ideally after excision.
Despite the merits of the article, we would like to highlight 2 potential limitations of their study. First, we query whether many of the “keloids” may in fact have been hypertrophic scars,2–4 and wonder how comparisons can be made in terms of outcomes given the potential for inherent heterogeneity. At the very least, it would be expected of the authors to recognize this possibility in the discussion of the article. In particular, reported recurrence rates less than 20% may suggest that these were not all true keloids, but rather hypertrophic scars. In these cases, the opportunity exists to offer patients surgery, given the fact that “something different” may be effectively implemented to actually have an impact on the final outcome. By better distributing and reducing tension across the incision, by avoiding infection, and by paying meticulous attention to the technical aspects of wound closure, one may obviate the need for post–excisional radiotherapy of any form for hypertrophic scars.
Second, we have concerns regarding the definition of “recurrence” in the article.1 We wonder how it is possible to make use of this term in the context of a lesion that has not been completely eradicated. For a lesion to recur, some form of removal, debulking, or reduction in size should have occurred for this to be concluded. As a result, we wonder how it is possible to quantify recurrence and to compare lesions that have been excised and then subjected to post–excisional radiotherapy, with those that have only received radiotherapy.
Notwithstanding these considerations, we would like to commend the authors for their contribution to the literature, especially given the considerable challenges inherent in undertaking research in this area. We agree that larger series are required to determine the optimal doses and schedules to obtain the best results in the management of both hypertrophic and keloid scars.

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