CANDIDATES FOR HIPPOCAMPAL SPARING 14 Methodology To evaluate which patients would be higher priority candidates for hippocampal sparing, 3,000 participant treatment plans were evaluated via a cross-sectional differential research method. The method of research used in this study is considered differential and cross-sectional because groups of participants are different ages are compared on a set of variables and because participates of this study were assigned to groups based on preexisting factors. Patients over the age of 18 and parents of participants under the age of 18 were asked to take part in the research. The aim of research was explained to them and informed consent was obtained by all participants prior to participating in the study. It was explained to participants, or parents of the participants, that data was going to be collected based on the treatment they received and that no additional experimentation with radiation was to be added to their treatment for the benefit of the research study, therefore, there was no additional risk to their treatment plan implemented by this differential research study. The study was subject to external review several credible institutions including the American Society for Therapeutic Radiology and Oncology (ASTRO). Participants. Participants of this study were subjects who required WBRT and were evaluated in two categories. The two categories were based on treatment intent and will be separated into preexisting palliative and prophylactic categories. With age thought to be the most influential variable, participants in each category were further categorized into two subcategories based on age. Subjects of this study included subcategory A participates who were required to be 25 years of age and younger and subcategory B participants who were required to be 26 years old age and older based on prior research on brain development studies done by Giedd & Rapoport. The cumulative sample size for the research study was 2,000 participants. 500 subcategory A and 500 subcategory B participants were included in each intent category. Subject exclusions included patients who were on hospice care, those on a concurrent chemotherapy regimen during their radiation therapy treatment and patients who had a treatment plan change after beginning their initially recommended treatment. Treatment Intent Total Number of Participants A: Under 25 B: Over 25 Prophylactic 500 500 Palliative 500 500 Table 1. Visual representation of participants. Data Collection Method. Data was collected from 20 Radiation Oncologist between 21 different cancer centers over a course of 18 months between January 2014 and June 2015. Two Oncologists at each cancer center participated in the study by collecting research and all had an average of 3 new WBRT patients per month. Each cancer center then treated an average of 6 new WBRT patients per month, 2,000 of which agreed to participate in the study. Data was collected from each ph ...

1. CANDIDATES FOR HIPPOCAMPAL SPARING 14
Methodology
To evaluate which patients would be higher priority candidates
for hippocampal sparing, 3,000 participant treatment plans were
evaluated via a cross-sectional differential research method.
The method of research used in this study is considered
differential and cross-sectional because groups of participants
are different ages are compared on a set of variables and
because participates of this study were assigned to groups based
on preexisting factors.
Patients over the age of 18 and parents of participants under the
age of 18 were asked to take part in the research. The aim of
research was explained to them and informed consent was
obtained by all participants prior to participating in the study. It
was explained to participants, or parents of the participants, that
data was going to be collected based on the treatment they
received and that no additional experimentation with radiation
was to be added to their treatment for the benefit of the research
study, therefore, there was no additional risk to their treatment
plan implemented by this differential research study. The study
was subject to external review several credible institutions
including the American Society for Therapeutic Radiology and
Oncology (ASTRO).
Participants. Participants of this study were subjects who
required WBRT and were evaluated in two categories. The two
categories were based on treatment intent and will be separated
into preexisting palliative and prophylactic categories. With age
thought to be the most influential variable, participants in each
category were further categorized into two subcategories based
on age. Subjects of this study included subcategory A
participates who were required to be 25 years of age and
younger and subcategory B participants who were required to be
26 years old age and older based on prior research on brain

2. development studies done by Giedd & Rapoport.
The cumulative sample size for the research study was 2,000
participants. 500 subcategory A and 500 subcategory B
participants were included in each intent category. Subject
exclusions included patients who were on hospice care, those on
a concurrent chemotherapy regimen during their radiation
therapy treatment and patients who had a treatment plan change
after beginning their initially recommended treatment.
Treatment Intent
Total Number of Participants
A: Under 25
B: Over 25
Prophylactic
500
500
Palliative
500
500
Table 1. Visual representation of participants.
Data Collection Method. Data was collected from 20 Radiation
Oncologist between 21 different cancer centers over a course of
18 months between January 2014 and June 2015. Two
Oncologists at each cancer center participated in the study by
collecting research and all had an average of 3 new WBRT
patients per month. Each cancer center then treated an average
of 6 new WBRT patients per month, 2,000 of which agreed to
participate in the study. Data was collected from each physician
at the end of each month. The physicians were asked to report
on particular variables via a data collection template sheet that
was created for this study. Completed data templates were
collected on the first of each month for a total of 18 months.
Procedure. To collect primary data, physicians were asked to
check a box that indicated treatment intent and another that
indicated if the patient was over or under the age of 25. To

3. avoid the common confusion that typically results from the
several additional differing variables typically found in
differential studies, secondary variables were included in the
study. These variables included treatment demand at each
facility, which was evaluated by physicians documenting the
number days between treatment recommendation and first day
of treatment, the urgency of presented symptoms on a scale of
1-10, the risk of cancer spread or progression of disease during
the treatment planning process on a scale of 1-10, if the
physicians recommend hippocampal sparing and whether or not
the patient agreed to the physicians recommendations. These
variables were evaluated based on trends and were documented
and evaluated helped to explain the rationale behind results of
this study.
Results
Results of the study revealed 1,184 participants, or 59% of the
population, received conformal treatment with hippocampal
sparing. The study revealed that 100% of patients under the age
of 25 who are being treated with a prophylactic intent were
treated with a hippocampal sparing method. This means that this
patient population was declared highest priority and therefore
the best candidates for hippocampal sparing with IMRT or
IMAT methods above all other candidates who participated in
the study. 97%, or 487/500, of patients over the age of 25 who
were being treated prophylactically were treated with
hippocampal sparing, making the prophylactic category
dominant over the palliative category.
Results
Treatment Intent
# of Participants Who Received H.S/ Total Participants
A: Under 25

4. B:Over 25
Prophylactic
500/500
100%
487/500
97%
Palliative
150/500
30%
47/500
9.4%
Table 2. Visual representation of primary results
With the data collected, the study revealed that candidates were
considered a priority in the following descending order:
Table 3. Candidates in descending order
Discussion
The primary variables in this study were treatment intent
and age. The study proved that younger patients and those who
were being treated with prophylactic intent were more likely
candidates for hippocampal sparing with IMRT or IMAT
methods. The secondary variables included in this study were
used to understand the rationale behind the primary results.
Secondary variable evaluation revealed trends that implied
physicians were less likely to recommend a conformal method
with hippocampal sparing when patients presented with
emergency symptoms that were deemed dangerous or often life
threatening such as seizures, strokes or hemorrhages. When a
patients risk for their disease progression during the treatment
planning process is low they become better candidates for
hippocampal sparing. Also, some physicians are more likely to
recommend hippocampal sparing than others. Some physicians
might be more inclined to treat with a more conventional lateral
method because hippocampal sparing has only recently become
a popular trend. Patients who are eager to begin treatment might
also choose a conformal method rather than an IMRT or IMAT

5. method because it may be less expensive, because it’s a much
shorter treatment or because certain patients may be eager to
begin treatment would rather not wait the extra time to begin
treatment.
Conclusion
Hippocampal sparing is necessary to preserve neurological
function when patients are being treated with whole brain
irradiation, however, this technique can only be implemented
with complex, conformal methods such as IMRT or IMAT that
are often time consuming. The research study proved that
younger patients who are more likely to survive are of highest
priority when it comes to hippocampal sparing methods that
preserve the hippocampus to prevent neural stem cell toxicity
that could potentially lead to memory loss, decreased IQ or
dementia.
References
1. Chargari, C., & Kirova, Y. M. (2011). Authors' reply: Whole-
brain radiation therapy concerns about neurotoxicity. Nature
Reviews.Clinical Oncology, 8(8), 506.
doi:http://dx.doi.org/10.1038/nrclinonc.2011.119-c2
2. Boundless. “The limbic system.” Boundless Psychology.
Boundless, 20 Aug. 2015. Retrieved 12 Oct. 2015 from
https://www.boundless.com/psychology/textbooks/boundless-
psychology-textbook/biological-foundations-of-psychology-
3/structure-and-function-of-the-brain-35/the-limbic-system-154-
12689/
3. Dunlop, A., Welsh, L., McQuaid, D., Dean, J., Gulliford, S.,
Hansen, V., & ... Newbold, K. (2015). Brain-Sparing Methods
for IMRT of Head and Neck Cancer. Plos ONE, 10(3), 1-13.
doi:10.1371/journal.pone.0120141
4. Giedd, J. N., & Rapoport, J. L. (2010). Structural MRI of
pediatric brain development: What have we learned and where

6. are we going? Neuron, 67(5), 728-734.
doi:http://dx.doi.org/10.1016/j.neuron.2010.08.040
4. Kazda, T., Jancalek, R., Pospisil, P., Sevela, O., Prochazka,
T., Vrzal, M.,.Laack, N. N. (2014). Why and how to spare the
hippocampus during brain radiotherapy: the developing role of
hippocampal avoidance in cranial radiotherapy. Radiation
Oncology, 9, 139. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA373040856&v=
2.1&u=nu_main&it=r&p=AONE&sw=w&asid=71c883113bac7f
7241fa92563aa70347
5. Lutz, S. (2007, December 1). Palliative whole-brain
radiotherapy fractionation: convenience versus cognition?
Cancer. 110(11), 2363+. Retrieved from
http://go.galegroup.com/ps/i.do?id=GALE%7CA172278455&v=
2.1&u=nu_main&it=r&p=AONE&sw=w&asid=ab51881551ba6e
947335ec54b10e0d63
6. McTyre, E., Scott, J., & Chinnaiyan, P. (2013). Whole brain
radiotherapy for brain metastasis. Surgical Neurology
International, 4, 236-244. doi:http://dx.doi.org/10.4103/2152-
7806.111301
7. Pokhrel, D., Sood, S., Lominska, C., Kumar, P., Badkul, R.,
Jiang, H., & Wang, F. (2015). Potential for reduced radiation-
induced toxicity using intensity-modulated arc therapy for
whole-brain radiotherapy with hippocampal sparing. Journal of
Applied Clinical Medical Physics, 16(5).
doi:10.1120/jacmp.v16i5.5587
8. Shaw, M., & Ball, D. (2013). Treatment of brain metastases
in lung cancer: Strategies to avoid/reduce late complications of
whole brain radiation therapy. Current Treatment Options in
Oncology, 14(4), 553-67.
Prophylactic under the age of 25
100%
Prophylactic over the age of 25
97%
Palliative under the age of 25
30%

7. Palliative over the age of 25.
9.40%
Evaluation of various methods of treating keloids and
hypertrophic scars: a
lo-year follow-up study
M. A. Darzi, N. A. Chowdri, S. K. Kaul and M. Khan
Department of Plastic and Reconstructiae Surgery, Sher-i-
Kashmir Institute of Medical Sciences and
Department of Surgery, S.M.H.S. Hospital, Srinagar, Kashmir,
India
SUMMARY. An attempt was made to assess the value of beta
radiation alone or in combination with surgery, and
of intralesional triamcinolone acetonide in treating 100 keloids
and hypertrophic scars in 65 patients. Beta radiation
alone was found to be effective in the eradication of symptoms
(55 % symptomatic relief), while results in the reduction
of size of lesions have been poor (11% success rate). Surgery
combined with postoperative beta radiation therapy
yielded a 67% success rate. The success rate was 75% when
radiation was delivered within 48 h of surgery.
Preoperative radiation was found to be of no advantage.
Intralesional triamcinolone acetonide produced symptomatic
relief in 72 % and complete flattening in 64 % of the lesions.
The management of keloids and scar hypertrophy
poses a difficult and intriguing problem. The recur-
rence rates after surgical excision alone vary from
50-80% (Cosman et al., 1961; Cosman and Wolff.
1974; Mathangi Ramakrishnan et al., 1974). This has
led to the development of many adjuvant therapeutic

8. modalities.
Post-excisional radiation therapy for keloids has
been shown to reduce the recurrence rate to 2.450%
(Craig and Pearson, 1965; King and Salzman, 1970;
Amar-Inalsingh, 1974; Levy et al., 1976; Ollstein et al..
1981; Borok et al., 1988; Kovalic and Perez, 1989). A
variety of techniques, including photons, electrons and
interstitial therapy have been used. Many of these
studies have short follow-up, leaving the number of
late recurrences in question. Intralesional and post-
operative injections of triamcinolone acetonide have
been used with some success (Ketchum et al., 1966;
Griffith et al., 1970; Kiil, 1977).
This study assesses the value of beta radiation alone
or in combination with surgery and of intralesional
triamcinolone acetonide in the treatment of keloids
and hypertrophic scars.
Materials and methods
A total of 65 patients with 100 lesions of keloids and
hypertrophic scars were treated over a 12-month
period from August 1979 to July 1980. There were 25
males and 40 females. 20 patients (31 %) had multiple
lesions. Of the 100 lesions. 58 were keloids and 42
hypertrophic scars. Although there is no absolute way
to distinguish with certainty a keloid from a true
hypertrophic scar (Cohen and Peacock, 1990) the
clinical criteria we used for labelling keloid scars were :
(1) encroachment beyond the confines of the original
wound, (2) lack of spontaneous resolution for 9
months or more and (3) recurrence after previous
excision.

9. Four categories of treatment were employed. The
keloids were randomly assigned to all four treatment
groups using a simple random sampling procedure.
However, hypertrophic scars were randomly allocated
to categories I and TV only, as surgery used in groups
II and III was not appropriate for them. The dis-
tribution of lesions in four categories of treatment is
shown in Table 1.
Category I (beta radiation alone)
400 cGy were given twice a week to a total dose of
16 Gy per course.
The Isotope used as a source of beta radiation was
Strontium’” (Sr’“) kept at a distance from the lesion. In
order to protect the normal areas of body from
exposure to radiation a collimator of perspex was
designed. The collimator is the shape of a rectangular
box with an adjustable bottom (Fig. 1). It has two
holes on the top surface through which the source of
radiation can be inserted or removed. Radiation dose
to the lesion is adjusted by increasing or decreasing the
SSD (source skin distance) which is indicated by the
scale mounted on the rod of radiation source. De-
pending upon the size of lesion the bottom of the
collimator is adjusted so that only the lesion remains
exposed to radiation.
Table 1 Distribution of keloids and hypertrophic scars in
various categories of treatment
Nature of Caregor) Told
lesion I II III II’ no.
Keloids II 15 15 17 58

10. Hypertrophic 34 - ~ 8 42
scars
Total 45 15 I5 25 100
374
Evaluation of Various Methods of Treating Keloids and
Hypertrophic Scars : a IO-Year Follow-Up Study 375
area of 2-6 cm* and 612 cm” were given 40-80 mg
and 80-I 20 mg per course respectively. The total dose
of triamcinolone was given in four injections, the
interval between injections being one to two weeks.
Courses were repeated wherever necessary.
The patients were regularly followed for the as-
sessment of results for nearly 10 years. In categories I
and IV the symptomatic success and reduction in scar
thickness were used as parameters for assessing the
results. In categories II and III the results were assessed
in terms of any recurrence, The data thus obtained was
finally analysed statistically using the Chi-Square test.
Results
Fig. 1
Figure 1-A patient receiving radiation from collimator for a
lesion
on anterior abdominal wall.
Category II (Surgery combined with pre- and
postoperative beta radiation)

11. Preoperative radiotherapy was as for group 1,
There was an interval of approximately 7-10 days
between preoperative radiotherapy and surgery. Post-
operative radiation was delivered either within the first
48 h after keloidectomy (early postoperative) or de-
layed until after the removal of stitches and healing of
the wound (late postoperative). 400 cGy were given
twice a week to a total of 16 Gy.
Results of treatment in category I are shown in Table
2, from which it is evident that beta radiation alone
was more effective in the amelioration of symptoms as
compared to reduction in the size of lesions. The
results were significantly better (P < 0.05) for hyper-
trophic scars in comparison to keloids (Fig. 2). This
may be attributed to the fact that resolution in some of
the hypertrophic scars may not have been due solely to
our treatment, but time alone would have resulted in
their improvement.
In total 30 keloidectomies were performed, 15 each
in categories II and III. Diagnosis of keloid was
confirmed in all cases by histopathological exam-
ination. The results are comparable between the two
categories. Overall response in categories II and III as
summarised in Table 3 shows that out of 30 keloids, 20
Category III (Surgery combined with only
postoperative beta radiation) Table 2 Results of treatment in
category I
As in category II, postoperative radiation was given
either early or late with the same dosage.
Category IV (Intra-lesional triamcinoione acetonide)

12. Lesions with a surface area of l-2 cm* were given a
total dose of 2040 mg drug per course; those with an
Reduction in size of lesion
S.wlptomatic Mild or no Partial Full
QPe ?f relief change ,jlattening flattening
lesion No. no. (%) no. I% j 11”. (%I no. (%)
Keloids II 3 (27) 8 (73) 3 (27) 0 (0)
Hypertrophic 34 22 (65) 21 (62) 8 (23) 5 (151
scars
Total 45 25 (55) 29 (64) I I (24) 5(ll)
Fig. 2
Figure t-_(A) Hypertrophic scar on medial aspect of right ankle
following an accidental injury. (B) complete regression after
beta ray therapy
alone (category 1).
I5 BPS 45
376 British Journal of Plastic Surgerv
Table 3 Results of treatment in categories 11 and III
CUtegOr) II III Orrrall resulls
No. of lesions
Success

13. (No recurrence)
Failure
Partial
recurrence
Full
recurrence
Lost to
follow-up
15 15 30
IO (67 %) 10 (67 %) 20 (67 %)
4 (27 %) 3 (20%)
9 (30%)
1(7%) 1(7%)
1(7%) I (3 %)
Table 4 Effects of early postoperative radiation versus late
postoperative radiation in both categories II and III
Nature qf
posiopwatiw
radiution
No. qf
keloids
Early 16 12 (75) 3 (19) I (6)
Late 14 g (57) 6 (43) 0 (0)
Total 30 20 (67) 9 (30) l(3)

14. Table 5 Results of treatment in category IV
(67 %) were successfully treated in that they remained
recurrence free (Figs 3,4) and 9 (30 %) were not, while
1 patient (3 %) with an ear lobe keloid was lost to
follow-up.
Table 4 shows the effects of early postoperative
radiation versus late postoperative radiation in both
categories II and III, from which it is clear that results
were better when radiation was given in the early
postoperative period, but this was not statistically
significant (P > 0.10).
Reduction in size of lesion
Symptomatic Mild or no Partial Full
Nature of relief change Jattening Jattening
lesion No. no. I%) no. (% / no. (“6) 110. (%I)
Keloids 17 12(71) 0 (0) 5 (29) 12 (71)
Hypertrophic 8 6 (75) 2 (25) 2 (25) 4 (50)
scars
Total 25 18 (72) 2 (8) 7 (28) 16 (64)
Results of treatment in category IV are indicated in
Table 5. The drug gave dramatic relief of symptoms
and marked improvement in the appearance of lesions
Fig. 3
Fig. 4
Figure 3+A) A keloid on dorsum of left hand in a 15-year-old
girl developing after burns. (B) Results of treatment after

15. excision and split
thickness skin grafting combined with pre- and postoperative
beta ray therapy (category II), 10 years follow-up. Figure WA)
A large keloid
on the medial aspect of right thigh and two small keloids on leg
following kangri burns, (B) Results of treatment after 12
months following
surgery combined with only postoperative beta ray therapy
(category III) for larger keloid and intralesional triamcinolone
acetonide
(category IV) for smaller keloids.
Evaluation of Various Methods of Treating Keloids and
Hypertrophic Scars: a lo-Year Follow-Up Study
Fig. 5
Figure %(A) A midline infra umbilical keloid develouina in a
caesarean section scar. (B) Full regression after intralesional
triamcinolone . -
acetonide (category IV), 2 years follow-up.
Table 6 Comparison of treatment results for hypertrophic
scars in categories I and IV in relation to reduction in size of
lesion
Reductiotl Category I Category IV
in size no. = 34 no. = 8
of fesiun no. (% I no. (%j P z>alue Remarks
Mild or no 21 (62) 2 (25) > 0.10 Not
change significant
Partial g (23) 2 (25) > 0.50 Not

16. flattening significant
Full 5 (15) 4 (50) > 0.05 Not
flattening significant
Table 7 Comparison of treatment results for keloids in
categories I and IV in relation to reduction in size of lesion
Reduction Categ0r.v I Category IV
in size no. = Ii no. = I7
of lesion no. (%) no. (%/ P value Remarks
Mild or no g (73) 0 (0) -C 0.001 Highly
change significant
Partial 3 (27) 5 (29) > 0.50 Not
flattening significant
Full 0 (0) 12 (71) < 0.005 Significant
flattening
(Fig. 5). Results were better for keloids as compared to
hypertrophic scars but not significantly (P > 0.50).
Of the total 9 recurrences seen in categories II and
III, 6 (67 %) were noticed within the first 6 months, 2
(22 %) between 612 months and 1 (11%) during the
2nd year of follow-up. None of the successful cases has
since had a recurrence.
On comparing categories I and IV in relation to
reduction in the size of lesions, the results were
statistically insignificant for hypertrophic scars (Table
6). In keloids, mild or no change was significantly
more common in category I, whereas full flattening
was significantly more frequent in category IV. How-

17. ever, partial flattening was comparable between the
two groups (Table 7).
Local complications of treatment included super-
ficial burns in 3 lesions (7 %) in category I, depigmen-
tation in the area of excision in 3 lesions (10 %) in
categories II and III and atrophy of skin in 1 lesion
(4%) in category IV. In all three patients who
developed depigmentation the area resumed normal
colour within 18 months.
Discussion
No universally effective method of treatment for
keloids and hypertrophic scars is available. Surgery
alone alters the lesion but has an excessively high
recurrence rate. Devices that provide constant pressure
have been found to be beneficial (Kischer er al., 1975 ;
Brent, 1978). However, pressure must be maintained
day and night for a minimum of 6-9 months and
premature release is frequently followed by recurrence
of the lesion. Silicone gel has been used as a topical
therapy for keloids and hypertrophic scars (Quinn,
1987) with some success, but there is difficulty with
large lesions in holding the gel in contact with the
entire surface.
The value of radiation therapy in the treatment of
keloids has been known for many years. From pub-
lished reports (Van Den Brenk and Minty, 1960;
Cosman et al., 1961; Brown and Bromberg, 1963;
King and Salzman, 1970; Edsmyr et al., 1973) as well
as from the present study with beta rays, it appears
that results of primary irradiation of keloids and
hypertrophic scars have been limited to symptomatic
success only, while efforts to reduce the size of lesions

18. have been poor.
On the other hand, consistently reliable control of
keloids has been reported by several authors using
postoperative irradiation (Craig and Pearson, 1965 ;
King and Salzman, 1970; Amar-Inalsingh, 1974;
Edsmyr et al., 1974; Mathangi Ramakrishnan et al.,
1974; Levy et al., 1976; Ollstein et al., 1981; Borok et
al., 1988 ; Kovalic and Perez, 1989). A similar response
was seen in the present series.
378 British Journal of Plastic Surgery
We encountered all our recurrences in categories II
and III during the first 2 years of follow-up. Cosman et
al. (1961) reported a median time of recurrence of 12.9
months. This shows that 2-3 years is the minimum
acceptable follow up necessary before any new method
of treatment can be assessed with reasonable certainty.
Obviously any series with less than 2 years of follow-
up is missing a significant number of recurrences.
References
Amar-lnalsingh, C. H. A. (1974). An experience in treating 501
patients with keloids. Johns Hopkins Medical Journal, 134. 284.
Borok, T. L., Bray, M., Sinclair, I., Platker, J., LaBirth, L. and
Rollins, C. (1988). Role of ionizing irradiation for 393 keloids.
International Journal of Radiation Oncology, Biology, Physics,
15.
865.
Levitt and Gillies (1942) found the results of

19. combined pre- and postoperative radiotherapy more
rewarding than surgery combined with postoperative
radiotherapy only. In our study nothing was gained by
giving preoperative irradiation, as in both categories II
and III a success rate of 67% was attained. Cosman
et al. (1961) also claimed no advantage from giving
preoperative radiotherapy.
Brent, B. ( 1978). The role of pressure therapy in management
of ear
lobe keloids. Preliminary report of a controlled study. Anna& of
Plastic Surgery, 1, 579.
Brown, J. R. and Bromberg, J. H. (1963). Preliminary studies on
the
effect of time-dose patterns in the treatment of keloids.
Radiology.
80, 298.
The present results are strongly in favour of excision
followed by early postoperative radiotherapy and
suggest that radiation is most effective in the early
phases of wound healing. This concept of giving early
postoperative radiation is also supported by other
investigators (King and Salzman, 1970; Levy et al.,
1976), although Kovalic and Perez (1989) found no
difference between the recurrence rate of patients
receiving early and delayed postoperative irradiation.
Cohen, 1. K. and Peacock, E. E. Jr. (1990). Keloids and
hypertrophic
scars. In McCarthy, J. G. (Ed.). Plastic Surgery. Philadelphia,
London. Toronto, W. B. Saunders Company, Vol. 1, p. 732.
Cosman, B., Crikelair, C. F., Ju, D. M. C., Gaulin, J. C. and
Lattes,

20. R. (1961). The surgical treatment of keloids. Plastic and Recon-
structiw Surgery. 21, 335.
Cosman, B. and Wolff, M. (1974). Bilateral earlobe keloids.
Plastic
and Reconstructice Surgery, 53, 540.
Craig, R. D. P. and Pearson, D. (1965). Early postoperative ir-
radiation in the treatment of keloid scars. British Journal of
Plastic Surgery, 18. 369.
Beta radiation was found to be the most convenient,
cheap and portable source of radiation with an active
penetration power of only 3 mm approximately. To
date this has been free from any oncogenic effect and
we suggest it can be used safely in children and young
people.
Edsmyr, F., Larsson, L. G., Onyango, J., Wanguru, S. and
Wood, M.
(1973). Radiotherapy in the treatment of keloids in East Africa.
East A.frican Medical Journal. 50. 457.
Edsmyr, F., Larsson. L. G., Onyango, J., Wanguru, S. and
Wood, M.
(1974). Radiation therapy in the treatment of keloids in East
Africa. Acta Radiologica. Therapy, Physics, Biology, 13. 102.
Griffith, B. H., Monroe, C. W. and McKinney, P. (1970). A
follow-
up study on treatment of keloids with triamcinolone acetonide.
Plastic and Reconstructive Surgery. 46, 145.
Ketchum, L. D., Smith, J., Robinson, D. W. and Masters, F. W.
(1966). The treatment of hypertrophic scar, keloid and scar
contracture by triamcinolone acetonide. Plastic and Recun-

21. structive Surgery, 38. 209.
Triamcinolone acetonide was found to be effective
in the majority of lesions in the present study. Similarly
encouraging results have been reported by Ketchum et
al. (1966, 1971); Vallis (1967); Griffith eraI. (1970) and
Kiil (1977). On comparing categories I and IV, the
treatment results were found to be significantly better
in keloids with intralesional triamcinolone acetonide
alone than with beta irradiation alone; however, the
variation was statistically insignificant for hyper-
trophic scars.
Ketchum, L. D., Robinson, D. W. and Masters, F. W. ( 197 I ).
Follow-
up on treatment of hypertrophic scars and keloids with tri-
amcinolone. Plastic and Reconstructiae Surgery, 48. 256.
Kiil, J. (1977). Keloids treated with topical injections of tri-
amcinolone acetonide (Kenalog). Immediate and long term
results. Scandinarlian Journal qf Plastic und Reconstructire Sur-
ger?, 11, 169.
King, G. D. and Salzman, F. A. (1970). Keloid scars : analysis
of 89
patients. Surgical Clinics of North America, 50. 595.
Kischer, C. W., Shetlar, M. R. and Shetlar, C. L. (1975).
Alteration
of hypertrophic scars induced by mechanical pressure. Archit!es
of
Dermatolog,v. 11 I, 60.
Minor side effects of triamcinolone acetonide in the
form of subcutaneous atrophy are seen in the literature
(Griffith et al., 1970). We noticed this complication in

22. 1 lesion (4 %), and we believe that such complications
occur only if the drug is injected beyond the margins of
the lesion.
Although both large and small scars showed a
similar response to triamcinolone acetonide, we found
that patients with large lesions often show reluctance
to further treatment as multiple injections are too
painful. Thus we recommend triamcinolone acetonide
as a first line treatment for small keloids. For large
lesions, keloidectomy with early postoperative beta
radiation should be considered.
Kovalic, J. J. and Perez, C. A. (1989). Radiation therapy
following
keloidectomy : a 20 year experience. International Journal of
Radiation Oncologv, Biology, Physics, 11, 77.
Levitt, W. M. and Gillies, H. (1942). Radiotherapy in the
prophy-
laxis and treatment of keloids. Lancer, I. 440.
Levy, D. S., Salter, M. M. and Roth, R. E. (1976). Post
operative
irradiation in the prevention of keloids. American Journal qf
Roentgenology, 127. 509.
Mathaugi Ramakrishnan, K., Thomas, K. P. and Sundararjan, C.
R.
(1974). Study of 1000 patients with keloids in South India.
Plastic
and Reconstkctirle Surgery. 53, 276.
Ollstein. R. N.. Siepel. H. W.. Gilloolev. J. F. and Barsa, J. M.
(198 1 i. Trea;men;oi keloids by corndined surgical excision
and

23. immediate post operative X-ray therapy. Annals q/ Plastic
Surger!. 7. 28 I.
Quinn, K. J. (1987). Silicone gel in scar treatment. Burns, 13.
S33.
Vallis, C. P. (1967). Intralesional injection of keloids and hy-
pertrophic scars with Dermojet. Plastic and Reconstructire Sur-
gery. 40, 255.
Acknowledgments
Van den Brenk, H. A. S. and Minty, C. C. J. (I 960). Radiation
in the
management of keloids and hypertrophic scars. British Journal
of
Surgery. 41. 595.
The authors would like to express their gratitude to Dr S. J.
Supe
(PhD). Head Division of Radiological Protection. Baba Atomic
Research Centre. Bombay. India for providing the source of
radiation.
The Authors
We are also grateful to our staff, especially Mrs Mir Maryam
for Mohd Ashraf Darzi, MBBS, MS, MCh, Assistant Professor
and
her assistance in the preparation of the manuscript. Head,
Department of Plastic and Reconstructive Surgery. PO
Evaluation of Various Methods of Treating Keloids and
Hypertrophic Scars : a IO-Year Follow-Up Study 379

24. Bag No. 27, Sher-i-Kashmir Institute of Medical Sciences,
Srinagar 190 011, Kashmir, India.
Nisar Ahmad Chowdri, MBBS, MS, Lecturer, Department of
Plastic
and Reconstructive Surgery, Sher-i-Kashmir Institute of
Medical
Sciences.
Surrender Kumar Kaul, PhD, DRP, Associate Professor and
Head,
Department of Medical Physics and Bio-Engineering, Sher-i-
Kashmir Institute of Medical Sciences.
Mahmooda Khan, MBBS, FRCS(Ed), FRCS(Eng), Professor and
Head, Department of Surgery, S.M.H.S. Hospital, Srinagar,
Kashmir, India.
Requests for reprints to Dr M. A. Darzi.
Paper received 8 July 1991.
Accepted 2 December 1991, after revision.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Combined therapy in the treatment of auricular keloids
Yencha, Myron W;Oberman, James P
Ear, Nose & Throat Journal; Feb 2006; 85, 2; ProQuest Central
pg. 93

25. Reference:
Yencha, M. W., & Oberman, J. P. (2006). Combined therapy in
the treatment of auricular keloids. Ear, Nose & Throat
Journal, 85(2), 93-4, 96-7. Retrieved from
http://ezproxy.nu.edu/login?url=http://
search.proquest.com/docview/209414955?accountid=25320
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.