case Study preservation on Superficial Radiotherapy following Ear lobe keloid excision

1. Superficial Radiotherapy (SXT)
following ear lobe Keloid excision
CASE PRESENTATION
Authored by
Kikwai Richard , Ann Waita and Antony Mamati
Presented
By
Mamati Antony

2. • Introduction
• Case Presentation
• Case Description
/Discussion
• SXT Process /
Technique
• Safety Measures
• Conclusion

3. Keloid disease
• A Keloid is a growth of dense fibrous tissue that extends beyond the boundariesof the original
wound.
• Compromise aesthetic, itchy , painful and impair function
Epidemiology :
• Higher incidence in female than in men attributed to ear piercing as an aesthetic value
activity.
Management :
• Management to prevent recurrence has been a challenge and combined treatment is
advocated for best results.
• Surgery followed by superficial radiotherapy documented to have successful rates to reduce
recurrence.
Post excision radiotherapy:
• Non- invasive treatment option that is applied within 24hrs to 48hrs post excision.
• Safety ensured throughapplication of the best practices in rdaiatiotherapy

4. Why present this case
• Safety concerns
• Share
technological
advancements
• Protocol reviews

5. • 22 year old female
• Developed Keloid 3 years on
the left ear lobe (suspected to be
as a resultant of ear piercing).
• No family history of Keloid
disease.
• Reason for excision; itchiness
and compromise aesthetic.
• Complained of numbness and
intermittent pain around the
infra auricular pinna region.
• A slight swelling was noted
around the excised area.

6. • Most common
presentation at NRC since
2000.
• The only SXT centre in East
and Central Africa
• Keloid located close highly
radiosensitive tissues to
radiation : eyes, ear drum ,
brain, salivary glands.

7. Routine Questionnaire to ascertain :
• Patient comfort.
• Skin tolerability to ionising radiation
• Explanation of the procedure.
• Expected side effects
appropriateness of the treatment
regime and
• Consent for treatment.

8. • Superficial radiotherapy treatment is the use of low-energy X-rays to
destroy unhealthy cells.
• Practitioners began using radiation therapy for treatment of keloids
in 1906.
• This is very good for treating lesions on or just beneath the skin
surface, as the X-rays don’t go deep into the body.
. Depths at Which the Dose is 100%, 80%, and 50% of the Maximum Dose for Common Photon Energies :
PHOTON BEAM ENERGY DEPTH (cm) VERSUS
PERCENTAGE OF MAXIMUM DOSE
100 % 80 % 50%
230 kV 0 3.0 6.8
60Co 0.5 4.7 11.6
4 MV 1.0 5.6 13.0
6 MV 1.2 6.8 15.6
10 MV 2.0 7.8 19.0
25 MV 3.0 10.2 21.8

9. SUPERFICIAL RADIOTHERAPY UNIT

11. STEP ONE: Definition of the
target volume ( REGION OF
INTEREST FOR TREATMENT)
• The gross tumour volume
(GTV) includes the whole scar
that is left after excision of
the Keloid.
• The CTV including the scar
and traumatised skin.
• Planning tumour volume
should cover an area of at
least 1cm-2cm around the
scar.

12. • Done within 24-
48hrs post excision
• Associated with the
cell cycle
Sensitivity to radiation;
G2(late G2 and M phase are the
most sensitive
S phase, (particularly late S
phase)- more resistant
G1 phase - average sensitivity

13. THE OXYGEN-FIXATION HYPOTHESIS
• Absorbed radiation –production of free radicals. highly
reactive molecules that break chemical bonds,produce
chemical changes and initiate the chain ofevents that
result in biological damage.
• Most of the indirect effects occur by free radicals
produced in water, since this makes up 70–80 per cent
ofmammalian cells.It is the fate ofthe free radicals
ultimately produced in the critical target,designated as R
• R=molecules are unstable and will react rapidly with
oxygen,if present,to produce RO2,which then undergoes
further reaction ultimately to yield ROOH in the target
molecule.Thus we have a stable change in the chemical
composition of the target.

14. • Patient lied prone
• Arms along the head on a
firm pillow case
• The head is immobilised
using immobilising tapes
and straps.
• Post excision dressing is
removed carefully to
exposé the excision scar.

15. Cone Identification:
Accessories used to
conform radiation to
treatment area.
• In this case a 4x6 cm
• 30SSD cone was used.
• 0.2mmcu filter used as a
beam hardener.

16. :
• TREATMENT TIME AND
DOSE CALCULATION:
determines the amount
of radiation to be
delivered and the
duration of delivery
Prescribed dose is 12Gy
using 100Kev 20mAS in
single fraction

17. SHIELDING AND RADIATION
PROTECTION MEASURES
• Provide shielding to
sensitive organs and
adjacent tissues that do
not fall within the target
volume.

18. • Irregular nature of the target
area.
• Minimise exposure to adjacent
structures not in the path
treatment

19. 1If the technology is safe, then
we will be safe.
2. If the human is safe, then we
will be safe
3. If the organization is safe,
then we will be safe’.

20. STEP FIVE
• PATIENT REASSURANCE OF
THE PROCEDURE:
• No pain during
treatment
• No scarring sounds or
manoeuvres
• Expected to remain still
during the treatment
• Estimated time of the
procedure is revealed to
the patient.

21. STEP SIX
• Verification of treatment set-up
• Treatment time calculations
• Radiation safety measures .

22. STEP SEVEN
• Treatment delivery
• Monitoring of the
patient. This was done using a
CCTV camera that is installed in
the treatment room with a
screen in a separate controll
room.

23. Completion of treatment
• Removal of lead shielding material around the
treated area
• Dressing the treated area.

24. • Skin care post superficial radiotherapy
• No harsh antiseptic to be applied on the treated
area.
• No rubbing, scratching or scrubbing the treated
area in the event of itchy.
• Minimise contact with water on the excised area,
for at least 14 days.
• Given referral note indicating the amount of dose
delivered and the fractionating regime.
• and booked for review after two months

25. • Use of SXRT is well tolerated for ear lobe
Keloid treatment post excision.
• Safe & Effective
• Short treatment sessions
• No pain
• No scarring
• No anesthesia required
• No post reconstructive surgery required
• High cure rates

26. AREAS OF CONCERN
1. Open sites post
excision.
2. Absorbable and non-
absorbable suture
materials.
3. Post radiotherapy
injection.

27. Don’t give up the fight to
overcome keloid recurrence

28. NRC
Says
THANK YOU