How do you approach breast conserving therapy in a woman who has formed bothersome keloids after prior surgeries?

I have only seen a few patients who developed keloids following breast surgery, whether or not they received radiation therapy. That also is true of individuals who have had keloids on other parts of their body. Hence, this fortunately seems to be a rare event, and I do not think prophylactic steroid injections or other measures are needed. Giving radiation should further reduce the risk of keloid formation. However, it is not likely that established keloids will resolve after radiation therapy.

Anecdotally, I have seen less keloid formation in women after BCT and RT even though RT is delivered after wound healing. In the past, for a few patients, I have done boost plan post op within 24 hrs (4Gy x3) treating scar and surgical bed followed by adjuvant whole breast after healing. When doing this, I have selected patients with low-grade type where low likelihood of any chemotherapy to avoid more gap between boost and whole breast RT.

I have managed this a couple of times. In one patient, I treated her incisions with standard 6-7 Gy x3 with electrons on days 1-3 postop, then completed WBI later. Another patient I plan on treating this month developed keloids after lumpectomy/SLNBx a year ago, but never followed up for adjuvant therapy - returning now. I am coordinating keloid resection on the day of RT start, will treat her as I would (40 Gy/15 to whole breast), but will place a small amount of bolus over fresh incisions. Interesting to consider if the large dose per fraction is important for keloid prevention, or just designed to minimize visits. We probably don't see this too often as the radiation we give probably helps prevent keloids even when delivered after a significant interval from surgery and with smaller doses/fraction.