Catheters

may be placed either parallel or perpendicular (Fig. 1) to the incision although mixtures with crossed ends can be useful. Parallel catheters usually are fewer and longer than perpendicular catheter arrays and may be most appropriate when the tumor bed contour follows the curvature of the extremity. Dabrafenib Catheters and planes of catheters are placed at 1–1.5-cm intervals to ensure adequate dosimetry. Single-plane implants generally require closer spacing than multiplane volume implants to avoid scalloping of the prescription isodose. It is important to understand that wound closure can affect the catheter configuration through traction and bending as tissues are opposed and sutured together. The wound closure and catheter placement, therefore, must be done in concert to achieve satisfactory coverage of the clinical target volume (CTV). Catheter stabilization is essential for quality treatment delivery. Catheters can be sutured directly into the surgical bed with absorbable sutures and are also anchored to the external skin surface with various devices such as fixing buttons. Another stabilization and spacing method is to thread the implant catheters through Jackson–Pratt drains that can be placed within the wound and on the skin. These drains are oriented perpendicular to the catheters that pass through

the drain holes to create a stable implant unit (Fig. 1) (32). Catheters may be open at one (single leader) or both (double leader) ends, if they run from skin to skin, or they may be blind ended and terminate within the wound. Stabilization of blind-ended tubes is more difficult than for skin-to-skin selleck kinase inhibitor catheter arrangements. The Jackson–Pratt technique fixes the blind-ended tubes within the wound and helps prevent postoperative catheter displacements. Tissue expanders can Vildagliptin be used to protect normal structures from high exposure rates from the radiation sources. Gelfoam, drains, or inflatable (removable) materials can be placed between the catheters and critical structures to prevent normal tissue injury in the very high–dose region. The radiation oncologist must consider the

effect of tissue expanders on target coverage during simulation and dosimetry calculations. Once the catheters are placed and the wound is closed, it is important to check the relationship of the catheters to the wound and ensure that there is sufficient space (∼0.5 cm) between the catheter buttons and the skin to allow for postoperative swelling. The implant should be oriented so the catheters exit the skin in such a way as to easily insert the radiation source. Drains placed at the time of surgery should not be removed (Fig. 2) until after the BT is completed and the implant catheters are taken out to prevent inadvertent displacement of the catheters. This measure may also help decrease the risk of developing a seroma.