Megan Sullivan

Brachytherapy Discussion

April 2016

The Freiburg Flap is a surface applicator used for high dose rate (HDR) brachytherapy cases for skin
cancers and other superficial tumors. In a conversation with a radiation physicist at Loyola University
Medical Center, ( Mike Mysz, MS, oral communication, April 2016) it was explained to be that this
applicator is made of a silicone rubber that is tissue equivalent and very flexible. This flexibility makes it
possible for the applicator to contour to irregular shapes and lie flush with the patients skin. The
Freiburg Flap comes in large sheets that can be cut down into custom shapes. The sheets are made up of
rows of connected spheres each with a 1 cm diameter. The appearance is not unlike that of bubble
wrap. Each sphere is hallowed out in the center and allows parallel rows of catheters to be inserted into
the applicator. The iridium-192 source is inserted into these catheters by the means of an afterloader
unit and remain in pre-determined dwell positions for a specified amount of time (usually seconds or
fractions of seconds). The 1 cm diameter bubbles displace the source 0.5 cm from the skin surface.
Loyola University Medical Center uses the Freiburg Flap applicator. There have been a few cases lately
that have come through including: upper lip sarcoma, squamous cell carcinoma of the scalp, basal cell
carcinoma of the ear, and T-cell lymphoma of the foot. I asked Mike why these cases are not treated
with electrons and he explained the option of HDR with the Freiburg Flap applicator requires fewer
fractions for the patient. The fractionation for these cases are 10 fractions twice a week at 4 Gy per
fraction. Additionally, the Freiburg Flap offers the ability to treatment complex surface contours that
may be considered challenging when planning with electrons.1
Mike emphasized the importance of consistency for each fraction just as is with external beam radiation
therapy. In order to maintain reproducibility for the three patient cases mentioned above, the Freiburg
Flap has been stitched to custom made Aquaplast masks with various materials including twine and
dental floss. This ensures the placement of the applicator is consistent for each fraction. The setup
photos for the lip sarcoma case can be seen in Figure 1. Radiopaque wire was also used to outline the
region of interest for the planning CT scan. Figure 2 corresponds with this case and shows the planning
system portion. Mike gave two reasons for having more material of the applicator than what is used.
The first reason is due to the need for having surrounding empty rows of material in order to help
contribute scatter dose. The second reason is simply foresight for treatment planning. It is always easier
to have too many rows and not need them all then to not have enough. The Freiburg Flap that was used
for the squamous cell carcinoma of the scalp can be seen in Figure 3, the basal cell carcinoma of the ear
can be seen in Figure 4, and the T-cell lymphoma of the foot can be seen in Figures 5a and 5b.

Megan Sullivan

Brachytherapy Discussion

April 2016

Figure 1. CT setup photos of patient undergoing HDR brachytherapy with the Freiburg Flap applicator for
upper lip sarcoma.

Megan Sullivan

Brachytherapy Discussion

April 2016

Figure 2. Treatment planning for upper lip sarcoma. Green region indicates used dwell positions. Purple
regions indicates unused dwell positions.

Megan Sullivan

Brachytherapy Discussion

April 2016

Figure 3. Custom mask with Freiburg flap for the treatment of squamous cell carcinoma of the scalp.

Figure 4. Custom mask with Freiburg flap for the treatment of basal cell carcinoma of the ear.

Megan Sullivan

Brachytherapy Discussion

April 2016

Figures 5a and 5b. Custom aquaplast with Freiburg flap for T-cell lymphoma to the entire left foot.

Megan Sullivan

Brachytherapy Discussion

April 2016

Reference:
1. Goddard AL, Vleugels R, LeBoeuf NR, et al. Palliative Therapy for Recalcitrant Cutaneous T-Cell
Lymphoma of the Hands and Feet With Low-Dose, High Dose-Rate Brachytherapy. JAMA
Dermatol. 2015;151(12):1354-1357. doi:10.1001/jamadermatol.2015.3028.