title: Novel eradicative high-dose rate brachytherapy for internal mammary lymph node metastasis from breast cancer.
abstract: OBJECTIVE
  To develop a method of delivering an eradicative high radiotherapeutic dose safely preserving the surrounding skin in the treatment of internal mammary lymph node metastasis (IMLNM) of breast cancer.
  
  
  METHODS
  We report a 38-year-old female patient with a solo IMLNM showing no response to 60 Gy in 2.5 Gy fractions of external beam radiotherapy. To eradicate this tumor, a boost brachytherapy plan was created after percutaneous insertion of an applicator needle into the IMLNM lesion avoiding the pleura and vessels under ultrasound monitoring. According to the dose distribution, the required thickness of a spacer between the skin and the tumor was determined, and hyaluronic gel was injected up to this thickness under ultrasound monitoring. We evaluated skin doses, target doses and clinical outcome.
  
  
  RESULTS
  All procedures were performed easily. Sixteen Gy (34.7 Gy equivalent in 2 Gy fractions calculated by the linear quadratic model at α/β = 10: EQD(2, α/β = 10), cumulative total was 101.9 Gy EQD10) to 100% of the target volume was irradiated with cumulative maximum skin dose of 70 Gy EQD(2, α/β = 3) which was 98.7 Gy EQD(2, α/β = 3) without spacer. No procedure related- or late complications and no local recurrence at the treated site were observed for three years until expiration.
  
  
  CONCLUSIONS
  We consider that this procedure will provide an eradicative high-dose irradiation to IMLNM of breast cancer, preserving skin from overdose complications.
authors.affiliation: Kazushi Kishi, Department of Radiation Oncology, Wakayama Medical University, Wakayama 641-8510, Japan.
authors.forename: Kazushi
authors.initials: K
authors.lastname: Kishi
authors.forename: Hirokazu
authors.initials: H
authors.lastname: Tanino
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Sonomura
authors.forename: Shintaro
authors.initials: S
authors.lastname: Shirai
authors.forename: Yasutaka
authors.initials: Y
authors.lastname: Noda
authors.forename: Morio
authors.initials: M
authors.lastname: Sato
authors.forename: Yoshitaka
authors.initials: Y
authors.lastname: Okamura