Do you recommend sentinel node biopsy or ALND in cT4 or cT3 cN0 breast cancer patients?

The major trials comparing SLNB versus ALND (i.e., Table 1 from Lyman et al. 2014) either required tumors to be small (<= 2-3 cm), or had few patients with larger tumors (e.g., NSABP B-32: less than 2% with tumor > 4 cm; ALMANAC: 2% with tumor > 5 cm). Similarly, the major surgical trials comparing SLNB alone versus SLNB plus completion ALND in patients with low nodal disease burden (i.e., IBCSG 23-01, ACOSOG Z0011, AMAROS) all required preoperative cT1-2 cN0. Furthermore, all of those patients received some sort of adjuvant RT that would have treated at least part of the axilla, with the exception of a small subset of IBCSG 23-01 who underwent BCS and IORT, or underwent mastectomy without PMRT.

For large tumors > 5 cm (i.e., cT3), the rate ...