In light of the AMAROS trial, how do you decide between ALND vs. axillary RT?

These clinical scenarios will be faced more often by radiation oncologists.

In the old French and NSABP B4 data, the regional control rates between surgery and radiation were very similar for clinically node negative patients, but these studies did not gain much traction because chemotherapy decision...

This is a great question that comes up constantly during tumor boards.

Short Answer:

In this specific case T3N1 (1/2 SLNB+), I agree with the above and would offer PMRT. Specifically, I would enroll this patient (if she did not have neoadjuvant chemo) on the MA.39 clinical trial.

Long Answer:

The big qu...

I completely agree with @Dr. First Last. Given that this patient needs post op rt based on the T3 tumor, the axillary area can be covered as part of that. Also, several surgical series indicate that in this setting, the number of additional nodes being positive is zero in the majority of cases, maki...

Thank you for the thoughtful discussion. @Dr. First Last and @Dr. First Last, is there a number of sentinel lymph nodes that would impact your recommendation to go back for ALND? AMAROS had very few patients with >/= 4 sentinel lymph nodes.

Even though both AMAROS and Z11 did not do a separate analysis on ECE (they allowed microscopic ECE and excluded gross ECE), we would not change our discussion based on focal ECE alone.

Does your answer change on the role of axillary dissection if there was focal extranodal extension on a positive sentinel node?

I would not let ECE affect my decision either. I have not seen convincing data that it increases the risk of axillary failure.

In the absence of ALND, are there instances in which you would treat high tangent only, without SC field? (intact breast)