Would you consider regional nodal irradiation for a patient who refused initial adjuvant breast RT who now presents with locally recurrent multifocal breast cancer s/p lumpectomy with positive margins and no nodal evaluation?

I would recommend margin re-excision with a sentinel node biopsy at that time prior to any radiation. If the SNB is negative, I would not recommend coverage of the regional nodes.

Re-excision and repeat SNLN.

If can’t track/identify SNLN, then breast with level 1 and 2 nodes in tangent beam.