Adjuvant Regional Nodal Irradiation Recommendations After ACOSOG Z۰۰۱۱ (Alliance) Trial Results: “Our Doubtsand Uncertainties Maybe Traitors for Undertreated Patients”

Predicting breast cancer (BC) outcome based onsentinel lymph node (SLN) status without axillarylymph node dissection (ALND) is an area ofuncertainty in patients with limited SLNinvolvement. These uncertainties automaticallyinfluence the decision-making on adjuvant regionalnodal irradiation (RNI). The updated clinicalpractice guidelines report from the AmericanSociety of Clinical Oncology on the use of SLN forpatients with early-stage BC concluded that womenwithout SLN metastases and those with ۱-۲metastatic SLNs receiving whole breast irradiation(WBI) should not undergo ALND. Women withSLN metastases who will undergo total mastectomy(TM) should be offered ALND. These recommendationsare mainly based on randomized trials.۱-۳However, several concerns remain including theshort follow-up periods of these trials and theuncertainty of axilla coverage by the tangential fields(TgFs) irradiation, especially with ۳-D conformaltechniques.