Stage IIB ER/PR Positive Breast Cancer With Positive Sentinel Lymph Nodes; Axillary Lymph Node Dissection vs Radiotherapy

Regarding this pt with a 4.2cm ILC and 3/3 SLN + (+ENE) it would be helpful to know the size of the nodal metastasis. Given the ENE, I suspect there is macrometastatic (>2mm) disease in the sentinel nodes.
Per ASCO and NCCN guidelines, ALND cannot be omitted in this pt because she has 3/3 positive lymph nodes, as well as extranodal extension, which suggests her level of axillary disease is significant. To adequately stage her, she requires ALND. While we only know of 3 positive axillary nodes currently, she may be found to have pN2 disease with adequate staging.
While it is understandable to want to spare the patient further axillary surgery, extrapolating from the AMAROS trial is not appropriate because in AMAROS 95% pts had <3 positive sentinel nodes and much less tumor burden in the axilla (40% had only ITCs or micrometastatic disease). Similarily, we must be careful not to extrapolate from ACOSOG Z-0011, evaluating the need for completion axillary dissection in patients who will receive radiation, to this patient. ACOSOG enrolled clinically node negative patients with T1-T2 tumors with <3 positive sentinel nodes.