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The ACOSOG Z0011 trial (NEJM JW Oncol Hematol Oct 12 2010) showed that axillary lymph node dissection (ALND) is unnecessary in patients with clinically axillary node-negative T1 or T2 breast cancer and one or two positive sentinel lymph nodes who undergo lumpectomy, radiotherapy, and systemic therapy. That practice-changing trial generated much discussion, debate, and angst among clinicians as the results were applied to clinical practice. One concern is that a bias may have been introduced by radiation oncologists treating patients randomized to sentinel lymph node dissection (SLND) without ALND, resulting in more extensive radiation, including extra tangents to nodal basins, beyond the protocol-stipulated standard tangential fields and a …