Correspondence Radiotherapy or surgery for the axilla in nodepositive breast cancer? The beneﬁts of adjuvant radiotherapy in positive axillary nodal regions after breast-conserving and postmastectomy surgery have been recently demonstrated.1,2 Even though sentinel lymph node biopsy has largely replaced lymphadenectomy in the assessment of micrometastases in sentinel lymph nodes, it is still debated in axillary management, owing to the unfavourable eﬀect of macrometastatic sentinel lymph nodes on breast cancer outcome.3 In the EORTC 10981-22023 AMAROS trial,4 patients with positive sentinel lymph nodes received either axillary radiotherapy or axillary lymph node dissection. However, the small number of axillary recurrences observed in the study meant that the test for non-inferiority was underpowered. Axillary recurrence occurred in four of 744 patients in the axillary lymph node dissection group, and in seven of 681 patients in the axillary radiotherapy group. 5-year axillary recurrence was 0·43% (95% CI 0·00–0·92) after axillary lymph node dissection versus 1·19% (0·31–2·08) after axillary radiotherapy. The very low incidence of axillary recurrence in both study groups does not allow us to draw any deﬁnitive conclusions about the best interventional approach. Moreover, the trial did not take into account all the low-risk patients (probably not negligible) that could not undergo any intervention in the axillary region in case of a positive sentinel lymph node. We also have to consider the suboptimal dose of radiotherapy delivered in the adjuvant setting in the presence of residual axillary disease, and the technical challenge of re-irradiation in cases of locoregional recurrence in already irradiated patients. In particular, re-irradiation www.thelancet.com/oncology Vol 16 February 2015 could aﬀect both cosmesis and local disease control. Although modern radiotherapy techniques allow the dose to organs at risk to be decreased, while at the same time improving target coverage, it is well known that radiation could lead to an increase in deaths not related to breast cancer, mainly by induction of pulmonary diseases, cardiac diseases, and secondary cancers. These radiation-related complications probably aﬀect the overall beneﬁt of radiotherapy on breast cancer mortality after extended follow-up. We need to continue to assess results of the contemporary multidisciplinary management of breast cancer to better understand the complex interaction between the contributions of systemic and locoregional treatments to the ﬁnal outcome, including survival and toxic eﬀects.5 In our opinion, this outstanding study cannot change clinical practice. Conversely, it does support an alternative for locoregional axillary management in selected patients. Axillary radiotherapy should be a valid option if there is no indication for lymphadenectomy, and it will represent one more method in the armamentarium of oncologists. A multidisciplinary approach will be an even more complex and crucial step in the management of patients with breast cancer. Finally, longer follow-up of the AMAROS trial population is strongly needed to conﬁrm not only the equivalence of axillary radiotherapy in terms of eﬃcacy but also to determine the early and late toxicity proﬁles. We declare no competing interests. Lorenzo Livi, *Icro Meattini icro.meattini@uniﬁ.it Department of Radiation Oncology, University of Florence, Florence, Italy (LL, IM) 1 Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Eﬀect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised trials. Lancet 2011; 378: 1707–16. 2 3 4 5 EBCTCG (Early Breast Cancer Trialists’ Collaborative Group). Eﬀect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 2014; 383: 2127–35. Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with earlystage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2014; 32: 1365–83. Donker M, van Tienhoven G, Straver ME, et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 noninferiority trial. Lancet Oncol 2014; 15: 1303–10. Poortmans P. Postmastectomy radiation in breast cancer with one to three involved lymph nodes: ending the debate. Lancet 2014; 383: 2104–06. We read Donker and colleagues’ study1 reporting the results of the AMAROS trial with great interest. The study conﬁrmed that axillary radiotherapy and axillary lymph-node dissection (ALND) provide comparable local control. However, despite reduced lymphoedema in the axillary radiotherapy group, no signiﬁcant diﬀerences were recorded in range of motion and quality of life. The investigators postulated a bias due to low sensitivity or a response shift of the quality-of-life measures, but did not discuss the potential eﬀect of axillary radiotherapy on range of motion and quality of life. Restrictions in motion were less common after irradiation of the breast tissue alone in patients who underwent sentinel lymph-node biopsy compared with those who underwent ALND.2 Since no diﬀerences were observed in the AMAROS trial, it is reasonable to postulate that the dose delivered in the axillary radiotherapy group counteracted the beneﬁts expected by omitting ALND. Although irradiation of the periclavicular area might have aﬀected the range of motion, the potential morbidity of additional axillary radiotherapy deserves further investigation, as it can be associated with shoulder problems and can aﬀect quality of life.3 In particular, conventional breast irradiation includes e53