We present the case of a 55-year old postmenopausal female with bilateral early stage clinically node negative breast cancer who was treated with bilateral lumpectomy with axillary lymph node dissection revealing N1a nodal disease in her right breast with extra-nodal extension and micrometastatic disease in her left breast. Given the controversy in management for low nodal burden for macroscopic and microscopic nodal disease, we review the key trials in regional nodal management that have

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... ed patients with low nodal burden to explain our reasoning for treatment decisions. Our patient was treated with both hypofractionation and conventional treatment. She is an excellent teaching case to demonstrate how much of an impact the decision regarding fractionation can have on long term breast cosmesis and toxicity.