deciding abt lymph node surgery after positive SLNB with TN IDC

I think you should definitely consider a second opinion.  I've read some recent research suggesting that rads can replace lymph node removals in situations that sound similar to yours.

I'm no expert, but maybe a second opinion could help out with that?

Here's one paper that is relevant:

http://jco.ascopubs.org/content/29/34/4479.full

In conclusion, on the basis of the results of Z0011, a significant proportion of patients with one to two positive SLNs and BCS can safely forego ALND. The majority of these patients do not need to be subjected to the short-term and long-term morbidity of ALND. The multidisciplinary approach of adjuvant systemic therapy and WBRT is important in reducing the risk of locoregional recurrences. Until additional data are available, including analysis of the Z0011 radiation fields, it remains our policy to assess the risk of microscopic involvement in the regional nodes and to target nodes that are at significant risk in the radiation treatment plan. Table 1 summarizes a suggested approach for radiation field design. Using this approach, we will provide patients with excellent locoregional control and, in combination with surgery and adjuvant systemic therapy, optimize the patient's probability of cure. The data from Z0011 also give additional justification for the use of BCS for patients with positive SLNs. The potential for avoiding ALND, coupled with the high rates of locoregional control that are associated with BCS and WBRT, should make this approach more appealing than mastectomy for most patients. 

What I don't know is the risk of lymphedema with radiation sans ALND versus the big ALND and "regular" radiation... but I feel like the goal there is to reduce the risk of lymphedema.

And I'm totally with you on the avoidance of lymphedema - that stuff is SCARY!  I ended up with costochondritis, and I was so worried that it was the beginning of truncal lymphedema...  Suppose it still might be, but the doc I saw yesterday was not worried at all about lymphedema. He did order up a chest xray just in case... but I just got that call - the happy call - you look normal - yay!  (literally - minutes ago!).  ANyway, costocondritis - oweeeee ribs - I can deal with that.

bexH: Just returned from holidays and read your post. It takes me back - as I thought I had everything figured out too, and then another decision point would come along. Very stressful! I can't tell you how long I researched ALND versus additional rads. My best advice would be to google the latest research from reputable medical journals and put pointed questions to your BS, onc and rad onc. You'll know in your gut what feels right, when you have enough information. 

My background, for what it's worth: I had Lx and SLNB that showed 2 nodes clear, 1 with a few ITCs and another with many ITCs, which if they were clumped together would properly be categorized as micromets (2mm). Path report said the node should be treated as such. RO said he would radiate the heck out of them  (that does carry risk of LE too, albeit usually less than surgery). BS though I should have ALND - even shceduled after chemo, if I wanted. (I was anxious to get on with chemo being TN). MO recommended ALND as it was standard of care at the time, and if I wanted to participate in any clinical trials, that may be a qualifying criterion. Made sense. A lot of the research that was emerging at the time, showed that rads could be an acceptable alternative to ALND, and that ALNDs were being done less frequently. However, there was nothing definitive, at the time. In the end, I chose to have an ALND because I trust my BS completely and as she said, rads may in fact take care of it, but it's only through surgery (and resulting pathology) that you KNOW definitively if you have caught any spreading cancer). She had a cancellation on a surgery and I got in right away. 10 more nodes taken, and, as it happened, all 10 were clear. Peace of mind for me. So far, I have had no issues with LE at all. I wear a sleeve when I fly as a precaution. 

I wish you well with your decisions. Whichever way you go, it will feel much less traumatic 3 years out!