2 lumpectomy's without clear margins..mastectomy now or wait after radiation?

I've been diagnosed with Stage IIIa infiltrating ductal carcinoma.  Tumor was 3.5 cm with 10 of 15 positive nodes.  After initial lumpectomy, axillary disection and then MRI wire guided re-exision found another tumor within margin measuring 1.2 cm in size.  My question is should I go ahead with the mastectomy now and have to wait for tram flap reconstruction until after radition?  Or should I now go to chemo and do the mastectomy with reconstruction after radition?  Thoughts on remaining disease suseptibilty to chemo (not well vasularized) and risks associated with waiting.  I'm large breasted and will be lopsided for about a year.  But obviously my main concern is to be cancer free after treatments.  Plese advise....much thanks in advance!!

[CCF-RN,MSN-rf]

Dear 39andlovinit:  There is no absolute right way to approach the situation.  If reconstruction is important to you, it would be advisable to meet with your breast surgeon, a plastic surgeon, a medical oncologist and a radiation oncologist (preferably who have breast cancer expertise) to get their respective opinions on the best approach for you.  Large medical
facilities may be more likely to offer appointments with these specialists in a coordinated way.  By having this conversation with all the experts, taking into consideration all of the facts of your case (age, tumor pathology, etc.) a more specific recommendation could be made as it pertains to your situation.

[surgeon]

If you have mastectomy, radiation might not be part of it; usually it's lumpectomy with radiation, OR mastectomy without radiation. With some tumors, however, radiation is done after mastectomy, and yours might well be one in which that's recommended. It depends on information not provided. In my opinion -- which is only an opinion, and is even less worthwhile given the fact that I don't know you or all the details -- delaying chemo for a long time in order to have reconstruction is not a great idea. I think aggressive treatment of the cancer takes priority, in terms of timing, over reconstruction. But there are no absolute answers; you need to talk it over thoroughly with your doctors, especially the medical oncologist, who'll be doing the chemo.

[39andlovinit]

I will be having radition even after the mastectomy and thank you for your opinions.  I have decided, after your notes and discussions with my plastic surgeon to wait for the reconstruction until after radiation.  I'm going in for the mastectomy Monday and will begin chemo asap after healing.  Think happy thoughts...please!

[rkmsim]

I have no recommendations to your question.  But, I noticed you mentioned TRAM reconstruction.  If you are open to any suggestions, please check out DIEP reconstruction.  It doesn't compromise the abdominal muscle and I know a lot of women, including myself, who had BM with DIEP recon and are very happy with the results.  You can get a lot of information on the message board at www.facingourisk.org which is the website for FORCE and deals with hereditary breast and ovarian cancer.  The women there are great and very helpful.