adjuvent chemo or mastectomy w/ reconstruction?

[pgf]

my wife presented with a 4-5 cm lump in her right axilla in november; surgery to remove right axilla single lymph node done on 1/7/04; pathology report states:  "lymph node almost completely replaced by metastatic carcinoma, consistent with mammary duct carcinoma (apocrine type)"; her estrogen and pregesterone receptors showed possitive; mri scan was done on 1/17/04 and showed the left breast completely normal and the right breast: "no focal masses are identified ... no regional or segmental enhancement abnormalities are present ... [but] deep within the breast [three distinct] short linear zones of enhancement [at the 7:00, 6:00 and 4:00 positions] within which are evident Type III perfusion kinetics ... though no mass lesions ... [also] in the operative bed of the right axila there is noted a 2.2 x 4.2 non-cystic soft tissue "mass" exhibiting heterogeneous generalized contrast enhancement [and] Type I and Type II perfusion curves ... a few sampled foci (tiny areas no more than 2mm) do show rapid perfusion with evidence of wash-out (Type III curves) [while] imediately adjacent to these areas the curves are Type I."  Breast surgeon recomends mastectomyy and axillar disection with transflap reconstruction asap; medical oncologist recomends adjuvent chemotherapy/hormone therapy with radiation of breast and possible axillar disection post 24 weeks of chemo.  It is now 2/8/04; I'm concerned of rapid metastasis post lymph node surgery and delay occasioned by recovery from breast surgery before chemo can begin.  It is now a systemic desease ... chemo first surgery later? thanks

[CCF-RN,MSN-rf]

Dear pgf:  There is no single "right" answer here.  Both methods, local control followed by chemotherapy and chemotherapy followed by local control are accepted options.  In this situation, given the size of the original tumor, we would likely recommend chemotherapy first (neoadjuvant chemo) - address the systemic disease and follow with surgery.  If the margins after surgery are positive or close, then radiation "might" be considered.

[surgeon]

Studies of how to handle this specific timing are few: it's fairly uncommon to present with an axillary metastasis without finding the primary. In general, when it occurs, it's felt by most that the breast treatment ought to be mastectomy: radiation of the breast supposes removal of the primary, and an extra boost of radiation to the area where it occurred. When the primary isn't found, then radiation to the breast would not include such a local boost. So, ultimately, if it were my patient, I'd suggest mastectomy. However, as you suggest, the timing is a major issue; since the known tumor was removed, I'd be inclined to go for chemo now, and surgery later. So my feeling is different from either of the doctors you mention: chemo now, then mastectomy. The choice of reconstruction or not, by what method, and whether to do it all at the time of the mastectomy can be decided later. Please also understand I'm an experienced breast surgeon who chimes in here, but I'm not offically associated with the site, and there will be an answer from them, presumably Monday.