Expert: Claes-Gustaf Nordquist, M.D. - 1/22/2010

Question
My sister is a 60 year old woman presenting with primary squamous cell carcinoma of the breast.  Her PET scan is negative for any other carcinoma.  Her surgeon recommends treating this cancer as a regular breast cancer and has given her the option of lumpectomy or mastectomy.  The mass was less than 2 cm.  He recommends that with a lumpectomy that she have follow-up radiation therapy or with a mastectomy that there be no follow-up treatment.  A friend of our family, who is an oncologist, has suggested that my sister seek a second opinion from an oncologist prior to surgery, which just today (Thursday) has been scheduled for Monday.  He has suggested that she receive some chemotherapy treatment prior to the surgery so that the tumor's response can be traced and documented.  He also suggested that tumor would likely respond best if treated oncologically as a head and neck tumor rather than as a typical breast tumor.  The surgeon when presented with this view said the surgery should be done as he is recommending because he wouldn't be able to tell about lymph node involvement if chemo treatment was given prior to the surgery.  What are your views?

Answer
Both views have their advantages and disadvantages. The surgeon is correct in his observation with regards to lymph node involvement (even including sentinel nodes) but the oncologist also has points with regards to the nature of this particular cancer and its treatment. In fact there are other possibilities too. I'm personally somewhat unhappy with a lumpectomy of a tumor as big as close to 2 cm in size (1 inch = 2.54 cm). Chemotherapy before surgery may reduce its size but will inluence the possibility of evaluating any lymph node involvement in any way as already mentioned. Presurgical radiation therapy can give the same result but will influence the postsurgical radiation therapy. Or you could go for a mastectomy with chemotherapy afterwards (but without knowing if the tumor is sensitive or not) or even different combinations of surgery, radiation therapy & chemotherapy. So there are in fact many possibilities. The surgeon is suggesting a procedure that is common with ordinary breast cancer. The oncologist one that is more common with head & neck cancers. But head and neck cancers and cancers in the breasts have clear differences with regards to options, possibilities and concerns even if this cancer in its pathology is closer to head and neck cancers than to ordinary breast cancers (adenocarcinomas). It is actually impossible to say that one is right and the other wrong. This is an unusual cancer. In head and neck cancers it is usually easier to check for any lymph node involvement prior to any treatment. That is less easy with breast cancers due to their location. I hope I have been able to make my position clear. This is uncertain territory. Experience with this type of breast cancer is more limited.




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