Expert: Claes-Gustaf Nordquist, M.D. - 7/17/2006

Question
I'm 61, had a slow-growing tumor of 4 cm,  long assumed to be
a cyst (by me and at least 3 doctors), & never seen on annual
mammograms. No metastasis per PET/CT scan. Oncologist
wanted to try to shrink it before surgery for breast conservation,
so had 4 cycles of neoadjuvant chemo in a clinical trial with
Taxotere and Xeloda. Had a before and after MRI, and after MRI
says: "FINDINGS: Compared to the prior study, the dominant
enhancing mass in the lateral aspect of the left breast has shown
marked interval reduction. IMPRESSION: Interval resolution of
[the mass.]" My oncologist says this means it is gone, destroyed,
which is puzzling as there is still a palpable mass (he suggested
scar tissue.) But the primary surgeon still recommends
mastectomy instead of lumpectomy, and my oncologist now
recommends that for me too, as it appears the cosmetic result
of lumpectomy may not be good, and I don't want autologous
reconstruction.

So 1)  what is left after a tumor is destroyed by chemo? I know
people whose tumors (other cancers) shrunk and no surgery was
done. Does this tissue necrotize or get absorbed or what
happens?

2) Why do surgery now? (My clinical trial requires it, but I know I
have a choice. I am not opposed, just curious.) Is it simply
conservative treatment to do surgery, to avoid possible
recurrence from microscopic active cancer cells? Is the MRI (not
the more accurate Aurora/RODEO breast MRI I've read about)
simply not adequate to know what the surgeon may find?

Thank you.  

Answer
Your question makes me curious! How was the cancer diagnosis made? You have written that it was not seen on X-ray mammograms, was it seen on MRI mammograms? You have written that it can be felt. Was a biopsy ever done? If so what kind of biopsy? Surgical? Thin needle? Ordinary needle?  What was the EXACT result of the biopsy? No MRI can replace a pathology examination. The question about lumpectomy or mastectomy is a technical question which is impossible to answer from here (Sweden, Stockholm) without an examination. However surgery is important as living cancer cells may still be around, even though most of them may have died. As may be obvious from what I wrote above it is important to examine the tumour microscopically in order to find out if everything has come out - as far as that can be determined. A 4 cm tumour (>1.5 inches) is quite large! If any biopsies were made when was the first one done? If a lumpectomy would be made you would still need radiation therapy. I think given the size of the tumour that a mastectomy should have been decided from the beginning - if a biopsy has shown cancer. So that is what I recommend & I think you will still need postsurgical radiation therapy and maybe even more chemo therapy. Good Luck!