Yesterday we had an appointment with Dr. Manders, a breast surgeon at Christ Hospital.  This was a consult and a second opinion and we're still yet to decide who the surgeon will be.  Cathy really liked Dr. Manders, but didn't care for the drive to Christ.  It's in Mt. Auburn, between Clifton and downtown, so it's a good bit farther away than Bethesda North.  It is, however, a really good hospital, the same hospital where I had my thyroidectomy.  At that time we were really impressed with the hospital.  Traffic was horrible on the way home and Cathy was tired.  She was too tired to really be able to think about whether or not Dr. Manders is the right surgeon for her.  I was, of course, desiring to talk it through right away, but Cathy's fatigue served as a good buffer that will allow both of us to have a clearer mind when we do talk about it.  

Dr. Manders was very thorough, spending over an hour talking with us.  We talked about the protocol for Cathy's triple negative cancer and the Plans A, B, C, etc. for attacking it surgically and otherwise.  I'll try to summarize what we learned.  Like most of our doctor appointments it was a lot to process, but it seemed to align clearly with other consults we've had and with what I've read.

Right away, triple negative and BRCA1+ meant bilateral mastectomy to Dr. Manders.  There was never any other discussion.  This was pretty comforting to us because it indicated that she understands what we're dealing with and she's aggressive in her approach to long term healing and cancer fighting for Cathy.  We talked about the mastectomy and about reconstruction options.  Dr. Manders would prefer that a consult with a radiation oncologist help us in refining Cathy's choice in reconstruction.  I have a lot more reading to do to learn about types of reconstruction, but I'll try to accurately summarize some ideas we talked about.

Reconstruction using the abdominal wall is not a good choice because it is very risky in terms of maintaining blood supply, fighting infections, and opens the door to future abdominal hernias because of a thinned abdominal wall.

Reconstruction using fatty tissue from Cathy's belly could be good, but Dr. Manders doesn't think Cathy has enough fatty tissue to make two regular sized breasts.  Further discussion of this will be had with the plastic surgeon, though.

The two best options, in Dr. Manders's mind, are expanders under the pectoral muscle to be replaced by implants later and use of the latissimus dorsi muscle with or without an implant.  

I'll go more into the reconstruction process when I learn more.  The important thing about this appointment is the strategy, though.  After meeting with the radiation oncologist it will be determined whether or not radiation will be necessary and to what extent.  A needle biopsy and/or staged sentinel node biopsy about a week prior to the mastectomy will help to confirm or change the radiation plan.  If there is no evidence of cancer in the lymph nodes, reconstruction can be done in conjunction with the mastectomy or shortly thereafter.  If there is evidence of cancer in the nodes, radiation will most likely need to come before reconstruction.  Radiation can have some adverse effects on reconstructed tissue and particularly on implants.  

Dr. Manders looked at Cathy's MRI, scans, and other films, as well as conducting her own exam.  She could see the marker left at biopsy on the MRI, but could not see the tumor.  She could also not feel the tumor, thus declaring, "Awesome."

So now we can kind of see a plan, but we know that within that plan there are many contingencies and subplans, if and if and if and if.  At least we can see a clearer picture.