I presume the diagnosis of CA breast and the node negativity has been confirmed by FNAC / tru-cut biopsy.

I also presume that the said woman is pre-menopausal. So, the TNM staging is T1N0M0 (Early CA breast). One of the important high risk factor is her mother also suffered from CA breast (BRCA positive). Taking for granted no other risk factors in this woman, we have two options as you have mentioned. If the lady has given consent for mastectomy, then the best treatment may be Modified Radical Mastectomy and follow up (may not require any adjuvant therapy depending upon the H/P report of the resected specimen). Otherwise, as per American Society of Clinical Oncolgy recommendation, BCS in the form of Lumpectomy with / without Sentinel Lymph Node Biopsy is fine though the relative contraindication is strong family history with BRCA mutation. SLNB is not mandatory in this case as the only palpable lymph node is reactive. As per ASCO, If you had BCS, you will most likely have radiation on the entire breast, and an extra boost of radiation to the area in the breast where the cancer was removed to help prevent it from recurrence. If cancer was found in the axillary lymph nodes, radiation may be given to this area as well.

Dear Habibollah,

This is only a female point of view: She is young, after some years it is better for the women to have a silicon breast that can be adjusted to the form of the other breast. A breast after lumpectomy and radiation is always different in shape and form after some years and the nipple is on a very different height on the body. After all, with a lot of information about the pros and cons the woman she herself has to decide. I would with her genetic history perhaps take the whole breast but at the same time make the appointments for reconstruction. 

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Dear Habibollah

I agree with Dra Beatrice.

You must provide all the possibilities for treatment. The decision should be together: the patient, family and physician.

Always at the end, the decision must be patient.

For this patient - 31-41 years ?, premenopausal with BRCA1 + mother:

1 report on the severity of the disease, but with hope of cure (?),

2-Knowing how breast the breast is important for the patient,

3- What is the degree of satisfaction with patient has breasts.

4- Always offer and make the best cancer treatment: surgery, radiotherapy and chemotherapy, hormone therapy and targeted treatment, as needed.

After these data, in this case we can offer:

1- Search of sentinel node with axillary dissection or not, depending on the outcome,

2 Mastectomy if the patient does not care about your breasts.

2 If the patient has small breasts and is satisfied, avoid damaging the breasts, would make a quadrant with "round block"

3-If she has small breasts and want to increase the breasts, offer quadrantectomy with implant.

4-also offer adenomastectomy with implant, unilateral or bilateral.

5- For the patient who does not want to deploy, use techniques of oncoplasty

What the patient choose, within the best cancer treatment, it would also be my decision

I think that  we don´t know too many variable like  HER2 statuS and  estrogens and progesterone receptors to answer  the question easily.

Yes, freez her eggs. On the other hand only one doctor out of 10 may be willing to increase ovulation in the face of mastectomy and chemotherapy. A woman though gave her "testimony" on TV and said she was very happy  that she found such a doctor and was able to have her own children some years later. 

Dear Habibollah,

I am not sure if the woman herself or her mother have the BRCA mutation?

If only her mother have the BRCA mutation you have to make at genetic evaluation to ensure if the woman herself have the mutation as well, and if she have, you must recommend a mastectomy - eventually a primary reconstruction in the same procedure.

If the woman do not have the BRCA mutation, I would recommend you to consider an oncoplastic procedure with immediate partial reconstruction. For further details please se my paper

I agree with Dr. Ceferino and Dr. Michael. There are many variables in determining the prognosis and eventual treatment of breast carcinoma and one of them is presence of BRCA mutation. We have not clearly identified all those prognostic factors in this particular patient and for that reason I have mentioned a possible treatment protocol for the same.

NCCN Guidelines Version 1.2016 Invasive Breast Cancer

SPECIAL CONSIDERATIONS TO BREAST-CONSERVING THERAPY REQUIRING RADIATION THERAPY Contraindications for breast-conserving therapy requiring radiation therapy include:

Absolute:

• Radiation therapy during pregnancy

• Diffuse suspicious or malignant-appearing microcalci cations

• Widespread disease that cannot be incorporated by local excision through a single incision that achieves negative margins with a

satisfactory cosmetic result 1 • Diffusely positive pathologic margins

Relative:

• Prior radiation therapy to the chest wall or breast; knowledge of doses and volumes prescribed is essential. • Active connective tissue disease involving the skin (especially scleroderma and lupus)

• Tumors >5 cm (category 2B)

• Positive pathologic margin1

• Women with a known or suspected genetic predisposition to breast cancer:

May have an increased risk of ipsilateral breast recurrence or contralateral breast cancer with breast-conserving therapy Prophylactic bilateral mastectomy for risk reduction may be considered.

From the diagnostic biopsy you could get hormonal receptors, Ki 67 and HER2 status of the tumor. Her axilla must be treated with sentinel node. If one or two of the sentinel nodes are positive and patient is going to have BCS, you can spare the rest of the axillary lymphnodes or proceed to mastectomy.

The main issue is, to me, her BRCA status. If it is positive, patient slould be offered bilateral mastectomy and inmediate reconstruction. Of course, bilateral oophorectomy should be considered later.

I would get an urgent BRCA mutation analysis. This can be done in about 3 weeks, if you have access to this. A short delay will not make any difference to her long term outcome.

If you can see an axillary node on US, I would do an US guided FNA or core biopsy of the node whilst you wait for the BRCA test. "Ultrasound Reactive nodes" sometime contain metastastic disease. You may wish also to consider a sentinel node biopsy alone whilst you wait, if the US FNA/core is negative. If she has positive axillary nodes, this might affect your decision about whether to offer her an immediate reconstruction, if she has a mastectomy.

If she has a BRCA mutation, then she ought to consider bilateral mastectomy (+/- reconstruction). If she is BRCA negative, then breast conserving surgery would be fine. She will have a 2-3x relative risk of local recurrence (compared to women aged over 35), but no difference in overall survival.