“I Wish I’d Known” – Part 1

“I Wish I’d Known” – Part 1

Dr. Ordoyne speaks on modern breast cancer care and how integration of the oncology and reconstructive teams maximizes outcome quality.

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Male voiceover: Welcome to the YPO GCC “I Wish I’d Known,” a woman’s guide to modern breast cancer care and breast reconstruction. It’s my pleasure to introduce Betsy Roudi from YPO Gold Arizona.

Roudi: Hello, and welcome to our call today. It’s my privilege to be a part of the new YPO Spouse/Partner Community and to host this very important call through YPO member-to-member services. YPO has always been the place that many of us have turned to in times of guidance and need in finding the best of whatever topic we are interested in.

In this case today, it’s breast cancer and reconstruction.

My name is Betsy Roudi. I’m a spouse from YPO Gold Arizona and YPO Gold Aspen. YPO was one of the first channels that I reached out to for direction when getting breast cancer. I am forever grateful to my friend Dr. Kaveh Alizadeh, fellow YPO member from New York, acclaimed plastic surgeon. Dr. Alizadeh was instrumental in advising us when selecting our dream team, my dream team, of surgeons and style of surgery. Well, I chose to use my team in Arizona.

I have come to know the Center for Restorative Breast Surgery through a good friend who had an incredibly successful experience in New Orleans. Dr. Frank DellaCroce is a plastic and reconstructive microsurgeon and a founding partner of the Center for Restorative Breast Surgery. Dr. William Karl Ordoyne is a surgical oncologist also at the Center for Restorative Breast Surgery. Both visionaries in the art of breast reconstruction, their team welcomes women from around the world for treatment in their dedicated facility in New Orleans, Louisiana, the Big Easy.

Today’s call will be recorded and stored in the YPO library. The call will last one hour. Please type questions in the Q&A section of Zoom below on your screen. Questions will be answered in the final 15 minutes of the call. Thank you, thank you to YPO management for your dedication to this call. It’s very emotional. It will be very revealing for those of you on the call, and thank you for supporting YPO connections all over the world.

It’s my distinct pleasure to welcome Dr. DellaCroce and Dr. Ordoyne to YPO. Thank you for taking the time to share your knowledge and give hope to the many women in the world on this call facing the challenge of breast cancer. Welcome.

Dr. D: Thank you. Good morning or good afternoon — or whatever time of day it is in your time zone, depending on where you are in the world. I’m Dr. DellaCroce, more often known as Dr. D, and my partner Dr. Ordoyne and I have some very exciting and encouraging things to share with you today. We’re going to talk a bit about breast cancer care and its combination with cutting-edge reconstructive techniques that take the art and science of breast cancer surgery and outcomes to a different level.

Again, thank you for having us today. It’s a pleasure to be here. I’m going to turn the mic over to Dr. Ordoyne, who is a highly qualified and esteemed breast surgical oncologist. He’s going to spend a few minutes talking to you about breast cancer care specifically and mastectomy, and then I will follow him with some of the things we’re doing here at the Center for Restorative Breast Surgery on the reconstructive side. So with that, I’ll turn things over to Dr. Ordoyne, and, away we go.

Dr. Ordoyne: Hi, everyone. Like Frank said, I’m Karl Ordoyne. I’m a surgical oncologist at the Center for Restorative Breast Surgery. What that means is that I was a general surgeon initially and then did extra training specifically in cancer surgery. Now, I have devoted my career to just operating on patients with breast cancer or breast diseases. Let’s jump right into how we determine if a lady has a problem with her breast, specifically in the detection of breast cancer.

The one thing that’s made a difference over the years in a woman’s survival is early detection of breast cancer, so I think educating the ladies on how to palpate the breasts, make sure they determine if they feel an area that is lumpy or bumpy in their breast that is new to them and persists through a cycle or persists, beyond a couple of weeks, they should seek medical attention for that.

Also, ladies should have yearly mammograms once they get over the age of 40 to detect breast cancer at its earliest possible stage. Sometimes the mammograms may be suspicious and are not confirming any specific nodule, and then you will see the radiologist or the surgeon recommend that a lady go on to an ultrasound of the breast or possibly even an MRI.

In this picture, this is a mammogram of the breast specifically showing a lady that has ductal carcinoma in situ of the breast. If you look at the spiculated calcifications or bright areas in the breast, this is a classic indication that a lady has breast cancer. Some things to be cognizant of — if you look at the far left of the screen, there’s a bright area. That is the skin.

As you come in a little closer, you see a grayish area. That is a subcutaneous tissue, that’s fat, blood vessels, sometimes the ligaments of the breasts in this area, and then where you see the border of the calcifications or those bright spots, that’s where the breast tissue actually begins. I mean, I’m leading into this giving you some of this information because where I operate is between the breast tissue and the skin in removing the breast tissue.

Here’s another picture of the ultrasound that shows some calcifications. These aren’t quite as dramatic, but if you look to the middle of the screen, the far left, they have some bright spots right underneath the nipple. Those are calcifications also indicative of ductal carcinoma in situ. If the radiologist recommends an ultrasound, this may be a picture that we may see with a lady that has a solid tumor in the breast. Specifically, in this case, it would be an infiltrating ductal carcinoma.

In the center of the screen, you see a black spot. That just shows there’s density of the lesion. If you look at the very top, that’s the skin. As you come down off of the skin, there is literally a grey area that you see, and then right past that, just below where the number 1 mark is to your right, you’ll see that there’s a density of breast tissue below that. This particular cancer in the top middle of the screen is situated just on top of the breast tissue in the subcutaneous fat.

I use ultrasound a lot in planning my operations, and this is another picture that is showing in the center portion of the image an infiltrating ductal carcinoma, and the bright signals within that dark area are actually clips that were placed to mark exactly where the tumor was located. When I do the ultrasounds, I’ll measure the distance from the bottom of the skin to the top of where the cancer is located, and this helps me plan out my operation in determining what type of margins I can get around the tumor or if, in the previous example, I may have to remove some skin directly over the cancer.

These are great images. These are MRIs of the breast. This has given us a lot of opportunity to detect lesions even smaller than before. Usually, its resolution is somewhere between five and six millimeters in size.

In this particular example, you can see a bright spot in the far right of the image here. That’s actually the left breast, and that’s an infiltrating tumor in that area. This would have happened to be an infiltrating lobular carcinoma, and you can see an extremely good blood supply to the breast on the medial portion of that breast.

Here’s another image. The bright signal within the right breast, which is to the left of the screen, is an infiltrating ductal carcinoma. Usually when lesions are this size, we may opt to send a lady for preoperative chemotherapy, depending on some of the tumor markers that they may have.

This is a great image that I wanted to show people about, on the cellular level, what’s going on with the breasts. If you look at the great-like structures on this screen, those are the lobules of the breasts. That’s where milk is produced in ladies when they’re pregnant. The straighter purple lines that you see connecting the grapes, those are the ductal structures. When you look at ladies with breast cancer, the majority of breast cancers occur in the ductal system, which is the straight tubules that you see leading to the great-like structures. Only 10% of the breast cancers occur in the lobular areas of the breast.

What’s really important about the lobular carcinoma — I think — is that they’re a little bit more difficult to detect on routine mammography. Usually, MRIs may be a little bit better way to detect these malignancies. They’re the sneaky ones, so to speak, so a combination of radiographic modalities, it’s helpful in diagnosing this particular disease. The ductal carcinomas tend to grow in a more compact fashion, especially the infiltrating components, and they’re a little bit easier to detect.

So, let’s talk about some of the reasons why a lady may choose to have a mastectomy. Absolute indications or ladies that have invasive breast cancer, those would be infiltrating ductal carcinoma or infiltrating lobular carcinoma. Some of the non-invasive breast cancers are DCIS or lobular carcinoma in situ, which some people are concerned not to be an invasive breast cancer, but it carries at least a 30% risk of developing breast cancer as another indication.

Over the last several years, genetic disorders have really become a popular reason for mastectomy. Everyone’s probably heard of the BRCA genes. The “BR” stands for “breast,” the “CA” stands for “cancer.” So, they just took the first part of “breast,” the first part of “cancer,” and put those letters together, and that’s why they came up with BRCA. There’s particularly two genes, 1 and 2, that predispose ladies to breast cancer. However, there’s multiple other genes that are out there that can predispose ladies to develop breast cancer.

When we decide to perform a mastectomy, these are some of the incisions that we have fashioned. If you look horizontally, extending from the nipple out to the axilla, that is an incision that we commonly use, especially for ladies. I’ll let Frank talk about that in a little bit, but especially for ladies that do not have ptosis of the breast, that’s a good incision.

We also perform incisions that extend from the nipple down to the inframammary fold, which is that dark line that you see at the bottom of the breast, and actually, we’ll use a combination of incisions or patterns that extend from that 3 o’clock to 6 o’clock position, depending on how much access we need into the breast region.

Another incision that we have used is an inframammary incision that is at the crease of the lower breast, a nice incision especially if you want to hide that incision in that fold. Also during these operations, some ladies may need sentinel lymph node biopsies, which are biopsies of the lymph nodes that drain the breast. The sentinel lymph node is considered the first-draining lymph nodes of the breast. Usually, those are easily found in the axilla or armpit once the breast is removed.

As soon as I’m done with the operation, then I turn over the surgery to our plastic surgeons who do an excellent job in reconstructing the breasts, and at this time, I’ll turn it over to you.

Watch Part 2 on
Breast Reconstruction