De-escalation of oncoplastic surgery and prediction of breast cancer survival beyond serial axillary dissection – A prospective study

Background: After introduction of the radiotherapy in breast cancer multimodality treatment has disregarded the therapeutic value of axillary lymph node dissection (ALND). Common practice is sentinel lymph node biopsy to count positive nodes only to forecast breast cancer prognosis. Exclusion of symmetry surgery, skin sparing breast reconstruction after oncologic resection of cancer, and addition of ipsilateral ALND might induce spontaneous enlargement of reconstructed smaller breast due to lymphedema effect thus help standardization of technical and safety aspects of Level 2 oncoplastic surgery (OPS). The objectives of study were (1) to observe the outcome after inclusion of ipsilateral ALND in place of symmetry surgery of contralateral normal breast in level 2 OPS and (2) to observe power of assessment of prognosis of pathological node stages and ALND based lymph node ratio (LNR) subgroups. Methods: Study conducted on 51 surgically treated breast cancer patients of a single institution. Data were collected and analyzed of three breast cancer patients treated with oncologic resection of tumor, skin sparing breast reconstruction and ipsilateral ALND avoiding contralateral symmetry surgery, and data of total and positive axillary node counts, patient distribution as per pathological node (pN) stages and LNR subgroups, and DFS and OS at follow-up date when all patients of high-risk LNR died. Results: Six years follow-up of patients who were treated with alternative OPS model indicated spontaneous enlargement of all operated breasts, perfect symmetrisation, and no loco-regional recurrence. The median DFS and overall OS on December 2022 were 49 ^. 23 and 52 ^. 63 months respectively. Significant statistical difference was observed of the distribution of patients among pN stages and LNR subgroups ( p = 0 ^. 000001) and of estimated mean DFS between low- and high-risk ( p = 0 ^. 000003 ), and intermediate- and high-risk LNR ( p = 0 ^. 000115 ), and of OS between low- and high-risk ( p = 0 ^. 000041 ), and intermediate- and high-risk LNR ( p = 0.000161 ) subgroups. Conclusions: Ipsilateral ALND model of OPS is a simpler therapeutic procedure causing spontaneous enlargement of the treated cancer bearing breast leading to almost natural symmetrisation, de-escalate surgical work load and is a safer procedure. ALND is powerful independent forecaster of breast cancer prognosis too.