Ipsilateral Proactive Oncoplastic Enlargement of the Breast and Prognostic Stratification of Lymph Node Ratio after Axillary Dissection – A Prospective Study
Authors: Authors: Prof. A. K. Mostaque, Senior Consultant, Department of Surgical Oncology, Ahsania Mission Cancer and General Hospital, Uttara, Dhaka-1230, Bangladesh. Prof. A. M. M. Shariful Alam, Senior Consultant, Department of Clinical Oncology, Ahsania Mission Cancer and General Hospital, Uttara, Dhaka – 1230, Bangladesh.
Institution: Ahsania Mission Cancer and General Hospital
Introduction
Axillary lymph node dissection (ALND) maintain therapeutic values by removing regional tumor bulk, accurately counts positive lymph nodes (LNs), and guiding treatment stratification - ultimately improving longevity in high-risk breast cancer (B) patients. Standard level-2 oncoplastic surgery (OPS) balances the cancer-affected breast mastopexy using a matching procedure on healthy breast (symmetrization mastopexy), typically assuming ALND is irrelevant. However, operating on a healthy breast is ethical concerns regarding non-maleficence, highlighting the need to de-escalate this invasive symmetrization. To address this, we propose a paradigm shift: Skin-sparing OPS with concomitant ipsilateral ALND (Novel OPS). This technique naturally balances the reconstructed breast’s volume and elevation over time, helps standardize level-2 OPS by naturally balancing the volume and elevation of the reconstructed breast over time, achieving symmetry in shape, size and degree of ptosis compared to un-operated breast. By removing the need for healthy breast mastopexy, Novel OPS resolve the tension between aggressive oncologic resection and protecting healthy organs, standardizing level-2 OPS without unnecessary contralateral surgery. ALND-derived lymph node ratio (LNR) may provide a stronger prognostic indicator than pathological node (pN) staging potentially identifying high-risk patients within lower pN stages who require aggressive adjuvant therapies to improve disease free-survival (DFS) and overall survival (OS). This study aimed to: (1) evaluate efficacy and long-term outcome of Novel OPS, and (2) compare the accuracy of prognostic and patient stratification power of pN staging and LNR sub-grouping following ALND.
Methods
This single-center prospective cohort study was conducted on 51 consecutively treated BC patients including three patients treated with Novel OPS. The number of novel OPS was restricted because of integration of ALND in level-2 OPS. The novel OPS procedure were oncologic resection of the BC performed through double dough-nut periareolar incisions, de-epithelialization in between incisions with mean 30% breast tissue excision, and ipsilateral axillary fibro-fatty tissue dissection containing level-1 and 2 LNs to assess total/positive node counts, pN stages, and ALND-derived LNR subgroupings. Postoperative evaluation included loco-regional recurrence, lymphedema, patient reported cosmetic satisfaction and psychosocial quality of life. DFS and OS survivals were calculated at follow-up date focusing on the high-risk cases either of pN stages or LNR subgroups where all patients eventually died (on December 2022 follow-up) to understand their full survival trajectory.
Results
Of the 51 patients, 48 (94.1%) underwent modified radical mastectomy and 3 (5.9%) a novel OPS. The OPS cohort demonstrated recurrence-free survival with balanced, healthy, and symmetrical breasts at >7 years of follow-up. Median DFS and OS for the entire cohort were 49.23 and 52.63 months, following deaths of all high-risk LNR subgroup. Patient stratification differed significantly between the pN and LNR subgroups (p < 0.001). Estimated mean DFS was differed significantly when comparing low- vs. high-risk LNR (p < 0.001) and intermediate- vs. high-risk LNR (p < 0.001) against the standard pN stages. Similarly, OS differences between low- vs. high-risk (p < 0.001) and intermediate- vs. high-risk (p < 0.001) LNR subgroups were highly significant and superior to pN stage stratification. Univariate Cox regression analysis indicated that LNR and LNR-subgroups are independent prognostic factors.
Conclusion
Novel level-2 oncoplastic surgery with concomitant ipsilateral axillary lymph node dissection is an effective and proactive procedure that achieves natural breast symmetrization by utilizing the favorable physiological volume changes (i.e., organization of lymphedema) of the treated side, eliminating the need for contralateral healthy breast surgery. Furthermore, axillary lymph node dissection-derived lymph node ratio serves as a robust prognostic indicator and independent predictor in breast cancer and provide superior risk stratification crucial for tailoring adjuvant therapies. Routine implementation of ipsilateral axillary dissection provides a powerful dual-purpose benefit: spontaneous cosmetic symmetrization and precise prognostic stratification.