Oncological outcomes of selective axillary dissection with 4% carbon marking

BUDEL, LUCAS ROSKAMP; SPAUTZ, CLEVERTON CÉSAR; LOUVEIRA, MARIA HELENA; CAVALCANTI, TERESA CRISTINA SANTOS; FORNAZARI, ALESSANDRA CORDEIRO; GASPERIN JUNIOR, PLINIO; NISSEN, LEONARDO; BUDEL, VINICIUS MILANI

doi:10.1590/0100-6991e-20243697-en

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Original article • Rev. Col. Bras. Cir. 51 • 2024 • https://doi.org/10.1590/0100-6991e-20243697-en linkcopy

Oncological outcomes of selective axillary dissection with 4% carbon marking

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: The use of axillary marking prior to Neoadjuvant Systemic Therapy (NST) is a controversial matter regarding patients with positive Lymph Nodes (LN). Several methods were tested to make possible the decrease of false negative rate in comparison to sentinel lymph node adding more accuracy to the results. This study aims to evaluate the oncological outcomes in patients who had undergone selective axillary dissection with 4% carbon marking before TSN.

Methods: A prospective study was performed with cT1-T4, cN1-N2 breast cancer patients classified as suspected LNs undergoing concomitant 4% carbon marking. After TSN, targeted LNs were identified and resected associated to the sentinel lymph node (SLN) biopsy. The oncological outcomes pointed out were overall survival (OS), causespecific survival (CSS), distant disease-free survival (DDFS), axillary recurrence (AR) and local recurrence (LR).

Results: A total of 168 patients were evaluated for a median period of 49 months. The axillary emptying was reached in 89 (50.6%) cases. Five of 168 patients (2.9%) had axillary recurrence (AR). There was a significant link between axillary emptying and AR (0 vs. 6% p = 0.012). The DDFS was 140/168 (83.3%), OS 158/168 (94%) and CSS 158/163 (96.9%).

Conclusion: The use of carbon marking in selective axillary dissection is a reliable low-cost method with simple execution. Among the oncological outcomes AR may not be considered for post downstaging axillary evaluation analysis since it is a rare event and not necessarily related to OS or DDFS.

Keywords:
Breast Neoplasms; Sentinel Lymph Node; Carbon; Neoplasm Staging; Neoadjuvant Therapy

Variable	Valid N	Classification	n	%
T	176	1	18	10,2%
		2	97	55,1%
		3	49	27,8%
		4	12	6,8%
N	176	1	152	86,4%
		2	24	13,6%
Clinical stage	176	2nd	17	9,7%
		2b	90	51,1%
		3rd	55	31,3%
		3b	14	8,0%
Histological Type	176	Ductal	141	80,1%
		Lobular	12	6,8%
		Duct lobular	7	4,0%
		Mucinous	7	4,0%
		Micropapillary	3	1,7%
		Apocrine	2	1,1%
		Medullary	2	1,1%
		Metaplastic	2	1,1%
RE	170	Negative	45	26,5%
		Positive	125	73,5%
RP	170	Negative	56	32,9%
		Positive	114	67,1%
HER2	170	Negative	129	75,9%
		Positive	41	24,1%
Variable	Valid N	Classification	n	%
Positive FNA	176	No	63	35,7%
		Yes	113	64,2%
Axillary dissection	176	No	89	50,6%
		Yes	87	49,4%

Variable	Valid N	Classification	n	%
Positive SLN	176	No	101	57,4%
		Yes	44	25,0%
		Not found	31	17,6%
Positive SLN (pooled)	176	No	101	57,4%
		Yes/Not Found	75	42,6%
Positive CLLN	176	No	109	61,9%
		Yes	59	33,5%
		Not found	8	4,5%
Positive CLLN (pooled)	176	No	109	61,9%
		Yes/Not Found	67	38,1%
Coincident lymph nodes	176	Not applicable	39	22,1%
by both methods		No	44	25%
		Yes	93	52,8%
Coincident lymph nodes	137	No	44	32,1%
by both methods (excluding non-applicable ones)		Yes	93	67,8%

Positive SLN	Positive CLLN		Total
Positive SLN	No	Yes
No	91	10	101
	51,7%	5,7%
Yes	18	57	75
	10,2%	32,4%
Total	109	67	176

Outcome	Classification	n	Follow-up (months)
Outcome	Classification	n	Mean ± standard deviation	Median (range; IQR)
Local recurrence	No	161	49 ± 12	49 (24 - 87; 19)
	Yes	7	43 ± 11	40 (31 - 62; 17)
Axillary recurrence	No	163	49 ± 12	49 (24 - 87; 19)
	Yes	5	30 ± 19	24 (13 - 60; 23)
Distance recurrence	No	140	49 ± 12	49 (24 - 87; 19)
	Yes	28	24 ± 15	24 (0,9 - 51; 22)
Specific death	No	158	49 ± 12	49 (12 - 87; 19)
	Yes	5	32 ± 5	33 (25 - 38; 7)
Death	No	158	49 ± 12	49 (24 - 87; 19)
	Yes	10	34 ± 12	34 (12 - 54; 17)
Overall		168	49 ± 12	49 (12 - 87; 19)

Variable	Classification	n	death (%)	p*
Age (years)	<50	88	5 (5,7%)
	≥50	80	5 (6,3%)	0,867
Clinical stage	2nd	17	0 (0%)
	2b	87	2 (2,3%)
	3rd	50	6 (12%)
	3b	14	2 (14,3%)	0,017
Subtype	Luminal HER	26	1 (3,8%)
	Luminal	93	5 (5,4%)
	HER 2 super expression	14	1 (7,1%)
	Threefold-	29	3 (10,3%)	0,414
Positive FNA	No	61	3 (4,9%)
	Yes	107	7 (6,5%)	0,694
Axillary Dissection	No	85	2 (2,4%)
	Yes	83	8 (9,6%)	0,035

Clinical Axillary Status	Outcome	Classification	n (%)	p*
cN1	Axillary recurrence	No	144 (98)	0,078
cN1		Yes	3 (2)
cN2		No	19 (90,5)
cN2		Yes	2 (9,5)
cN1	Distant recurrence	No	127 (86,4)	0,003
cN1		Yes	20 (13,6)
cN2		No	13 (62,9)
cN2		Yes	8 (38,1)
cN1	Death	No	140 (95,2)	0,069
cN1		Yes	7 (4,8)
cN2		No	18 (85,7)
cN2		Yes	3 (14,3)

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