Indexed and abstracted in Science Citation Index Expanded and in Journal Citation Reports /Science Edition Bratisl Lek Listy 2014; 115 (5) 311 – 312 DOI: 10.4149/BLL_2014_063 CASE REPORT A tattoo pigmented node and breast cancer Soran, A, Kanbour-Shakir A, Bas O, Bonaventura M Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA. asoran@magee.edu Abstract: Over the last decade, the axillary SLNB has replaced routine ALND for clinical staging in early breast cancer. Studies describe a potential pitfall in the identification of a true sentinel node during surgery due to lymph node pigmentation secondary to migration of tattoo dye. These pigmented “pseudo-sentinel” nodes, if located superficially in the axilla, may mimic the blue sentinel node on visual inspection, therefore missing the true sen- tinel node and potentially understaging the patient. Here, we present a case report of a breast cancer patient with a tattoo and discuss the importance of tattoo pigment in the LN (Fig. 1, Ref. 8). Text in PDF www.elis.sk. Key words: breast cancer, sentinel node, tattoo, upgrade. Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA Address for correspondence: A. Soran, MD, MPH, Magee-Womens Hos- pital, 300 Halket St Suite 2601, Pittsburgh, PA, 15213, U.S.A. Fax: +412.6411446 Acknowledgement: All of the authors declare that they have no conflict of interest in the information contained in the manuscript. Abbreviations: SLNB – sentinel lymph node biopsy, ALND – axillary lymph node dissection, LN – lymph node, SLN – senti- nel lymph node. In recent years, tattooing has dramatically increased in popular- ity among both men and women. Tattooing is no longer confined to sailors, gang members, prisoners and specific subcultures, but includes career women, college students and celebrities. Statisti- cal data shows that 14 % of Americans (all ages), 36 % of adults 18–25 years and 40 % of adults 26–40 years have at least one tattoo while the practice is gaining social acceptability and is be- coming more popular. The preferred tattoo regions, in order, are arms, trunk, legs, feet, head/neck, hands, trunk/arms and genital area (1–2–3). The process of tattooing, which involves the repeti- tive piercing of the skin with ink-filled needles, results in a minor skin injury and permanent imprint of a design. Histologically, it creates a typical acute inflammatory reaction immediately, and within a few days, macrophages engulf the pigment (pigment-laden macrophages). It is well known that tattoo pigment can migrate to the regional lymph nodes and cause varying degrees of inflamma- tory reaction. Lymphadenopathy can result when tattoo pigment drains to regional lymph nodes and causes hyperplasia. Studies in mice demonstrate that by day 3, pigment is already detectable in the lymph nodes, and that there is more pigment deposition and hyperplasia specifically in inguinal and axillary lymph nodes. The carbon particles mobilize and migrate through the lymphatics and can be seen within the macrophages or extracellularly. This migration is similar to that seen with melanoma cells. Melanoma metastasis was presumed in discolored, enlarged lymph nodes that were later found to have only extracellular tattoo pigment deposi- tion and hyperplasia. Additionally, the size of the tattoo appears independent of the amount of lymph node pigmentation. Even if the patient has removed the tattoo by laser surgery or dermabrasion, the lymph node pigmentation does not disappear (4–5). Here, we present a case report of a breast cancer patient with a tattoo and discuss the importance of tattoo pigment in the LN. Case report A 73-years-old female presented with complaint of right nipple bloody discharge. Physical exam revealed that the right nipple was inverted with no palpable lump masses. A tattoo on her shoulder and right chest wall was noted. The patient’s mammogram showed 2 areas of calcifications, and subsequent core biopsy revealed duc- tal carcinoma in situ. Patient underwent right total mastectomy and sentinel lymph node biopsy. Intra-operatively four colored nodes were harvested, labeled and sent separately for histopatho- Fig. 1. Tattoo pigments deposits and within macrophages in Axillary Sentinel Lymph node (H&E 20X).