Feasibility of Charcoal Tattooing of Cytology-Proven Metastatic Axillary Lymph Node at Diagnosis and Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients

Seho Park, Ja Seung Koo, Gun Min Kim, Joohyuk Sohn, Seung Il Kim, Young Up Cho, Byeong-Woo Park, Vivian Youngjean Park, Jung Hyun Yoon, Hee Jung Moon, Min Jung Kim, Eun-Kyung Kim, Seho Park, Ja Seung Koo, Gun Min Kim, Joohyuk Sohn, Seung Il Kim, Young Up Cho, Byeong-Woo Park, Vivian Youngjean Park, Jung Hyun Yoon, Hee Jung Moon, Min Jung Kim, Eun-Kyung Kim

Abstract

Purpose: Sentinel lymph node biopsy (SLNB) can be performed when node-positive disease is converted to node-negative status after neoadjuvant chemotherapy (NCT). Tattooing nodes might improve accuracy but supportive data are limited. This study aimed to investigate the feasibility of charcoal tattooing metastatic axillary lymph node (ALN) at presentation followed by SLNB after NCT in breast cancers.

Materials and methods: Twenty patientswith cytology-proven node metastases prospectively underwent charcoal tattooing at diagnosis. SLNB using dual tracers and axillary surgery after NCT were then performed. The detection rate of tattooed node and diagnostic performance of SLNB were analyzed.

Results: All patients underwent charcoal tattooingwithout significant morbidity. Sentinel and tattooed nodes could be detected during surgery after NCT. Nodal pathologic complete response was achieved in 10 patients. Overall sensitivity, false-negative rate (FNR), negative predictive value, and accuracy of hot/blue SLNB were 80.0%, 20.0%, 83.3%, and 90.0%, respectively. Retrieving more nodes and favorable nodal response were associated with improved performance. The best accuracy was observed when excised tattooed node was calculated together (FNR, 0.0%). Cold/non-blue tattooed nodes of five patients were removed during non-sentinel axillary surgery but clinicopathological parameters did not differ compared to patients with hot/blue tattooed node detected during SLNB, suggesting the importance of the tattooing procedure itself to improve performance.

Conclusion: Charcoal tattooing of cytology-confirmed metastatic ALN at presentation is technically feasible and does not limit SLNB after NCT. The tattooing procedure without additional preoperative localization is advantageous for improving the diagnostic performance of SLNB in this setting.

Keywords: Charcoal; Neoadjuvant therapy; Sentinel lymph node biopsy; Tattoo; Breast neoplasms.

Conflict of interest statement

Conflict of interest relevant to this article was not reported.

Figures

Fig. 1.
Fig. 1.
Gross and microscopic findings of a charcoal-tattooed lymph node in a patient presenting with a false-negative sentinel lymph node biopsy using dual tracers. (A) Gross picture of a retrieved charcoal-tattooed axillary lymph node. (B) Ex vivo radioisotope counts of the tattooed node showing minimal uptake (value, 35). (C) Microscopic photograph of residual metastatic carcinomas and charcoal pigments in the tattooed axillary node (H&E staining, ×100).
Fig. 2.
Fig. 2.
Intraoperative photographs and pathologic slides of a sentinel lymph node. (A) Charcoal tattoo (black arrow) and blue dye (blue arrow) tracks during axillary surgery. (B) Excised sentinel node marked with the tattoo and blue dye. Low-power field (H&E staining, ×20) (C) and high-power field (H&E staining, ×100) (D) microscopic views show tattoo pigments with no residual metastatic carcinoma in the sentinel node.
Fig. 3.
Fig. 3.
Images and tattooed sentinel node of a patient with an axillary arch. (A) The 18F-fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (PET-CT) scan shows increased FDG uptake by the metastatic axillary lymph node in the level I left axilla (arrow). (B) The PET-CT scan demonstrates the left axillary arch that is also known as the axillopectoral muscle (double arrow). (C) The hot and tattooed sentinel lymph node is retrieved.

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Source: PubMed

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