Tattoo pigment in an axillary lymph node simulating metastatic malignant melanoma.
ABSTRACT We report a case of axillary lymphadenopathy thirty years after a decorative tattoo clinically mimicking metastatic melanoma. The importance of relying on histological confirmation of metastatic disease before altering extent of surgery is discussed. The importance of recording presence of decorative tattoos is stressed.
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ABSTRACT: Background: Previously described methods for removal of tattoos are chemical, mechanical, surgical, termal and laser assited methods. Invention of the Q-switch mode, advanced the laser method, to be one of the most effective methods of tattoo removal. Objective: Comparing the tattoo removal and rate of lymphatic elimina-tion of 3 different wavelengths of Q-switched Nd-YAG laser (532nm, 1064nm, combination 532 + 1064). Methods: In this study we examined lymphatic elimination and the effect of 532 nm, 1064 nm, and the com-bination (532 + 1064 nm) wavelength of laser pulse for the possible lymphatic cleansing mechanism of black pigmented tattoos. This study was performed on 18 New-Zealand rabbits, black pigmented tattoos were en-graved on the back and the four extremities of the animals. 532 nm wavelength of Q switched Nd: YAG la-ser beam was applied on the left upper and bilateral lower extremities of the rabbits. During this period, ex-cisional skin biopsies and lymph node biopsies were performed on days 7, 14 and 21. Results: Day 21 lymph node biopsies revealed mixed type of reactive hyperplasia and intracellular pigments were markedly seen in the laser treatment group and no intracellular tattoo pigment was seen in the control group. Conclusion: The findingd of this study indicate that lymphatic elimination may be one of the significant mechanisms of tattoo removal and the application of different wavelengths of Q-switched Nd-YAG laser do not show statistically significant differences in tattoo removal.
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ABSTRACT: Any person with a tattoo known to their family or friends could potentially be identified from the presence of such personal identifying markers. Problems in identification utilizing tattoos may arise when these markers are removed or defaced in some way. This paper uses infrared wavelengths at 760, 850, and 950 nm to improve the visualization of laser-removed or covered up tattoos and also to establish whether the ink pigments used can be observed on radiographs from any metal that may be present. The results obtained indicate that some older inks have a high enough metallic content to allow them to be viewed on a radiograph, while infrared light can demonstrate latent ink still present in the skin after laser removal and can also be utilized to distinguish an original tattoo through a secondary "cover-up" tattoo. Infrared photography and radiography have been shown to improve tattoo visualization in a forensic context.Journal of Forensic Sciences 07/2013; · 1.31 Impact Factor
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ABSTRACT: The case of a 37-year-old man with a Clarkes level III, Breslow thickness 1.2 mm superficial spreading melanoma of his forearm is described. Intraoperatively, a black-pigmented ipsilateral axillary sentinel lymph node, highly suspicious for metastatic disease, was harvested. The patient had a faded tattoo in the vicinity of the malignant melanoma. Histological examination of the lymph node demonstrated normal lymphoid tissue and the presence of pigmented macrophages due to tattoo ink. Metastatic malignant melanoma was ruled out.The importance of histological confirmation of an enlarged pigmented node before complete dissection of the regional lymph nodes is discussed. The importance of recording the presence of decorative tattoos is stressed as the tattoo pigment may clinically mimic metastatic disease in those with malignant melanoma undergoing sentinel lymph node biopsy.Case Reports 10/2010; 2010.
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International Seminars in Surgical
Tattoo pigment in an axillary lymph node simulating metastatic
CM Jack, A Adwani* and H Krishnan
Address: Breast Unit and Pathology Department Mayday University Hospital, London Road, Croydon, CR7 7YE, Surrey UK
Email: CM Jack - firstname.lastname@example.org; A Adwani* - email@example.com; H Krishnan - firstname.lastname@example.org
* Corresponding author
Tattoo PigmentLymphadenopathyMalignant Melanoma
We report a case of axillary lymphadenopathy thirty years after a decorative tattoo clinically
mimicking metastatic melanoma. The importance of relying on histological confirmation of
metastatic disease before altering extent of surgery is discussed. The importance of recording
presence of decorative tattoos is stressed.
The presence of lymphadenopathy requires further inves-
tigation. Often its presence is explained by a simple viral
illness or trauma. Rarer causes are often made apparent by
thorough history taking and examination. The need for a
biopsy is controversial. We report a case where the answer
may have been staring us in the face if we knew where to
look. The fact that a tattoo causes lymphadenopathy is
well known in the acute phase. This is thought to be due
to local inflammation from the initial insult. However, to
our knowledge there have been no reports of a palpable
node after time delay this long.
A 54 year old man presented with a lump in the right
axilla of six months duration. The lump was non tender
and had not changed in size. He complained of weight
loss of 5 kg over the past two months. He denied foreign
travel, night sweats, recent injury, cough, or the presence
of any other lumps. His past medical history was unre-
markable. There was no family history of breast or bowel
cancer. The lump was clinically palpable and measured 3
cm. It was firm, non tender, not attached to the skin or
deep tissues and was consistent with a clinical diagnosis of
axillary lymphadenopathy. The left axilla and supraclavic-
ular fossae were normal. There was no skin lesion in the
drainage area of the axilla. Examination of the breasts,
chest and abdomen were unremarkable. Haematology,
Biochemistry and Chest X-rays were normal. Ultrasound
confirmed a benign appearing lymph node with a fatty
centre. In view of the size and longstanding nature of the
lymph node, an excision biopsy was performed. At sur-
gery the node was firm, suspicious and black in colour.
On histology, the specimen of the lymph node with
attached fatty tissue measured 3 × 2 × 0.8 cms. Black dis-
colouration was present on the cut surface.
Microscopic examination of the routine haematoxylin
and eosin sections of the lymph node showed preserva-
tion of architecture with follicular hyperplasia. Black car-
bon like pigment was seen lying within the macrophages
and dispersed outside them in the sinuses. There was asso-
Published: 01 December 2005
International Seminars in Surgical Oncology 2005, 2:28doi:10.1186/1477-7800-2-28
Received: 28 August 2005
Accepted: 01 December 2005
This article is available from: http://www.issoonline.com/content/2/1/28
© 2005 Jack et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
International Seminars in Surgical Oncology 2005, 2:28http://www.issoonline.com/content/2/1/28
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ciated fibrosis. Multiple sections did not reveal any evi-
dence of metastatic malignant melanoma.
Immunohistochemical staining for S 100 protein and his-
tochemical stain (Masson's Fontana) was done to further
exclude that possibility.
Retrospectively we noted the 30-year old tattoo that the
patient had on his right arm.
Lymphadenopathy refers to nodes that are abnormal in
size, consistency or number . There are various classifi-
cations of lymphadenopathy, but a simple and clinically
useful system is to classify lymphadenopathy as "general-
ized" if lymph nodes are enlarged in two or more non-
contiguous areas or "localized" if only one area is
involved. Localised lymphadenopathy of the axilla is sug-
gestive of infections, Cat-scratch disease, Lymphoma,
Breast cancer, Silicone implants, Brucellosis and
Melanoma. The presence or otherwise of a tattoo may not
be noted in history taking for lymphadenopathy . Little
information exists to suggest that a specific diagnosis can
be based on node size. However, in one series of 213
adults with unexplained lymphadenopathy, no patient
with a lymph node smaller than 1 cm2 had cancer, while
cancer was present in 8 percent of those with nodes from
1 cm2 to 2.25 cm2 in size, and in 38 percent of those with
nodes larger than 2.25 cm2 . In children, lymph nodes
larger than 2 cm in diameter (along with an abnormal
chest radiograph and the absence of ear, nose and throat
symptoms) were predictive of granulomatous diseases
(i.e. tuberculosis, cat-scratch disease or sarcoidosis) or
cancer (predominantly lymphomas) .
The fact that a tattoo causes lymphadenopathy is well
known in the acute phase due to local inflammation and
probably resolves spontaneously. The natural history of
tattoo is well documented. The tattoo ink particles may
range from 2–400 nm and are most commonly 40 nm.
They are initially found within large phagosomes in the
cytoplasm of keratinocytes, phagocytic cells including
fibroblasts, macrophages and mast cells. The skin layers
initially appear homogenised but at one month, the base-
ment membrane is reforming and aggregates are present
within basal cells. At 2–3 months and at 40 years, ink par-
ticles are only found in dermal fibroblasts surrounded by
a network of connective tissue that entraps and immobi-
lises the cell. The tattoo may appear blurred with time due
to ink movement into the deep dermis. Eventually the tat-
too ink appears in the regional lymph nodes.
This is thought to be due to local inflammation from the
initial insult. However, to our knowledge there have been
no reports of a palpable node after time delay this long.
The dye used in skin tattooing is carbon based.
The movement of dye through the lymph channels forms
the basis of sentinel node biopsy. Complications of
lymph node biopsy are reported as scaring, blood loss,
infection and more rarely nerve damage and lym-
phoedema. The question remains whether it was neces-
sary to biopsy this lymph node or was the presence of the
tattoo enough to give reason for the enlarged node. In this
The dark granular carbon pigment located in the sinuses
The dark granular carbon pigment located in the sinuses.
H&E × 400
Lymph node with preserved architecture and the pigment
Lymph node with preserved architecture and the pigment.
H&E × 100
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International Seminars in Surgical Oncology 2005, 2:28 http://www.issoonline.com/content/2/1/28
Page 3 of 3
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instance the co factor of the weight loss meant that leaving
the node would not be reasonable.
Anderson  and Moehrle  reported that tattoo pig-
ments in Lymph nodes can mimic metastatic malignant
melanoma, but do not comment on age of the decorative
tattoo. Such pigmentation in patients with malignant
melanoma can look metastatic and may prompt the sur-
geon to proceed to complete nodal dissection. Nodal dis-
section should be delayed till conclusive histological
diagnosis is made .
Migration of the carbon pigment through the lymphatics
is usually seen in the hilar lymph nodes draining the
lungs. The main differential diagnosis in our case would
be metastatic malignant melanoma. This was excluded by
the careful examination of the H&E sections for tumour
cells (Figure 1, 2) and employing special stains. Immuno-
histochemical staining for S 100 protein is a very sensitive
marker for melanoma cells and a Masson's Fontana stain
helps to differentiate melanin pigment from carbon pig-
Sentinel lymph node biopsy is becoming more common
in Melanoma and Breast cancer. History taking and exam-
ination should include presence, site, age and colour of
decorative tattoos especially in the drainage areas to the
axilla. History of removal of tattoos is also important as
nodes may persist for several years. Raising awareness of
this problem among surgeons and pathologists treating
malignant melanoma is important. Investigation of axil-
lary Lymphadenopathy should include tattoos in the
drainage areas as a probable cause.
The authors would like to thanks Mr SR Ebbs (Consultant Surgeon) for his
support and guidance.
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