Tattoo pigment in an axillary lymph node simulating metastatic malignant melanoma
CM Jack,1 A Adwani, 1 and H Krishnan1
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Copyright© 2005 Jack et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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.
Keywords: Tattoo Pigment, Lymphadenopathy, Malignant Melanoma
The presence of lymphadenopathy requires further investigation. 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 unremarkable. 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 supraclavicular 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 surgery 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 discolouration was present on the cut surface.
Microscopic examination of the routine haematoxylin and eosin sections of the lymph node showed preservation of architecture with follicular hyperplasia. Black carbon like pigment was seen lying within the macrophages and dispersed outside them in the sinuses. There was associated fibrosis. Multiple sections did not reveal any evidence of metastatic malignant melanoma.
Immunohistochemical staining for S 100 protein and histochemical 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 classifications of lymphadenopathy, but a simple and clinically useful system is to classify lymphadenopathy as "generalized" 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 suggestive 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 basement membrane is reforming and aggregates are present within basal cells. At 2–3 months and at 40 years, ink particles are only found in dermal fibroblasts surrounded by a network of connective tissue that entraps and immobilises the cell. The tattoo may appear blurred with time due to ink movement into the deep dermis. Eventually the tattoo 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 lymphoedema. The question remains whether it was necessary to biopsy this lymph node or was the presence of the tattoo enough to give reason for the enlarged node. In this instance the co factor of the weight loss meant that leaving the node would not be reasonable.
Anderson  and Moehrle  reported that tattoo pigments 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 surgeon to proceed to complete nodal dissection. Nodal dissection 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 (Figure1,1, ,2)2) and employing special stains. Immunohistochemical 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 pigment.
The dark granular carbon pigment located in the sinuses. H&E × 400
Sentinel lymph node biopsy is becoming more common in Melanoma and Breast cancer. History taking and examination 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 axillary 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.
In all fairness the previous post is regarding tattoo ink and supposedly SMP is somehow different and the ink is urinated out of the body. Sorry I do not believe that but I open to hearing it explained.
Great post topcat, honest and fair. I have been researching a bit on tattoos and health but this type of stuff ain't necessarily my strong point. What do you know about the health risks of tattoo's fading? Also @ Northeastguy do you have some doc or expert that has concluded that tattoos are safe that you can direct us too with a link or something? I think we should try and get to the bottom of the health factor as some sorry SOB is out there wanting to benefit from this and doesn't know what to do as we know we won't be educated by those pranksters and scallywag's that want to sell this SMP stuff as they just want to rake in there money yet the question has now be raised, is SMP safe?
Let me just say this, these health issues are a personal thing with me and are not just related to tattoos. If people want to believe that information is not often hidden from them in order to make the sale than they are free to believe that and maybe they are right. But I could in fact give hundreds and hundreds of examples here.
One doctor in the past stated that some of the European countries were not advanced because they have not approved Acell but maybe they have not approved Acell for human use and only use it on animals because it has not passed their testing. I brought up GMO foods at the time which many European countries will not let in as an example. The French just did a study that came out yesterday of rats fed GMO foods and they all had extensive tumor growth. To me this seems like a no brainer and I don’t need a study for someone to tell me having the grain crop genetically modified with the pesticide built into the seed is not something I want to be putting into my body, but nobody has to agree with it as it’s only my only personal opinion as I have become more aware and I am not going to continually be screwed over because somebody wants to make a buck.
The average person has no idea what Monsanto has been up to for the last 20 years but I have in fact have watched every move, seriously. What happens in real life has become very interesting to me who does what and why they do it. Most people seem to be very clueless but as I have often stated the HT industry was a huge awakening for me so for that I can thank them.
No one should take what I write personally as I would write the same on a GMO food forum. I’m sure some of these same guys would be thanking me for health information I might pass on to them if it were outside of HT but this is how they make their living so I understand.
@topcat and everyone out there that is considering SMP, I will say this, I don't know if you are right or wrong on this but I know if I ever did SMP I would do some serious research before hand as HT docs and their reps want nothing more than that money and you can't trust them.
The only problem I have with that case is it's small limited nature. It certainly will get someone thinking which is what you want. My issue is that there are probably tens of millions of people out there with tattoos and most are just fine. I would need to see a more consistent cause and effect before I'd panic. Even a few is not enough to cause an epidemic. Everything we do in life carries risk..... so does worry.
Just Google "is tattoo ink safe" and there's more than enough info out there for people to make an educated decision. Also, since Trico does not use permanent ink or tattoo ink, I can't really offer an opinion on it as of yet so discussing the safety of tattoo ink in this case is rather irrelevant.
Here's a little info from the FDA on tattoo ink which I thought was interesting.... Personally I think they are one of the most corrupt organizations out there but I did like the points they brought up.
Tattoo Ink Research
In a laboratory within FDA's Arkansas-based National Center for Toxicological Research (NCTR), research chemist Paul Howard, Ph.D., and his team are investigating tattoo inks to find out
the chemical composition of the inks and how they break down (metabolize) in the body;
the short-term and long-term safety of pigments used in tattoo inks;
how the body responds to the interaction of light with the inks.
"There have been no systematic studies of the safety of tattoo inks," says Howard, "so we are trying to ask—and answer—some fundamental questions." For example, some tattoos fade over time or fade when they are exposed to sunlight. And laser light is used to remove tattoos. "We want to know what happens to the ink," says Howard. "Where does the pigment go?"
NCTR researchers are exploring several possibilities:
The body cells may digest and destroy the ink, just as they rid the body of bacteria and other foreign matter as a defense against infection. NCTR studies show that a common pigment used in yellow tattoo inks, Pigment Yellow 74, may be broken down by enzymes, or metabolized. "Just like the body metabolizes and excretes other substances, the body may metabolize small amounts of the tattoo pigment to make it more water soluble, and out it goes," says Howard.
Sunlight may cause the ink to break down so it is less visible. NCTR researchers have found that Pigment Yellow 74 decomposes in sunlight, breaking down into components that are colorless. The pigment components may still be there, says Howard, and we don't know if these are potentially toxic.
The skin cells containing the ink may be killed by sunlight or laser light and ink breakdown products may disperse through the body.
Research has also shown that some pigment migrates from the tattoo site to the body's lymph nodes, says Howard. Lymph nodes are part of the lymphatic system, a collection of fluid-carrying vessels in the body that filter out disease-causing organisms. Whether the migration of tattoo ink has health consequences or not is still unknown. NCTR is doing further research to answer this and other questions about the safety of tattoo inks.
@Northeastguy, thanks for the research on this as your argument is pretty strong, yet I need to do more research as I am never surprised at what I hear from this industry. It is nice you guys are referencing your opinions as others like just throw out claims such as "you may only get 10 percent yield from FUE into a scar" and never state a single case or opinion from a HT doc that agrees with that assessment. Before this conversation the only thing I thought was bad when getting a tattoo was the sterile issue, yet now I understand the possible risks. I may be swaying towards Northeastguy on the safety thing as I have not seen much of it in my research yet I am still undecided, but I have to respectfully correct Northeastguy slightly on the risk thing, guys that have never done an HT should just go bald and be happy they have no scar whereas guys who have a scar should look towards this thing and realize there is a risk, and I am sure he meant to say that and was just assuming that for repair guys there will be some risk. However, balding is natural and is not the end of the world, it just took many young and insecure guys to realize that, but those out there that are considering this should stick to Propecia, Rogaine, and healthy ways of keeping their hair like Biotin, not surgery or tattoo's that will make a young Caucasian from the suburbs look like Wesley Snipes playing Willie Mays Hayes from the Major League, but again great post maybe in a couple months of studying on this topic and I can add something to it.
Spex previously you stated the ink contained iron and titanium oxide now you state you don’t know. Can you please explain that statement?
For the record if someone wants to get ink injected into their scalp that’s up to them. I am into healthy living so no one should take what I say as a personal attack.
I don't drink alcohol either but if someone I know drinks I could really care less mainly because I know they know the possible consequences and you see that is what it is about. Not telling people what they should and should not do but just giving them all the information and letting them make and informed decision.
Too much drinking makes you look puffy :-)
I meant drinking makes people look puffy in general not you specifically.
I was referring to the question asked regarding what is proprietary about the ink/method by the caller. At this time i'm not aware. The content/components of the temporary ink used by Beauty Medical were posted previously in this topic,as given to me by Milena Lardi.
Spex previously you stated the ink contained iron and titanium oxide now you state you don’t know. Can you please explain that statement?
Last edited by Spex; 09-27-2012 at 12:18 PM.
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