With Lymph Node Abnormalities, Consider Tattoo History

May 3, 2021
Whitney J. Palmer

Tattoo ink can migrate in female patients, potentially mimicking lymph node findings on breast imaging.

Tattoos do more than change a patient’s outward appearance. The ink used can also change the internal appearance, as well – specifically creating the appearance of lymph node abnormalities.

In a study released on April 30 in Clinical Imaging, investigators from Weill Cornell Medicine outlined how tattoo ink can migrate over time and can mimic these radiographic findings. Based on what they saw on four mammographic cases, the team led by Michele B. Drotman, M.D., a breast imaging specialist, tattoo ink can show up on screening scans as abnormal high-density material in axillary lymph nodes, mimicking calcifications.

If radiologists are unaware of a patient’s tattoo history, they may order unnecessary biopsies, the team said. Consequently, these findings point to a need for adding to the patient’s medical record.

“The four cases described here support the inclusion of tattoo history within a patient’s clinical history,” the said. “As tattoos continue to become more prevalent amongst women, our ability to observe how tattoo ink can present on radiological imaging must also be recognized.”

Based on the cases observed, patients with tattoos experienced various types of findings.

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Case 1: On a bilateral screening mammogram with tomosynthesis, a 50-year-old woman with tattoos on both her right lateral inframammary fold region and back had punctate densities within the right axillary lymph node. She was given a BI-RADS Category 0 and brought back in for another mammogram that confirmed the findings and showed a morphologically normal right axillary lymph node.

Case 2: A 51-year-old woman with tattoos on her right breast and upper arm had high-density material in bilateral axillary lymph nodes on a bilateral diagnostic mammogram. The findings were more prominent in the right breast, but were stable.

Case 3: After a new carcinoma diagnosis in the left breast, a 42-year-old woman underwent a mammogram of her right breast. The scan revealed high-density foci within multiple right axillary lymph nodes that were attributed to a large tattoo on her right shoulder. A lumpectomy of the left breast revealed invasive ductal carcinoma and ductal carcinoma, and three sentinel lymph nodes contained micro-metastatic carcinoma. The histology report showed the presence of foreign tattoo pigment in the excised lymph nodes, but, importantly, there were no high-density foci in the left axillary lymph nodes. It is possible, the team said, that the patient had an undocumented left-side tattoo.

Case 4: A 49-year-old woman with tattoos on her left back and abdomen and a known history of breast cancer underwent a pre-operative mammogram that revealed high-density foci in her left axillary lymph nodes. A bilateral lumpectomy and sentinel lymph node biopsy revealed high-density foci in the left breast only, but histology showed foreign pigment in the lymph nodes of both axillae.

Currently, Drotman’s team said, there is little clarity around which women with tattoos will experience these findings, so additional work is needed to pinpoint which characteristics will make individuals more susceptible to significant pigment migration. They team also suggested including any history of tattoo removal in the patient’s medical record.

“It may be useful to consider the role that tattoo size, location, age, and pigment(s) play in this presentation,” they added. “A greater understanding of tattoo migration and the resulting radiological presentation informs an important differential diagnosis.”