Skip to main content

Main menu

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
  • Other Publications
    • Ochsner Journal Blog

User menu

  • My alerts
  • Log in

Search

  • Advanced search
Ochsner Journal
  • Other Publications
    • Ochsner Journal Blog
  • My alerts
  • Log in
Ochsner Journal

Advanced Search

  • Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Info for
    • Authors
    • Reviewers
  • About Us
    • About the Ochsner Journal
    • Editorial Board
  • More
    • Alerts
    • Feedback
Case ReportCase Reports and Clinical Observations

Body Art Confounding a Case of Breast Cancer

Lena Gowharji, Dana Smetherman and Brett Roberts
Ochsner Journal December 2017, 17 (4) 430-433;
Lena Gowharji
Department of Radiology, Ochsner Clinic Foundation, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Dana Smetherman
Department of Radiology, Ochsner Clinic Foundation, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Brett Roberts
Department of Radiology, Ochsner Clinic Foundation, New Orleans, LA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • References
  • Info & Metrics
  • PDF
Loading

Abstract

Background: Heavy metals in tattoo ink can be deposited in axillary lymph nodes, mimicking malignant calcifications. High-density foci in axillary lymph nodes can be the sequelae of a benign or malignant process.

Case Report: A 34-year-old female presented with left breast discomfort. Mammography showed suspicious left breast calcifications for which biopsy revealed multicentric ductal carcinoma in situ. Imaging also showed high-density foci in her left axillary lymph nodes suspicious for nodal metastases; however, biopsy of the lymph nodes found the high-density foci to be pigment-laden histiocytes from tattoo ink metallic deposits.

Conclusion: High-density foci in axillary lymph nodes on mammography can be evidence of calcifications or metal deposits and can be the manifestation of a benign or malignant process. Thus, this finding may warrant additional diagnostic workup (including mammography, ultrasound, and possibly biopsy) and correlation with clinical history.

Keywords
  • Breast neoplasms
  • ink
  • lymph nodes

INTRODUCTION

A tattoo is a form of art in which pigment is deposited into the skin. The designs are eclectic, and the practice has become mainstream. In recent years, tattoos have become equally common between men and women.1 A 2006 report found that 24% of people in the United States have tattoos.1

We present a patient with ductal carcinoma in situ (DCIS) of the left breast who was radiographically found to have high-density material in bilateral axillary lymph nodes that was proven to be the result of tattoo pigment.

CASE REPORT

A 34-year-old premenopausal female presented with a 12-month history of intermittent focal discomfort in the inferior left breast. She had no significant medical or surgical history or family history of breast cancer. Menarche was at the age of 12, she was gravida 1 para 1, and her age at the time of the pregnancy was 28 years. She had an intrauterine device and reported a history of irregular periods. Physical examination revealed a <1-cm tender palpable lump in the lower left breast at 6 o'clock. No nipple inversion, abnormal nipple discharge, skin changes, or discoloration was present. The patient had no palpable axillary or cervical lymphadenopathy. She had numerous tattoos along her trunk and arms, including her left wrist.

Diagnostic mammogram demonstrated suspicious fine linear branching calcifications with a segmental distribution in the left breast at 6 o'clock corresponding to the palpable abnormality (Figure 1); these calcifications were considered American College of Radiology BI-RADS (Breast Imaging Reporting and Data System) category 4, and core needle biopsy of the calcifications was recommended. We observed high-density material within the nodes in the left axilla that manifested as hyperechoic foci within the left axillary nodes on ultrasound (Figure 2). The original tomosynthesis projection images showed similar findings in the right axillary lymph nodes. Of note, the axillary lymph nodes were not enlarged and did not demonstrate focal or diffuse cortical thickening. Bilateral breast magnetic resonance imaging with contrast demonstrated non–mass-like enhancement within the lower left breast (Figure 3) and unremarkable lymph nodes (Figure 4).

Figure 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1.

Left breast mediolateral oblique (A), cranial-caudal (B), and spot magnification (C and D) mammogram images show fine linear branching calcifications with segmental distribution in the left breast at 6 o'clock measuring 3.6 × 3.0 × 4.9 cm (thin arrows) as well as punctate hyperdense foci within the left axillary nodes (thick arrows). The 2 dots indicate a palpable abnormality.

Figure 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2.

Ultrasound image of the left axilla shows a node with several hyperechoic punctuate foci (white arrows).

Figure 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 3.

Non–mass-like enhancement within the lower left breast corresponds to biopsy-proven malignancy (white arrows).

Figure 4.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 4.

Magnetic resonance short TI inversion recovery imaging of the axillae demonstrates unremarkable lymph nodes. The pigment is not visualized (white arrow).

Stereotactic vacuum-assisted biopsy of the left breast calcifications revealed DCIS of intermediate nuclear grade. Ultrasound-guided core needle biopsy of a left axillary node was negative for malignancy. The patient underwent bilateral mastectomy with left sentinel lymph node biopsy. Because of the high risk of recurrent breast cancer and for cosmetic reasons, the patient opted for double mastectomy. Histopathology of the left sentinel lymph node demonstrated normal lymphoid tissue with pigment-laden histiocytes, negative for malignancy (Figure 5).

Figure 5.
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 5.

Left axillary lymph node demonstrates tattoo pigment–laden histiocytes (black arrows). (To see this image in color, click to https://education.ochsner.org/publishing-services/toc/gowharji-16-105-fig5.)

DISCUSSION

High-density foci within axillary lymph nodes on mammography can represent benign or malignant processes and warrant additional evaluation to exclude metastatic disease in the setting of a suspicious abnormality in the breast.2,3

Coarse, dense calcifications in axillary nodes can be caused by granulomatous diseases such as sarcoidosis, tuberculosis, or histoplasmosis. Other benign causes include fat necrosis or lymph node talcum deposition in patients with a history of inhalation or intravenous drug abuse.2-4 Gold salt deposits from intramuscular injections for treatment of rheumatoid arthritis can appear as high-density foci in nonenlarged lymph nodes.2

Metastatic breast cancer is the most common cause of malignant axillary lymph node calcifications. These calcifications are usually ipsilateral and may even occur without visualized calcifications within the breast tissue.4 Amorphous and peripherally located calcifications can be seen with metastatic thyroid or ovarian papillary carcinoma, secondary to the presence of psammoma bodies.2-4

Punctate radiopaque foci similar in appearance to calcifications can also represent tattoo pigment deposition in draining lymph nodes.2 Tattoo ink usually contains a heavy metal dye that varies according to the desired color. Iron and carbon are typically used for black, mercury sulfide for red, cobalt aluminate for blue, cadmium sulfide for yellow, and chromium oxide for green.5,6 Although highly suspicious for metastatic disease, nodal pigmentation may also represent tattoo pigment in a draining lymph node in patients with metastatic melanoma.7 Our patient had tattoos along her medial left wrist, along her back, and on both sides of her chest wall. Typical lymphatic drainage for the medial aspect of the upper extremities and portions of the anterolateral and posterior chest wall is to the axillary lymph nodes.8

To the best of our knowledge, radiographically high-density material in breast specimens resulting from tattoo ink was first reported in 1989 by Lager et al.9 In their case, tattoo pigment was used to orient an excised tissue specimen before mammography. The specimen revealed high-density foci caused by the tattoo pigment.9 In 2004, Honegger et al published a case of tattoo pigment mimicking nodal calcification.10 Fine-needle aspiration cytology of the axillary lymph node showed scattered benign lymphocytes and abundant obscuring black pigment with no calcifications; however, no core biopsy was performed. Matsika et al presented a case report in 2013 in which a core biopsy was performed, and, similar to our findings, no true calcifications or evidence of malignancy was present.5

CONCLUSION

High-density foci in axillary lymph nodes by mammography can be evidence of calcifications or metal deposits and can be the manifestation of benign or malignant processes. Thus, this finding may warrant additional diagnostic workup (including mammography, ultrasound, and possibly biopsy) and correlation with clinical history.

This article meets the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties Maintenance of Certification competencies for Patient Care and Medical Knowledge.

ACKNOWLEDGMENTS

The authors have no financial or proprietary interest in the subject matter of this article.

  • © Academic Division of Ochsner Clinic Foundation 2017

REFERENCES

  1. 1.↵
    1. Laumann AE,
    2. Derick AJ
    Tattoos and body piercings in the United States: a national data set. J Am Acad Dermatol. 2006 9; 55 3: 413- 421. pmid:16908345
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Cao MM,
    2. Hoyt AC,
    3. Bassett LW
    Mammographic signs of systemic disease. Radiographics. 2011 Jul-Aug; 31 4: 1085- 1100. doi: 10.1148/rg.314105205. pmid:21768240
    OpenUrlCrossRefPubMed
  3. 3.↵
    1. Matta HM,
    2. Watts M,
    3. Chetlen A
    Radiopaque densities within axillary lymph nodes. J Am Osteopath Coll Radiol. 2014; 3 1: 23- 25.
    OpenUrl
  4. 4.↵
    1. Yactor AR,
    2. Michell MN,
    3. Koch MS,
    4. Leete TG,
    5. Shah ZA,
    6. Carter BW
    Percutaneous tattoo pigment simulating calcific deposits in axillary lymph nodes. Proc (Bayl Univ Med Cent). 2013 1; 26 1: 28- 29. pmid:23382606
    OpenUrlPubMed
  5. 5.↵
    1. Matsika A,
    2. Srinivasan B,
    3. Gray JM,
    4. Galbraith CR
    Tattoo pigment in axillary lymph node mimicking calcification of breast cancer. BMJ Case Rep. 2013 Aug 8;2013. doi: 10.1136/bcr-2013-200284.
  6. 6.↵
    1. Timko AL,
    2. Miller CH,
    3. Johnson FB,
    4. Ross E
    In vitro quantitative chemical analysis of tattoo pigments. Arch Dermatol. 2001 2; 137 2: 143- 177. pmid:11176685
    OpenUrlPubMed
  7. 7.↵
    1. Chikkamuniyappa S,
    2. Sjuve-Scott R,
    3. Lancaster-Weiss K,
    4. Miller A,
    5. Yeh IT
    Tattoo pigment in sentinel lymph nodes: a mimicker of metastatic malignant melanoma. Dermatol Online J. 2005 3 1; 11 1: 14.
    OpenUrlPubMed
  8. 8.↵
    1. Fritsch H,
    2. Kuehnel W
    Color Atlas of Human Anatomy, Volume 2: Internal Organs. 5th ed. New York, NY: Thieme; 2008.
  9. 9.↵
    1. Lager DJ,
    2. O'Connor JC,
    3. Robinson RA,
    4. Brown RC,
    5. Urdaneta LF
    Factitious microcalcifications in breast biopsy material: laboratory-induced error by use of tattoo powder for specimen mammography. J Surg Oncol. 1989 4; 40 4: 281- 282. pmid:2927141
    OpenUrlPubMed
  10. 10.↵
    1. Honegger MM,
    2. Hesseltine SM,
    3. Gross JD,
    4. Singer C,
    5. Cohen JM
    Tattoo pigment mimicking axillary lymph node calcifications on mammography. AJR Am J Roentgenol. 2004 9; 183 3: 831- 832. pmid:15333377
    OpenUrlPubMed
PreviousNext
Back to top

In this issue

Ochsner Journal
Vol. 17, Issue 4
Dec 2017
  • Table of Contents
  • Index by author
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on Ochsner Journal.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Body Art Confounding a Case of Breast Cancer
(Your Name) has sent you a message from Ochsner Journal
(Your Name) thought you would like to see the Ochsner Journal web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
Body Art Confounding a Case of Breast Cancer
Lena Gowharji, Dana Smetherman, Brett Roberts
Ochsner Journal Dec 2017, 17 (4) 430-433;

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Body Art Confounding a Case of Breast Cancer
Lena Gowharji, Dana Smetherman, Brett Roberts
Ochsner Journal Dec 2017, 17 (4) 430-433;
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • CASE REPORT
    • DISCUSSION
    • CONCLUSION
    • ACKNOWLEDGMENTS
    • REFERENCES
  • Figures & Data
  • Info & Metrics
  • References
  • PDF

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Spontaneous Coronary Artery Dissection With Systemic Lupus Erythematosus
  • Jaundice Caused by Hyperemesis Gravidarum
  • Three-Dimensional Visualization With Virtual Reality Facilitates Complex Live Donor Renal Transplant
Show more CASE REPORTS AND CLINICAL OBSERVATIONS

Similar Articles

Keywords

  • Breast neoplasms
  • ink
  • lymph nodes

Current Post at the Blog

American Association for the Advancement of Science Surveys Scientists About Article Publishing Charges—And Uncovers More Problems

Our Content

  • Home
  • Current Issue
  • Ahead of Print
  • Archive
  • Featured Contributors
  • Ochsner Journal Blog
  • Archive at PubMed Central

Information & Forms

  • Instructions for Authors
  • Instructions for Reviewers
  • Submission Checklist
  • FAQ
  • License for Publishing-Author Attestation
  • Patient Consent Form
  • Submit a Manuscript

Services & Contacts

  • Permissions
  • Sign up for our electronic table of contents
  • Feedback Form
  • Contact Us

About Us

  • Editorial Board
  • About the Ochsner Journal
  • Ochsner Health
  • University of Queensland-Ochsner Clinical School
  • Alliance of Independent Academic Medical Centers

© 2023 Ochsner Clinic Foundation

Powered by HighWire