Percutaneous tattoo pigment simulating calcific deposits in axillary lymph nodes.

By | January 10, 2014

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CASE DESCRIPTION

A 30-year-old woman presented for a diagnostic mammogram with a

palpable lump in her right breast. She was 9 weeks postpartum and

otherwise healthy. In the palpable region of concern, prominent

lactational changes were seen without any apparent mammographic

abnormality. Normal-sized bilateral axillary lymph nodes with punctate

hyperdensities were identified, simulating the appearance of intranodal

calcium (Figure 1). A chest computed tomography (CT) scan confirmed

hyperdense foci within bilateral axillary lymph nodes (Figure 2). The

patient underwent left axillary lymph node excisional biopsy. Histology

demonstrated subcapsular and paracortical deposits of dark-colored

pigment and multiple histiocytes containing internal black pigment

granules (Figure 3). There was no evidence of malignancy. Although no

tattoos were present on her anterior chest, many multicolor tattoos were

present on her back (Figure 4).

DISCUSSION

Dermal tattooing provokes predictable body responses, including

initial sloughing of the overlying epidermis, variable dermal

inflammation, and gradual assimilation of pigment into macrophages. Much

of the pigment is eventually carried into regional draining lymph nodes

(1). The composition of tattoo pigments is highly variable, but most

consist of various metallic ions including aluminum and titanium (2). If

sufficient quantities of pigment reach lymph nodes, punctate

hyperdensities mimicking intranodal calcific deposits can be seen

radiographically.

[FIGURE 1 OMITTED]

The differential diagnosis of axillary lymph node calcific deposits

includes both benign and malignant etiologies. Benign causes include

prior granulomatous disease, most commonly histoplasmosis, which

typically demonstrates a more coarse appearance (3). Fat necrosis is an

additional cause of calcified lymph nodes (4, 5). Gold deposits can

mimic intranodal axillary calcific deposits on mammography in patients

with rheumatoid arthritis who have undergone chrysotherapy treatment

(6). Of the malignant causes, breast cancer is the most common.

Malignant axillary nodal calcium can occur with an ipsilateral occult

breast cancer and can be seen in the absence of any suspicious calcific

deposits in the breast parenchyma (7).

Axillary lymph node calcium due to metastatic ovarian cancer and

papillary thyroid carcinoma has also been reported (8, 9). Lymph node

calcific deposits may also be seen in the setting of treated lymphoma

(4, 5). The broad differential diagnosis of axillary intranodal calcific

deposits seen on radiologic examinations emphasizes the importance of

histologic examination when a benign etiology is not apparent.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

[FIGURE 4 OMITTED]

An additional clinical situation where intranodal tattoo pigment is

an important diagnostic consideration is with sentinel lymph nodes of

melanoma patients. Intraoperatively, a darkly pigmented lymph node is

concerning for metastatic disease but may represent a draining lymph

node containing tattoo pigment if a dermal tattoo is present in the area

of the primary melanoma (10). Histologic examination is warranted for

definitive diagnosis.

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histopathology, medical complications, and applications. Am J Forensic

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(2.) Timko AL, Miller CH, Johnson FB, Ross E. In vitro quantitative

chemical analysis of tattoo pigments. Arch Dermatol 2001;137(2):143-147.

(3.) Suwatanapongched T, Gierada DS. CT of thoracic lymph nodes.

Part I: anatomy and drainage. Br J Radiol 2006;79(947):922-928.

(4.) Hooley R, Lee C, Tocino I, Horowitz N, Carter D.

Calcifications in axillary lymph nodes caused by fat necrosis. AJR Am J

Roentgenol 1996;167(3):627-628.

(5.) Lucey BC, Stuhlfaut JW, Soto JA. Mesenteric lymph nodes seen

at imaging: causes and significance. Radiographics 2005;25(2):351-365.

(6.) Bruwer A, Nelson GW, Spark RP. Punctate intranodal gold

deposits simulating microcalcifications on mammograms. Radiology

1987;163(1):87-88.

(7.) Walsh R, Kornguth PJ, Soo MS, Bentley R, DeLong DM. Axillary

lymph nodes: mammographic, pathologic, and clinical correlation. AJR Am

J Roentgenol 1997;168(1):33-38.

(8.) Singer C, Blankstein E, Koenigsberg T, Mercado C,

Pile-Spellman E, Smith SJ. Mammographic appearance of axillary lymph

node calcification in patients with metastatic ovarian carcinoma. AJR Am

J Roentgenol 2001;176(6):1437-1440.

(9.) Chen SW, Bennett G, Price J. Axillary lymph node calcification

due to metastatic papillary carcinoma. Australas Radiol

1998;42(3):241-243.

(10.) Chikkamuniyappa S, Sjuve-Scott R, Lancaster-Weiss K, Miller

A, Yeh IT. Tattoo pigment in sentinel lymph nodes: a mimicker of

metastatic malignant melanoma. Dermatol Online J 2005;11(1):14.

Amy R. Yactor, MD, Michael N. Michell, MD, Meghan S. Koch, DO,

Tyler G. Leete, MD, Zeeshan A. Shah, MD, and Brett W. Carter, MD

From the Departments of Radiology (Yactor, Michell, Leete, Shah,

Carter) and Pathology (Koch), Baylor University Medical Center at

Dallas. Corresponding author: Amy R. Yactor, MD, Department of

Radiology, Baylor University Medical Center at Dallas, 3500 Gaston

Avenue, Dallas, TX 75246 (e-mail: YactorA@gmail.com).

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