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Breast Imaging |
1 Department of Radiology–Breast Imaging, Beth Israel Medical Center,
Phillips Ambulatory Care Center, New York, NY 10003.
2 Department of Radiology, Beth Israel Medical Center, First Ave. at 16th St.,
New York, NY 1003.
3 Department of Pathology, Beth Israel Medical Center, Phillips Ambulatory Care
Center, New York, NY 10003.
Received October 28, 2003; accepted after revision December 23, 2003.
Address correspondence to S. M. Hesseltine.
We present a patient with foci of calcification density in an axillary lymph node detected on screening mammography that mimicked true calcification but proved at pathology to be caused by tattoo pigment.
Case Report
A 35-year-old woman presented for baseline screening mammography. She reported that her mother had been diagnosed with breast carcinoma at 55 years old. The patient was taking no medications besides oral contraceptive pills. She had extensive tattooing on both shoulders and arms and on her back that was placed more than 7 years earlier; the pigments used were predominately black, blue, red, and some yellow (Fig. 1A). At the time of examination, the patient reported no medical problems, specifically no skin or inflammatory disease. No palpable axillary lymph nodes were found.
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Bilateral mammography performed in the routine projections revealed an axillary lymph node on the right containing foci of calcification density (Fig. 1B). The lymph node measured 3.0 cm in the long axis and 1.0 cm in the short axis. No other mammographic abnormality was found. Directed sonography of the right axilla revealed a prominent lymph node containing echogenic foci suggestive of calcification. Sonographically guided fine-needle aspiration of the lymph node was performed using a 22-gauge needle.
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The pathologist performed preparation and evaluation of the aspirated material on site. Slides were air-dried and prepared with DIFF-QUICK stains (Dade Behring). The smears showed scattered benign lymphocytes and abundant obscuring black pigment (Fig. 1C). The aspirates were negative for malignant cells, and no calcifications were observed. We concluded that the mammographic findings represented tattoo pigment mimicking calcification in the lymph node.
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Discussion
After a tattoo is placed, some of the pigment is phagocytosed by macrophages, which may slowly migrate to regional lymph nodes via the lymphatic system [2]. If tattoo pigment is present in sufficient quantity in axillary lymph nodes, it may mimic calcification on mammography.
An additional factor determining whether intranodal pigment will mimic calcification is the composition of the particular pigments in the tattoo. Most tattoo pigments are created by mixing various metallic ions, commonly including aluminum, titanium, and iron, but the composition of pigments varies widely. At least 30 different pigments are commercially available, and tattoo artists may mix them to obtain new shades. Furthermore, the composition is variable even among different pigments of similar color [3]. This variability of composition makes it difficult to predict the radiopacity of pigment from any particular tattoo.
Although it has previously been reported [4] that most patients with upper extremity tattoos show pigment in axillary lymph nodes at autopsy, to our knowledge, a case of tattoo pigment radiographically mimicking calcification has not previously been reported. A computerized MEDLINE search for articles published during the past 37 years failed to reveal any such cases.
The differential diagnostic possibilities for calcification in axillary lymph nodes visualized on mammography include both malignant and benign sources; in the absence of mammographic findings to suggest primary breast malignancy, a benign cause is most likely. Although the most common malignant origin is metastatic disease from occult breast malignancy, metastatic disease from other primary malignancies such as ovarian carcinoma should also be considered [1, 5]. Benign causes include tuberculosis and fat necrosis [6, 7]. Gold deposits after chrysotherapy for rheumatoid arthritis and tattoo pigment in axillary lymph nodes can also mimic calcification radiographically [8].
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