Tattoos Mistaken as Cancer Metastases, Surgery Performed

Nick Mulcahy

June 15, 2015

UPDATED June 17, 2015 // Physicians should be aware that tattoo ink can look like the spread of cancer to the lymph nodes on diagnostic imaging — and unnecessary treatment can result.

That is the take-home message from a case report of a 32-year-old woman with stage 1B cervical cancer that was originally diagnosed after a colposcopic exam and then mistakenly upgraded to metastatic disease.

The findings are "particularly important" because of the increasing popularity of tattoos, with 21% of adults reporting at least one tattoo in 2013," the authors, led by Narine Grove, MD, from the University of California, Irvine, report.

In this case, the 14 tattoos that extensively covered the legs of the mother of four had been applied over an 11-year period. Images included a black panther, the phrase "I've got baggage" (with the image of a suitcase), and the title of a children's show, Yo Gabba Gabba. The most recent tattoo had been applied 2 years before her presentation.

As in many cases of cervical cancer, imaging was performed before surgery to look for metastatic disease, the authors explain in their report, which was published online June 5 in Obstetrics and Gynecology.

A preoperative whole-body PET-CT scan revealed what appeared to be cancer spread in the left and right iliac lymph nodes, the team reports.

The patient then underwent surgery for the cervical cancer, which included a hysterectomy, salpingectomy, and regional lymph node dissection.

Exploratory lymph node dissection indicated a collection of enlarged pigmented iliac lymph nodes, ranging in size from 1.5 to 2.0 cm.

By the time the patient left the operating room, 40 lymph nodes had been surgically removed. However, when pathologists examined the nodal tissue, there was no cancer.

 
Pathologic assessment...indicated the presence of tattoo pigment with no malignant cells.
 

"Ultimately, pathologic assessment of the resected fluorine-18-deoxyglucose-avid nodes indicated the presence of tattoo pigment with no malignant cells," the authors write in their case report.

In other words, the iliac lymph nodes that lit up with the tracer used in the scanning had no cancer. (There was one other pelvic lymph node that had a very small amount of cancer — a 2 mm micrometastasis — which was not detected on scanning.)

The authors sum up what happened in one sentence: "In this report, we describe the case of a false-positive PET-CT scan resulting from the deposition of tattoo ink in the common iliac lymph nodes in a patient with cervical cancer."

This is the first case of tattoo ink migrating to the lymph nodes of a cervical cancer patient. But it is not novel in oncology.

Tattoo ink has appeared in the regional nodes of patients with breast cancer, melanoma, testicular seminoma, and vulvar squamous cell carcinoma.

The migration of the ink makes it "difficult to differentiate grossly between the pigment and the metastatic disease, resulting in unnecessary treatment," the authors acknowledge.

They also defend the practice of using PET-CT in this setting.

PET-positive nodes are significant independent prognostic biomarkers, predicting treatment response, pelvic recurrence risk, and survival. That helps with treatment planning and case management, they say.

The Centers for Medicare & Medicaid Services has approved the use of PET-CT imaging for the initial staging of patients with cervical cancer.

"Unfortunately," the authors observe, "false-positive findings may result in unnecessary interventions."

The authors have disclosed no relevant financial relationships.

Obstet Gynecol. Published online June 5, 2015. Abstract

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