Feasibility of Charcoal Tattooing of Cytology-Proven Metastatic Axillary Lymph Node at Diagnosis and Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients

Abstract

PurposeSentinel lymph node biopsy (SLNB) can be performed when node-positive disease is converted to node-negative status after neoadjuvant chemotherapy (NCT). Tattooing nodes might improve accuracy but supportive data are limited. This study aimed to investigate the feasibility of charcoal tattooing metastatic axillary lymph node (ALN) at presentation followed by SLNB after NCT in breast cancers.Materials and MethodsTwenty patientswith cytology-proven node metastases prospectively underwent charcoal tattooing at diagnosis. SLNB using dual tracers and axillary surgery after NCT were then performed. The detection rate of tattooed node and diagnostic performance of SLNB were analyzed.ResultsAll patients underwent charcoal tattooingwithout significant morbidity. Sentinel and tattooed nodes could be detected during surgery after NCT. Nodal pathologic complete response was achieved in 10 patients. Overall sensitivity, false-negative rate (FNR), negative predictive value, and accuracy of hot/blue SLNB were 80.0%, 20.0%, 83.3%, and 90.0%, respectively. Retrieving more nodes and favorable nodal response were associated with improved performance. The best accuracy was observed when excised tattooed node was calculated together (FNR, 0.0%). Cold/non-blue tattooed nodes of five patients were removed during non-sentinel axillary surgery but clinicopathological parameters did not differ compared to patients with hot/blue tattooed node detected during SLNB, suggesting the importance of the tattooing procedure itself to improve performance.ConclusionCharcoal tattooing of cytology-confirmed metastatic ALN at presentation is technically feasible and does not limit SLNB after NCT. The tattooing procedure without additional preoperative localization is advantageous for improving the diagnostic performance of SLNB in this setting.

Targeted axillary dissection after neoadjuvant systemic therapy in patients with node‐positive breast cancer

“…15 Other methods of localization of the axillary LN using charcoal suspension, Magseed or Savi Scout radar reflectors have been described and their respective published feasibility studies reveal high IRs. 10,17,18 The clipped node uptake of blue dye was only 58% and 83% for radioactive tracer. The clipped node was not retrieved as the SLN in 14% of patients in our series.…”

“…They reported an IR of 97% where three seeds were not retrieved . Other methods of localization of the axillary LN using charcoal suspension, Magseed or Savi Scout radar reflectors have been described and their respective published feasibility studies reveal high IRs …”

“…9 Targeted axillary dissection (TAD) is a technique where clinically node-positive breast cancer patients have the biopsied positive node marked before NAST with a clip, dye or radioactive iodine seed (RIS). [10][11][12] At the time of surgery, SNB is performed and the marked node is also removed. To facilitate the identification of the marked node, preoperative localization (e.g.…”

Initial results of a novel technique of clipped node localization in breast cancer patients postneoadjuvant chemotherapy: Skin Mark clipped Axillary nodes Removal Technique (SMART trial)

“…In addition, Magseed is not compatible with standard surgical instruments. Charcoal tattooing of positive lymph nodes at the time of biopsy has also been reported . However, there may be a small risk of charcoal migration, potential nonvisualization of the tattoo at the time of surgery.…”

“…The removal rate of SMART in our study was comparable to the rates reported for other localization agents. The radioactive seed, wire and tattooing techniques had a removal rate of nodes of 97%-100%, 6,20 71%-100%, 11,13,21,22 and 83%-100%, 16,17 respectively.…”