Anto Dujmović

Davor Mijatović

Krešimir Bulić

Marko Mance

Nikolina Jurišić

Vilena Vrbanović Mijatović

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47ACTA DERMATOVENEROLOGICA CROATICATattoo Pigment within Regional Lymph Nodes  Mimicking Cutaneous Melanoma MetastasisActa Dermatovenerol Croat                              2020;28(1):47-48                                  LETTER TO THE EDITORDear Editor, The diagnosis of malignant melanoma accounts for 1-2% of all cancer diagnoses, around 4% of all malignant skin diseases, and 80% of all skin cancer deaths (1). The prognosis depends on several factors including tumor size, Clark level, Breslow thickness, location, ulceration, and presence of metastases. Detection of lymph node metastasis is initially ac-complished by clinical examination and by operative evaluation for occult metastasis using sentinel lymph node biopsy (SLNB) when indicated (2). Lymph nodes (LN) with melanoma metastasis may appear normal in early stages, but eventually they become dark, firm, and enlarged (3).In 2017, a 32-year-old female patient was referred to our ward by a dermatologist following a biopsy ex-cision of a nevus under her right breast that tested positive for a cutaneous melanoma grade T2aNx with a Breslow thickness of 1.9 mm, with no sign of ulcer-ation and no history of previous illnesses or chronic diseases. Based on the American Joint Committee on Cancer (AJCC) guidelines, wide excision with a senti-nel lymph node (SLN) biopsy was indicated (4). The patient was injected with 0.4 mL CiTc 99m Nanocoll in all four quadrants around the primary scar. A 2 cm wide elliptical excision was performed circumferen-tially around the scar and to the depth of the mus-cular fascia of the thorax. With the aid of a gamma probe, a single radioisotope positive lymph node was located in the ipsilateral axilla, but 5 dark pigmented lymph nodes situated behind the SLN were visualized during manual dissection and thought to be consis-tent with metastatic disease (Figure 1). Due to this new finding, an excisional biopsy of all pigmented nodes was performed. Histology of the excised skin did not demonstrate any further cancerous cells. The size of the SLN was 15 mm, and immunohis-tochemistry for Melan A was negative for metastatic melanoma. Histological analysis of the darkly pig-mented nodes was negative for metastatic melanoma as the pigment was demonstrated to originate from the dermal tattoo on the patient’s back that had been removed by dermabrasion 3 years before melanoma development (Figure 2, Figure 3). Figure1. Darkly colored lymph node within the adipose tissue.Figure 2. Histopathology demonstrated tattoo pigment within the regional lymph nodes (hematoxylin and eosin ×10).Figure 3. Histopathology demonstrated tattoo pigment within the regional lymph nodes (hematoxylin and eosin ×40).ACTA DERMATOVENEROLOGICA CROATICA48Dermal tattooing results in initial sloughing of the overlying epidermis, variable dermal inflamma-tion, and gradual assimilation of pigment into mac-rophages. Much of the pigment is rapidly carried into regional draining LN, which was shown in 2010 on a SKH-1a mouse model, and causes lymphadenopathy which is thought to be a result of local inflammation (6). Importantly, even after removal of the offend-ing cutaneous tattoo the tattoo pigment can persist in draining or distant nodes visible to the naked eye (7). In such cases, LN can mimic metastatic malignant melanoma and may prompt the surgeon to proceed with radical lymph node dissection which may not be necessary. Despite clear guidelines for melanoma treatment in the general population, there are several questions that need to be addressed: firstly, how should a phy-sician approach a patient with unknown history of tattoo removal, a diagnosis of melanoma, and intra-operative darkly pigmented lymph nodes? Secondly, due to the lack of scientific data and treatment proto-col, if the SLN is normally colored while other regional nodes are darkly pigmented, what should the treat-ment plan entail?References: 1.  Arnold M, Holterhues C, Hollestein LM, Coebergh JW, Nijsten T, Pukkala E, et al. Trends in incidence and predictions of cutaneous melanoma across Europe up to 2015. J Eur Acad Dermatol Venereol. 2014 Sep;28:1170-8.2.  Esner R. Sentinel lymph node biopsy and mela-noma biology. Clin Cancer Res. 2006;12:2320s-5s.3.  Back L, Brown AS. Metastatic melanoma, or is it? Plast Reconstr Surg. 1986;77:138-40.4.  Roncati L, Piscioli F. AJCC 8th Edition (2017) versus AJCC 7th Edition (2010) in thin melanoma staging. Neoplasna. 2018;65:651-5.5.  Garbe C, Peris K, Hauschild A, Saiag P, Middle-ton M, Spatz A, et al. Diagnosis and treatment of melanoma. European consensus-based interdis-ciplinary guideline - Update 2012. Eur J Cancer 2012;48:2375-90.6.  Engel E, Vasold R, Santarelli F, Maisch T, Gopee NV, Howard PC, et al. Tattooing of skin results in transportation and light-induced decomposition of tattoo pigments- a first quantification in vivo using a mouse model. Exp Dermatol. 2010;19:54-60.7.  Bordea C, Latifaj B, Jaffe W. Delayed presentation of tattoo lymphadenopathy mimicking malignant melanoma lymphadenopathy. J Plast Reconstr Aesthetic Surg. 2009;62:e283-5.Anto Dujmović1, Nikolina Jurišić2, Marko Mance1, Krešimir Bulić1, Vilena Vrbanović Mijatović3, Davor Mijatović11University Hospital Centre Zagreb, Department of Plastic, Reconstructive and Aesthetic Surgery, Zagreb, Croatia; 2Institute of Emergency Medicine of Zagreb County, Velika Gorica, Croatia; 3University Hospital Centre Zagreb, Department of Anesthesiology, Reanimatology and Intensive Care, Zagreb, Croatia. Corresponding author: Nikolina Jurišić, MD nikolina.jurisic20@gmail.comLetter to the editor Acta Dermatovenerol Croat     2020;28(1):47-48

Tattoo Pigment within Regional Lymph Nodes Mimicking Cutaneous Melanoma Metastasis

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