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    r> Axillary Lymph Node Tattooing
    Seventy-five cNþ patients (64 biopsy-proven and 11 clinically suspected) underwent ALN tattooing before NAC initiation. Every biopsy-proven positive or strongly indicative node was marked. A suspension containing highly purified, very fine carbon particles (Spot, GI Supply, Inc, Mechanicsburg, PA) was used, which is an FDA-approved product for marking lesions in the gastrointestinal tract. It is a sterile, nontoxic suspension contain-ing water for injection, benzyl alcohol, glycerol, simethicone, polysorbate 80, and high purity carbon black. It is widely used in colorectal endoscopy and surgery, and remains in the site for months.20,21 In our patients, 0.3 to 0.7 mL of Spot suspension was injected into the ITF2357 of the lymph node with ultrasound guidance. The amount of ink that was used was dependent on 
    Statistical Analysis
    Statistical analysis of subgroups was performed. Significance of the difference (P value) was calculated using Fisher exact test and the c2 test for a significance level of 0.05.
    There were 75 patients who had TAD after ALN tattooing. However, 11 of 75 patients did not have biopsy-proven positive axilla before NAC but were considered as cNþ because of nodes highly indicative of disease in ultrasound imaging. The number of nodes that were marked ranged from 1 to 5 (median number, 2 nodes). Time from tattooing to surgery ranged from 90 to 231 days (median time, 141 days; Table 1).
    Ioannis Natsiopoulos et al
    Figure 2 Macroscopic Appearance of Tattooed Lymph Nodes. (A) “Nonsentinel/Black Pigment” Group. (B) “Sentinel/Black Pigment” Group
    Surgical Evaluation
    Sentinel lymph nodes were identified in 70 of 75 patients (IR, 93.3%). The number of SLNs harvested ranged from 1 to 10 (median number, 4 SLNs). Sites/nodes with black pigment in the axillary cavity were recognized macroscopically with visual inspec-tion during surgery, in all patients. In 71 of 75 patients, the number of black-pigmented sites/nodes identified intraoperatively was equal to the number of nodes marked before NAC whereas in 4 patients, it was lower (intraoperative IR of all marked nodes, 94.6%). Sometimes lymph vessels stained black were observed around black-pigmented lymph nodes. In 53 of 70 patients with identified SLNs, black-pigmented nodes were all within SLNs (correspondence rate
    Table 2 Surgical Assessment
    Variable Value P
    Total Patients, n 75
    Correspondence of Tattooed Nodes to
    Abbreviations: ALND ¼ axillary lymph node dissection; SLN ¼ sentinel lymph node; TAD ¼ targeted axillary dissection. 
    of marked nodes to SLNs was 75.7%). The correspondence rate was increased with the number of harvested SLNs but, statistical sig-nificance was observed only if <3 SLNs were harvested (P ¼ .011). The correspondence rate was decreased by the number of lymph nodes that were tattooed, which was statistically significant only if 1 node was marked (P ¼ .049). The number of lymph nodes har-vested during the TAD procedure (black-pigmented and SLNs) ranged from 2 to 10 (median number, 4 TAD nodes). In 29 of 75 patients (24 with residual disease in TAD nodes and 5 with no SLNs identified), complete ALND was performed (38.6%). Two of 24 patients with residual disease in TAD-nodes underwent com-plete ALND in a second intervention, because micrometastasis (<2 mm) was missed in frozen sections. The number of lymph nodes dissected in ALND ranged from 7 to 29 (median number, 14; Table 2).
    Pathological Evaluation
    Pathological examination of excised lymph nodes showed tat-tooed nodes in all cases (Figure 3A). Black pigment was found in the cortex of lymph nodes and/or in the adjacent fatty tissue. In 4 cases in which the intraoperative evaluation showed less black-pigmented sites than marked nodes, pathological examination revealed more lymph nodes with extensive presence of black pigment in the “sentinel/no black pigment” group. In these cases, the black pigment was found deep in the nodal cortex without pigment in the adjacent tissue around the node. In 3 cases, black-pigmented nodes in the pathology specimen were numerically less than the marked lymph nodes. In 2 of them, intraoperative identification of black-pigmented sites/nodes was in concordance with the number of marked nodes. The pathologist reported “areas of excessive fibrosis with granules of black pigment” possibly representing lymph nodes fully occupied by cancer cells that were completely regressed. The third patient underwent complete ALND (17 lymph nodes were excised) and no further tattooed lymph nodes were identified. Thus, surgical retrieval of all marked nodes was achieved in 74 of 75 pa-tients (98.6%). Histology revealed more lymph nodes with black pigment granules than those originally marked in 34 of 75 cases (45.3%). Additional pigmented lymph nodes ranged from 1 to 5 (median, 2 nodes). In 32 of 34 patients, at least 1 SLN was iden-tified successfully. The identification of additional pigmented lymph