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Tattoo Ink Showing Up on Mammograms
Susan Summerton, M.D.
August 20, 2021

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Dr. Susan Summerton is associate professor of clinical radiology at the University of Pennsylvania. Dr. Summerton joined us to talk about an issue that many people are unaware of: Ink from tattoos on the upper body migrating to the lymph nodes and showing up as white specks on a mammogram. In some cases, this can lead to more tests to rule out breast cancer.

Listen to the episode to hear Dr. Summerton explain:

  • how tattoo ink ends up in the underarm lymph nodes
  • how often this happens
  • how often tattoo ink leads to more testing
  • what women with tattoos who are getting regular mammograms should know

Running time: 15:26

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Show Full Transcript

Jamie DePolo: Hello, thanks for listening. Our guest is Dr. Susan Summerton, associate professor of clinical radiology at the University of Pennsylvania.

Dr. Summerton joins us today to talk about an issue that many people are unaware of: Ink from tattoos on the upper body may migrate to the lymph nodes and show up as white specks on a mammogram. In some cases, this can lead to more tests to rule out breast cancer.

Dr. Summerton, thanks for joining us to shed some light on this topic.

Dr. Susan Summerton: You’re welcome. It’s my pleasure to be here.

Jamie DePolo: So, I guess, let’s start with the basics. How does tattoo ink end up in somebody’s underarm lymph nodes?

Dr. Susan Summerton: So, tattoos that are done on the upper extremity, either the arm or on the front of the chest or the back of the chest, cause a response in your body. Your body senses the tattoo and the tattoo ink as a foreign body and sends special cells to the tattoo trying to take what was put into the skin that looked foreign and drain it away from the body, because it sees it as a foreign invader.

And to do that, it sends cells called macrophages, that — “phag” means to eat. So, these cells basically eat the foreign bodies. And when they eat them at the skin surface, they drain from pathways called lymphatics from the arm, chest, or back to the local depository for the lymphatic drainage. And that happens to be lymph nodes in the armpit, or the axilla.

Jamie DePolo: Okay. Thank you. So, I guess, that sort of sparks another question in me. If this happens whenever somebody gets a tattoo around their shoulder or chest or arm, how come the whole tattoo doesn’t disappear? Or is the response of the body kind of like a tattoo is big, and it can’t do the whole thing? I’m just curious… lots of people have tattoos.

Dr. Susan Summerton: Yeah. That’s an excellent question. So, these cells are very small, and often what they take away are the heavy metals that the pigments are attached to. And those heavy metals can look white on an X-ray, and that’s why at times when these heavy metals are taken from the tattoo site, sometimes with pigment as well, and dropped in lymph nodes, it can change the appearance of the lymph nodes both on imaging studies and in real life. When a surgeon is doing surgery and they look at the lymph nodes, the lymph nodes can actually look different than normal lymph nodes. But most of the pigment stays behind and not all of it is taken away.

Jamie DePolo: Okay. Good to know. Now, does this always happen, or is it more likely to happen in certain people? And I guess, obviously, women should get mammograms regularly, so that’s probably why it’s been noticed there. But I guess I’m wondering, does it happen with all tattoos? Like if you get one on your leg, does some of that end up in the lymph nodes around your groin?

Dr. Susan Summerton: So, yes. I don’t know the frequency with which it happens, but there have definitely been reports in the literature of patients who have had lower extremity tattoos where the macrophages, and that response to the tattoo, is carried from the area of the tattoo to lymph nodes in the groin. Patients who are undergoing either surgery for a skin cancer such as melanoma, they might have a surgeon explore the lymph nodes in the groin because that’s where skin from a lower extremity will spread to. And at times, surgeons will go in, and they’ll see a lymph node that is dark in color, and melanoma, when it metastasizes, can change the lymph node to a dark color. At the same time, tattoo pigment deposited in the lymph nodes can change it to a dark color.

So, when a surgeon’s in there, and they see the dark lymph node, they’re thinking it’s metastatic disease, and until they remove it and it’s looked at under the microscope, they won’t know whether or not it’s melanoma metastasis or pigment from a lower extremity tattoo.

One other scenario where this happens is patients who have cancer often have an imaging study called a PET-CT scan. And what a PET-CT scan does is it not only gives you anatomic information, like does a lymph node look enlarged, but it gives you physiologic information, meaning what’s happening? Is there a lot of activity? Is there a lot of metabolism in a certain area? So, when PET-CT scans are looking for metastatic disease, they look for lymph nodes that are showing increased metabolic activity or that they kind of light up on the PET-CT scan. Interestingly, when someone has had a tattoo, sometimes the lymph nodes get metabolically active, and they light up also on a PET-CT scan. So, from an imaging point of view, someone interpreting a PET-CT scan will see inflamed or increased activity in a lymph node and not know whether or not it’s from the tattoo response or from true tumor in the lymph node.

So, those are two examples of scenarios where having a tattoo and a response to it can mimic a worse process.

Jamie DePolo: That’s very interesting, and I have to say, I read an article in the newspaper about this, and that was the first I’ve heard about it. I know you said there aren’t really statistics on how common it is, but you’re a radiologist. In your experience, how often do you see something like this?

Dr. Susan Summerton: Well, years ago, it was reportable because it was very rare. But now that tattoos are becoming much more common — and interestingly, I just read an article last night stating that about 50% of women age 30 to 39 have tattoos, and those women are going to be eligible for mammograms in the next decade. So, I think we’re going to be starting to see more and more.

Like I mentioned before, it was more a case report. Now, I see it maybe a couple times a month. As a breast imager, that’s where you’re most likely to see the changes, in the lymph nodes in the armpit. And now I know as a response to ask the technologist, “Does this person have a tattoo?” Because I’ve seen it enough to know that that could be the case.

Jamie DePolo: Okay. If it’s going to happen, can it happen at any time? Or is it more likely to happen, say, within 6 months or a year after getting the tattoo? Do we know that?

Dr. Susan Summerton: I’ve read some articles that describe it appearing almost a decade later. So, it can be a delayed response. Most commonly, your body responds right away at the time you get the tattoo, and I would imagine within several months to a year, you’ll see changes in a lymph node. But they are finding delayed responses in lymph nodes from having had a tattoo a long time ago.

Jamie DePolo: Oh, that’s very interesting. So, it’s not like you need to think about it [once]. You have to think about it always.

Dr. Susan Summerton: Exactly.

Jamie DePolo: Okay. Now, is it all types of ink and all colors, or are there certain colors or types that are more likely to cause this? Do we know?

Dr. Susan Summerton: I read an article once saying that the green- and blue-colored tattoos tend to cause the metal deposition in the lymph nodes more commonly, though I haven’t seen that repeated in the literature. When I read that article, I had a technologist bring me a[n image], and I said — I saw that on one side there were white dots in the lymph nodes — “Does this woman have a tattoo?” She said, “She does. How do you know?” I said, “Wait, is it green or blue?” And she said, “It’s green. How did you know to ask that?” I’ve had a few cases where it has been green or blue in the tattoo. But I think it can be any color that can end up changing the appearance of lymph nodes and can cause a reaction in the lymph nodes.

Jamie DePolo: Okay. So, for somebody who’s having a mammogram, and these specks show up, if you know the person has a tattoo, would it automatically trigger more testing? I guess that's what I’m wondering. How do you know?

Dr. Susan Summerton: That’s a good question. It’s a difficult scenario at times. The article that you mentioned, I think you recently read, was a patient that I worked up who had a change on her mammogram, and we did an ultrasound at the time that she returned, and she had what looked like a small cancer in her breast. And in her, she had those dots in her lymph nodes. So, that can be an appearance of metastatic disease in lymph nodes — seeing those little dots that are usually calcium deposits when it’s a metastatic lymph node for breast cancer.

So, we didn’t know in her, and we had those lymph nodes removed, and fortunately for her, it turned out to be the tattoo pigment. We knew she had a tattoo, and we knew there was a differential diagnosis of the two possibilities, but you can’t tell from looking at it which it’s going to be. So, in that case, where she has a breast cancer, it’s more difficult.

In a woman who comes in, though, who has a normal-looking mammogram, who has a tattoo on the same side where we see those little dots, we’re learning more and more it’s safe to just call it a response to having had the tattoo.

Now, it should be noted, though, that there are more possibilities for finding those little dots in the lymph nodes. So, I will often question the patient about their history. So, patients who are treated for rheumatoid arthritis sometimes get an intramuscular injection of treatment that includes gold particles, and those gold particles can be taken up in lymph nodes. So, I ask patients, “Do you have rheumatoid arthritis? Have you been treated with a gold injection?” Sometimes people have a history of a disease such as sarcoidosis, which is an inflammation of lymph nodes most commonly in the chest, that we see findings on a chest X-ray, but those people also can get calcification of lymph nodes. So, I may ask them, “Have you ever been told you had sarcoidosis?”

So, I try to look for a reason besides having metastatic disease that this lymph node might have calcium in it, or pigment in it, or something like that. So, it leads to a whole list of questions and gathering of more history when we radiologists or breast imagers see this finding on a mammogram.

Jamie DePolo: Okay. Well, I guess that’s good to know, because if somebody, say, had normal-looking mammograms for several years in a row, got a tattoo, this showed up — well, it may initially be cause for concern. Once you take all of this into account, it usually means that it’s probably the tattoo ink.

Dr. Susan Summerton: Right. You’ll have to know as much as you can about them. Interestingly, ovarian cancer can metastasize to lymph nodes in the axilla, or armpit, and can lead to calcium deposits. So, that’s another thing we want to rule out. We want to make sure that they don’t have any mass in their pelvis. Most women will know that that’s part of their history, and if that is part of their history, and we see this finding, even in the setting of a tattoo, we’re going to worry about metastatic disease. So, anybody with a known cancer, even if they have a tattoo, the safest thing is likely to remove that lymph node to see which possibility you’re dealing with.

Jamie DePolo: Okay. Good to know. Now, if a woman has a tattoo, say she’s over 45, or whatever age she is starting to get her regular mammograms, should she tell her mammogram tech, “Oh, I have a tattoo on this side?” Is that helpful upfront? What should women do?

Dr. Susan Summerton: I think it’s a good idea to have women offer that information, especially once they listen to this program and know that’s something, because this has become a bit of a hotter topic lately. COVID has been a very hot topic lately, because COVID has been changing the lymph nodes on mammograms — after people get a vaccine, we’re seeing changes. So, there has been a lot of literature about how to deal with these abnormal lymph nodes we’re seeing, because just like tattoo pigments, seeing enlarged lymph nodes from a COVID vaccine can also be a way breast cancer presents.

So, we’ve been dealing with this a lot. We’ve gotten our techs used to asking, “Have you had a COVID vaccine and when?” I think we should also include, “Do you have a tattoo on your upper body, and if so, where?” And that is something we’re going to institute in our department shortly. But for now, if departments aren’t asking, it might save a woman a trip back for extra imaging or a phone call in the future. So, I definitely would recommend women offer that information. COVID vaccine status as well as tattoo status.

Jamie DePolo: Okay. And there’s nothing to suggest that somebody should not get a tattoo because of this?

Dr. Susan Summerton: No. First of all, I don’t think we’re going to stop women… or anybody for that matter, but I think it’s just important to know that this can happen. There’s been nothing shown about this phenomenon that it is going to harm you medically. It’s more an imaging finding. There’s not been shown to be an increased risk of cancer from getting tattoos. So, there’s not really a compelling reason not to get it, but it might, down the line, lead to a biopsy that you might not otherwise have had if you didn’t have a tattoo.

Jamie DePolo: Okay. But just as long as somebody is upfront with the technologist, tells them, that could possibly maybe avert the biopsy?

Dr. Susan Summerton: Correct.

Jamie DePolo: Okay. All right. Thank you so much. This has been really helpful. I appreciate your insights.

Dr. Susan Summerton: My pleasure.

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