Feasibility of Using Carbon Tattoo for Targeted Axillary Dissection in Node-Positive Breast Cancer Patients Treated with Neoadjuvant Systemic Therapy: Preliminary Results of a Prospective Study

Pornchanok Jaruvongvanich; Vipavee   Niyomnaitham

doi:10.64387/tjs.2026.278682

Authors

Pornchanok Jaruvongvanich Rajavithi hospital
Vipavee Niyomnaitham, MD

DOI:

https://doi.org/10.64387/tjs.2026.278682

Keywords:

Targeted axillary dissection, Carbon tattooing, Node-positive breast cancer, Neoadjuvant systemic therapy, Sentinel lymph node biopsy, Low-resource setting

Abstract

Background: Neoadjuvant systemic therapy (NST) frequently achieves axillary downstaging in node-positive breast cancer. Targeted axillary dissection (TAD)—combining sentinel lymph node biopsy (SLNB) with removal of pre-NST marked metastatic nodes—provides accurate post-NST axillary restaging. While advanced wireless markers are standard in high-resource settings, carbon tattooing offers an economical, radiation-free visual alternative. This prospective study evaluates the feasibility, accuracy, and volume-optimized safety of carbon tattooing for TAD within Thailand's public health infrastructure.

Materials and Methods: Patients with biopsy-proven axillary metastasis underwent dual marking (metallic clip + cortical carbon tattoo injection) prior to NST. We evaluated a refined injection volume (0.1 mL post-pilot) to minimize background spillage. After NST, we visually identified carbon-tattooed nodes intraoperatively and confirmed clip retrieval via specimen radiography. We performed SLNB using dual mapping with indocyanine green (ICG) fluorescence and blue dye to assess optical clarity between tracers. Primary endpoints were identification rate, accuracy (tattooed matching clipped node), and concordance (tattooed matching SLN).

Results: Twelve patients completed TAD post-NST (mean tattoo-to-surgery interval: 156 days). We visually identified carbon-tattooed nodes in 11 of 12 patients (identification rate: 91.7%). Mean targeted node retrieval was 5.58 nodes. Clipped and tattooed nodes were identical in 11 cases (accuracy: 91.7%), whereas tattooed nodes matched SLNs in 6 cases (concordance: 50.0%). SLN detection was 100% with ICG fluorescence without carbon interference, and 83.3% with blue dye. Cutaneous staining occurred in one patient (8.3%) with no procedural complications.

Conclusions: Carbon tattooing for TAD is a highly accurate, safe, and economical strategy post-NST. By optimizing injection volume and using real-time visual localization, this technique eliminates the need for expensive secondary radiologic localization procedures, providing a scalable TAD solution tailored to resource-constrained surgical oncology settings.

References

Spring LM, Fell G, Arfe A, et al. Pathologic Complete Response after Neoadjuvant Chemotherapy and Impact on Breast Cancer Recurrence and Survival: A Comprehensive Meta-analysis. Clin Cancer Res. 2020 Jun 15;26(12):2838-48. doi: 10.1158/1078-0432.CCR-19-3492.

Ashikaga T, Krag DN, Land SR, et al. National Surgical Adjuvant Breast, Bowel Project. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010 Aug 1;102(2):111-8. doi: 10.1002/jso.21535.

Kelly AM, Dwamena B, Cronin P, et al. Breast cancer sentinel node identification and classification after neoadjuvant chemotherapy-systematic review and meta analysis. Acad Radiol. 2009 May;16(5):551-63. doi: 10.1016/j.acra.2009.01.026.

Shirzadi A, Mahmoodzadeh H, Qorbani M. Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: Initially node negative and node-positive converted to node-negative - A systematic review and meta-analysis. J Res Med Sci. 2019 Feb 25;24:18. doi: 10.4103/jrms.JRMS_127_18.

Kuehn T, Bauerfeind I, Fehm T, et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol. 2013 Jun;14(7):609-18. doi: 10.1016/S1470-2045(13)70166-9.

Boughey JC, Suman VJ, Mittendorf EA, et al. Alliance for Clinical Trials in Oncology. Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial. JAMA. 2013 Oct 9;310(14):1455-61. doi: 10.1001/jama.2013.278932.

Boileau JF, Poirier B, Basik M, et al. Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study. J Clin Oncol. 2015 Jan 20;33(3):258-64. doi: 10.1200/JCO.2014.55.7827.

Shirzadi A, Mahmoodzadeh H, Qorbani M. Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: Initially node negative and node positive converted to node negative - A systemic review and meta-analysis. J Res Med Sci. 2019 Feb 25;24:18. doi: 10.4103/jrms.JRMS_127_18.

Caudle AS, Yang WT, Krishnamurthy S, et al. Improved Axillary Evaluation Following Neoadjuvant Therapy for Patients With Node-Positive Breast Cancer Using Selective Evaluation of Clipped Nodes: Implementation of Targeted Axillary Dissection. J Clin Oncol. 2016 Apr 1;34(10):1072-8. doi: 10.1200/JCO.2015.64.0094.

Woods RW, Camp MS, Durr NJ, et al. A Review of Options for Localization of Axillary Lymph Nodes in the Treatment of Invasive Breast Cancer. Acad Radiol. 2019 Jun;26(6):805-19. doi: 10.1016/j.acra.2018.07.002.

Ersoy YE, Kadioglu H. Review of Novel Sentinel Lymph Node Biopsy Techniques in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy. Clin Breast Cancer. 2018 Aug;18(4):e555-e559. doi: 10.1016/j.clbc.2018.01.004.

Lim GH, Teo SY, Gudi M, et al. 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). Cancer Med. 2020 Mar;9(6):1978-85. doi: 10.1002/cam4.2848.

Khallaf E, Wessam R, Abdoon M. Targeted axillary dissection of carbon-tattooed metastatic lymph nodes in combination with post-neo-adjuvant sentinel lymph node biopsy using 1% methylene blue in breast cancer patients. Breast J. 2020 May;26(5):1061-3. doi: 10.1111/tbj.13736.

Kim WH, Kim HJ, Kim SH, et al. Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study. BMC Cancer. 2019 Aug 30;19(1):859. doi: 10.1186/s12885-019-6095-1.

Park S, Koo JS, Kim GM, et al. 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. Cancer Res Treat. 2018 Jul;50(3):801-12. doi: 10.4143/crt.2017.210.

Choy N, Lipson J, Porter C, et al. Initial results with preoperative tattooing of biopsied axillary lymph nodes and correlation to sentinel lymph nodes in breast cancer patients. Ann Surg Oncol. 2015 Feb;22(2):377-82. doi: 10.1245/s10434-014-4034-6.

Mariscal Martínez A, Vives Roselló I, Salazar Gómez A, et al. Advantages of preoperative localization and surgical resection of metastatic axillary lymph nodes using magnetic seeds after neoadjuvant chemotherapy in breast cancer. Surg Oncol. 2021 Mar;36:28-33. doi: 10.1016/j.suronc.2020.11.013.

Greenwood HI, Wong JM, Mukhtar RA, et al. Feasibility of Magnetic Seeds for Preoperative Localization of Axillary Lymph Nodes in Breast Cancer Treatment. AJR Am J Roentgenol. 2019 Oct;213(4):953-7. doi: 10.2214/AJR.19.21378.

Kasem I, Mokbel K. Savi Scout® Radar Localisation of Non-palpable Breast Lesions: Systematic Review and Pooled Analysis of 842 Cases. Anticancer Res. 2020 Jul;40(7):3633-43. doi: 10.21873/anticanres.14352.

Gradishar WJ, Moran MS, Abraham J, et al. Breast Cancer, Version 3.2024, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2024 Jul;22(5):331-57. doi: 10.6004/jnccn.2024.0035.

Choy N, Lipson J, Porter C, et al. Initial results with preoperative tattooing of biopsied axillary lymph nodes and correlation to sentinel lymph nodes in breast cancer patients. Ann Surg Oncol. 2015 Feb;22(2):377-82. doi: 10.1245/s10434-014-4034-6.

Park S, Koo JS, Kim GM, et al. 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. Cancer Res Treat. 2018 Jul;50(3):801-12. doi: 10.4143/crt.2017.210.

Kim WH, Kim HJ, Jung JH, et al. Ultrasound-Guided Restaging and Localization of Axillary Lymph Nodes After Neoadjuvant Chemotherapy for Guidance of Axillary Surgery in Breast Cancer Patients: Experience with Activated Charcoal. Ann Surg Oncol. 2018 Feb;25(2):494-500. doi: 10.1245/s10434-017-6250-3.

Natsiopoulos I, Intzes S, Liappis T, et al. Axillary Lymph Node Tattooing and Targeted Axillary Dissection in Breast Cancer Patients Who Presented as cN+ Before Neoadjuvant Chemotherapy and Became cN0 After Treatment. Clin Breast Cancer. 2019 Jun;19(3):208-15. doi: 10.1016/j.clbc.2019.01.013.

Goyal A, Puri S, Marshall A, et al. A multicentre prospective feasibility study of carbon dye tattooing of biopsied axillary node and surgical localisation in breast cancer patients. Breast Cancer Res Treat. 2021 Jan;185(2):433-40. doi: 10.1007/s10549-020-05961-3.

Patel R, MacKerricher W, Tsai J, et al. Pretreatment Tattoo Marking of Suspicious Axillary Lymph Nodes: Reliability and Correlation with Sentinel Lymph Node. Ann Surg Oncol. 2019 Aug;26(8):2452-8. doi: 10.1245/s10434-019-07419-3.

Hartmann S, Kühn T, de Boniface J, et al. Carbon tattooing for targeted lymph node biopsy after primary systemic therapy in breast cancer: prospective multicentre TATTOO trial. Br J Surg. 2021 Apr 5;108(3):302-7. doi: 10.1093/bjs/znaa083.