Tattoo ink from 15 years ago mimics lymph node cancer: Case study

By Dr. Ananya Mandal, MDOct 4 2017

A 30 year old Australian woman presented to the doctors with numerous small lumps under her arms for around two weeks. When one of the nodes were put under the microscope, the doctors found pigments from tattoo ink that she’d got 15 years back. They speculated that her immune system was not reacting to the tattoo ink now and thus the swollen lymph nodes.  Her case details were published as a case report in the journal Annals of Internal Medicine this week.

She underwent a whole body scan after her initial presentation as advised by the team of doctors to look for more such lumps within her body. The doctors suspected the rubbery painless lumps to be enlarged lymph nodes caused due to a lymph node cancer or lymphoma. The scan showed several more swollen lymph nodes in her chest including the roots of her lungs around her heart. She complained of no fever, weight loss or any other symptom characteristic of lymphoma. She had had a breast augmentation surgery at the age of 19 and complained of headaches once in a while. Otherwise she had no other symptoms. She was a nonsmoker and was on oral contraceptive pills.

According to Dr. Christian Bryant, a hematologist at the Royal Prince Alfred Hospital in Sydney, who was part of the team of doctors treating the woman, the chance of this being a lymphoma is 99 percent. Lymphomas occur when the immune cells in the body become cancerous causing the lymph nodes to swell. Lymph nodes contain immune cells that may also swell up when there is a localized infection or inflammation. In this case, the doctors explain, the lymph nodes were swollen and inflamed because they were reacting to the old tattoo ink and were not cancerous. They removed the node in a short surgical process called a biopsy and looked at its specially stained sections under the microscope. They found it to be loaded with a black colored pigment. The pigment was from a 15 year old tattoo that covered her back and also a recent tattoo (2.5 years old) she had got on her shoulder.

The lymphatic system and the immune cells are the surveillance system in the body. When they found the tattoo pigment they treated it as foreign material. This led to their ingesting the pigments and the immune cells loaded with these pigments travelled up the lymphatic system and got accumulated within the lymph nodes over years. Small foreign matter is usually digested by these cells. Since the pigments are too large for the cells to digest, they remained after so many years, explained the doctors. What makes this case different and uncommon is the fact that the swelling of the nodes too so many years. They could not identify the trigger that caused the lymph nodes to swell now after so many years. Bryant explained that the patient did complain of itching over the tattoo for a few days each month and a localized inflammatory reaction called a granuloma was never detected over her skin. The uniqueness of this case, Bryant said, was the fact that this is the first time swollen and pigmented lymph nodes were mistaken for lymphoma. He said that it is not possible to know how common this is despite the fact that so many people get tattoos these days.

Lymphoma

Lymphomas are cancers of the immune system. Cancer of the lymphoid tissue can be treated using anticancer drugs, radiation or bone marrow transplantation therapy. The likelihood of the cancer being curable depends on its type, its stage and its grade.

Lymphoma forms around 5% of all cancers in the United States and nearly half of all the blood cancers. Lymphoma is the fifth most common cancer in the United Kingdom and the most common cancer to occur under the age of 30.

There are many types of lymphoma but they are broadly categorized as Hodgkin's lymphoma and non-Hodgkin's lymphoma. In 2008, the World Health Organization (WHO) introduced the latest classification system for these lymphomas which now lists 70 different forms which are broadly categorized into four groups. This classification system is based on the Revised European-American Lymphoma (REAL) classification system which divides the lymphomas according to cell type and cell characteristics.

The four classes outlined by WHO include:

1. Mature B cell cancers (Chronic lymphocytic leukemia - CLL, plasma cell cancers and Burkitt lymphomas).
2. Mature T cell and natural killer (NK) cell cancer (Adult T cell leukemia/lymphoma, T cell prolymphocytic leukemia and primary cutaneous CD30-positive T cell lymphoproliferative disorders)
3. Hodgkin lymphomas
4. Lymphomas associated with HIV AIDS, chemotherapy or radiotherapy.

Source: http://annals.org/aim/article/2656481/tattoo-pigment-induced-granulomatous-lymphadenopathy-mimicking-lymphoma