Tattooing Breast Cancers Treated with Neoadjuvant Chemotherapy
Marie-Christine Mathieu, Laurence Bonhomme-Faivre, Roman Rouzier, Monique Seiller, Lise Barreau-Pouhaer,
and Jean-Paul Travagil.
Annals of surgical oncology : the official journal of the Society of Surgical Oncology, 2007 Aug, 14(8):2233-8.
Epub: 2007 May 16
Interesting Fact:
The interesting fact that we learned from this paper is that tumours can be detected using a charcoal-based dye. A
well-tolerated, low diffusion charcoal suspension was designed to tattoo breast tumours. The tattoos can be
effective for localizing the tumours after treatment with chemotherapy.
Hypothesis:
The hypothesis that is being tested is whether or not the tattooing technique is efficient for localizing the tumour
after treatment with chemotherapy. No assumptions were stated.
Methods:
109 patients with operable, non-inflammatory breast cancers were treated with either 4% or 10% charcoal
suspension. 72 patients received .5 – 2 mL of the 4% suspension, and 37 patients received 1 mL of the 10%
suspension. These patients were ‘tattooed’ after being treated with neoadjuvant chemotherapy followed by surgery.
This surgical procedure was either a lumpectomy or a mastectomy. A description of the tumour location and a
photograph of the initial site of the tumour were obtained. During the surgery, the pathologist analyzed the
operative specimen in search of the charcoal. If the charcoal was found at any point, the surgeon was asked to resect
this area to completely remove the residual charcoal. The sample size was sufficiently large enough and there were
no obvious flaws in the experiment. Because it involved living patients, the experiment was very well designed and
controlled. The authors should have mentioned the ages of the patients as age directly influences the effectiveness of
the immune system and this may have interfered with the macrophages that took up the charcoal dye.
Results:
For each of the patients, surgery was performed from 62 to 126 days after the injection of the charcoal. An
intraoperative examination was performed in the 91 lumpectomy patients, and charcoal was seen in 86 of these
cases. The charcoal appeared as a black area, a black nodule or numerous black dots. Microscopic examination
revealed that the charcoal particles were either phagocyted by macrophages inside the tumour stroma, the normal
fibrous tissue of the breast, and the adipose tissue. In the 10 cases free of microscopic residual tumour, the
histological examination of the breast containing the charcoal revealed rare carcinoma cells inside the fibrosis in five
cases, diffuse infiltrating lobular carcinoma in three cases, ductual carcinoma-in-situ in one case and only fibrosis
without tumour cells in the last case. The charcoal facilitated the removal of the initial tumour site. In five surgical
specimens, no charcoal tattoo was seen during the intraoperative macroscopic examination. These results supported
the authors hypothesis.
Discussion:
The charcoal dye in tattooed breast tumours was visualized after 3 months of chemotherapy in 94% of cases. The
charcoal helped the surgeons find the initial tumour site in 10 cases and allowed the surgeon to perform a biopsy
instead of a quadrantectomy to remove the tumour. The charcoal is still visible after 6 months, suggesting that
tattooing is definitive. This tattooing permits the precise localization of any residual nodules after treatment. It
allows the surgeon to resect the initial tumour site when complete clinical regression is observed. The discussion
does repeat the results, but also offers insight in to why charcoal suspension is useful (it is cheap, easy to use,
tolerated, etc) and suggests ideas for future research, such as combing clip placement and tattooing to locate
tumours. The results defiantly support the authors’ interpretations, but no short-comings were mentioned. We
suggest that they should have mentioned the length of their study, as cancer is a long-term disease. They did mention
that the patients were ones that were referred to them between 1987 and 1992, but the article itself was not published
until May 2007.
Abstract:
The abstract was divided into sections describing the background, methods, results and conclusions. The paper
expanded on each section, therefore staying true to the abstract.
Opinion of the paper:
Overall, we think that this paper was well written and very interesting. It was clear, straightforward and to the point.
The authors stayed true to their original hypothesis. The results were laid out in a manner that was easy to follow.
The authors also included comparative methods of tracking tumours and what the advantages/disadvantages of each
were compared to the charcoal tattoos. The paper provided sufficient background information of the suspension
preparation why they used the two different concentrations.
Karen Schuster, Jerneja Stare