title: Potential Surgical and Oncologic Consequences Related to Skin Tattoos in the Treatment of Cervical Cancer.
abstract: Skin tattoos on the feet, legs, and lower abdominal wall are progressively gaining popularity. Consequently, the number of tattooed women with cervical cancer has significantly increased in the last decade. However, pigments of tattoo ink can be transported to regional lymph nodes and potentially clog lymphatic pathways that might also be used by sentinel labeling substances. Therefore, here we report whether the presence of tattoo ink affected pelvic lymph nodes in women with early cervical cancer and discuss its potential oncologic and surgical consequences.
  
  
  
  Prospective observational study.
  
  
  
  University Hospital in Hamburg, Germany (Canadian Task Force classification II2).
  
  
  
  Women affected by cervical cancer.
  
  
  
  Between January 2014 and May 2016, 267 laparoscopic oncologic operations, including at least a pelvic sentinel or complete lymphadenectomy, were performed in the Department of Advanced Surgical and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany. Among these, 191 patients were affected by cervical cancer.
  
  
  
  Data of patients in whom dyed lymph nodes without the use of patent blue as a sentinel marker or different from blue-colored pelvic lymph nodes in the case of sentinel procedure were identified and prospectively collected.
  
  
  
  In 9 patients, skin tattoos localized in the lower extremities caused discoloration of at least 1 pelvic lymph node. This effect was observed in 40% of women (9/23) with tattoos in this area of the body. Mean patient age was 34 years (range, 27-56). All women had cutaneous tattoos on their feet or legs, and in 1 woman an additional tattoo situated on the inferior abdominal wall was observed. The stage of cervical cancer was FIGO IB1 in all cases. One woman was at the 16th week of gestation at the time of cancer diagnosis. On average, 26 pelvic lymph nodes (range, 11-51) were harvested from both pelvic basin sides. None of the removed lymph nodes was tumor involved. Three patients (33%) developed postoperatively infected lymphoceles on the side of the tattooed lymph nodes, and 1 woman had multiple episodes of fever without a clear origin.
  
  
  
  In women affected by cervical cancer with skin tattoos located in the lower limbs, the pelvic lymph nodes can be partially or totally occupied by the ink. This must be taken into consideration, especially for women scheduled exclusively for sentinel node biopsy. Infectious complications related to nodal dissection, in particular infected lymphoceles, may be more frequent in this population.
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Christhardt
authors.initials: C
authors.lastname: Köhler
authors.affiliation: Department of Gynecologic Oncology, Erasto Gaertner Hospital, Curitiba, Brazil.
authors.forename: Tariane
authors.initials: T
authors.lastname: Foiato
authors.affiliation: Department of Radiooncology, University of Cologne, Cologne, Germany.
authors.forename: Simone
authors.initials: S
authors.lastname: Marnitz
authors.affiliation: Institute for Cytology and Dysplasia, Fürstenberg-Carree, Berlin, Germany.
authors.forename: Achim
authors.initials: A
authors.lastname: Schneider
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Xin
authors.initials: X
authors.lastname: Le
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Nasuh Utku
authors.initials: NU
authors.lastname: Dogan
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Pfiffer
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Anna Elena
authors.initials: AE
authors.lastname: Jacob
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany.
authors.forename: Andrea
authors.initials: A
authors.lastname: Mölgg
authors.affiliation: Department of Gynecology, Park Clinic, Kiel, Germany.
authors.forename: Ingke
authors.initials: I
authors.lastname: Hagemann
authors.affiliation: Department of Advanced Operative and Oncologic Gynecology, Asklepios Hospital, Hamburg, Germany. Electronic address: g.favero@asklepios.com.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Favero
mesh_terms: D000328:Adult; D005260:Female; D005858:Germany; D006801:Humans; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000473:pathology*; D008875:Middle Aged; D009367:Neoplasm Staging; D010388:Pelvis; D011446:Prospective Studies; D021701:Sentinel Lymph Node Biopsy / Q000379:methods; D013653:Tattooing / Q000009:adverse effects*; D002583:Uterine Cervical Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Early cervical cancer; Lower limb skin tattoo; Sentinel lymphadenectomy