search for


Targeted Axillary Biopsy with Preoperative Ultrasound-Guided Tattooing for Suspicious Axillary Lymph Nodes in Patients with Early Breast Cancer
J Surg Ultrasound 2020;7:47-54
Published online November 30, 2020;
© 2020 The Korean Surgical Ultrasound Society

Jin Hyang Jung, Jeeyeon Lee, Wan Wook Kim, Ho Yong Park, Ji-Young Park1, Sang Woo Lee2, Won Hwa Kim3, Hye Jung Kim3

Department of Surgery, 1Department of Pathology, 2Department of Nuclear Medicine, 3Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
Correspondence to: Ho Yong Park
Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, 807 Hogukno, Buk-gu, Daegu 41404, Korea
Tel: +82-53-200-2704
Fax: +82-53-200-2027
Received September 14, 2020; Revised October 12, 2020; Accepted October 12, 2020.
Journal of Surgical Ultrasound is an Open Access Journal. All articles are distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose: This study evaluated the efficiency of preoperative ultrasound (US)-guided tattooing of the axillary lymph nodes with activated charcoal and the correlation between sonographically suspicious nodes and final histologic results by node-to-node analysis. The concordance rate between the tattooed nodes and sentinel nodes was also determined.
Methods: US-guided tattooing of sonographically suspicious axillary nodes was performed preoperatively by an injection of activated charcoal. The identification of black pigment and the concordance between the sentinel and tattooed nodes was evaluated.
Results: Regarding node-to-node analysis, the false-negative rate of US-fine needle aspiration (FNA) was 43.3%. The sensitivity and negative predictive values were 56.7% and 81.7%, respectively. The specificity and positive predictive values were 100%. The accuracy of US-FNA was 85.2%. In the final pathology, 45/125 patients (36.0%) had positive nodes, including two micrometastases. The false-negative rate of sentinel lymph node biopsy (SLNB) was 4.0%, but there were no skip metastases. The sensitivity and specificity of SLNB were 95.6% and 100%, respectively. The negative predictive value was 97.6%, and the positive predictive value was 100%. The accuracy of SLNB was 98.4%. In 117 of 125 patients (93.6%), there was concordance between the charcoal tattooed axillary lymph nodes and SLNs.
Conclusion: SLNB, in conjunction with US-guided tattooing of sonographically suspicious axillary lymph nodes, is a useful procedure to reduce the false-negative rate of SLNB and improve the accuracy of an intraoperative evaluation of axillary nodes in breast cancer patients. This paper proposes the concept of targeted axillary node biopsy with preoperative US-guided tattooing for the most accurate axillary staging in patients with breast cancer.
Keywords : Breast cancer, Lymph nodes, Axilla, Tattooing, Charcoal

November 2020, 7 (2)