PS5-06-01: Tattoo Ink Fluorescence Interfering with Axillary Reverse Mapping Using Indocyanine Green in Breast Conservation Surgery

Abstract Introduction: Breast cancer-related lymphedema (BCRL) is a significant postoperative complication, affecting approximately 1 in 5 women undergoing surgical treatment for breast cancer. Axillary reverse mapping (ARM) aims to reduce BCRL by differentiating lymphatic drainage paths in the arm versus the breast. Sentinel lymph node biopsy (SLNB) using dual tracers such as radioisotope (RI) and/or blue dye (BD) has been considered the standard of care for early breast cancer surgical management. Recently, indocyanine green (ICG) has been utilized as an alternative for blue dye due to safety and limitations with blue dye utilization. However, ICG and certain tattoo inks can demonstrate fluorescence and therefore limit ICG’s utility in certain cases. We present a case of a 55-year-old woman whose tattoo ink interfered with the ARM procedure. Case Presentation: The patient is a 55-year-old postmenopausal woman diagnosed with ER/PR positive, HER2 negative, Grade 1 Invasive Ductal Carcinoma (IDC) following abnormal findings in the right breast on screening mammography. She underwent right breast lumpectomy with SLNB, using a radioactive tracer and ICG for lymphatic mapping. Intraoperatively, green fluorescence was unexpectedly observed in axillary lymph nodes containing pigment from previous tattoos, raising concerns about false-positive identification of sentinel lymph nodes. Discussion: Tattoo ink-stained lymph nodes are indicated in the literature as a source of interference during SLNB. In this case, the fluorescence of tattoo pigment mimicked that of ICG, complicating intraoperative differentiation between nodes draining the arm lymphatics and those stained by ink. This may lead to over-excision of axillary nodes, under-staging of cancer due to misidentification, or increase the risk of lymphedema. Literature suggests that lipid-bound ICG utilizes the hydrophobic suspension in black tattoo ink to bind to and travel to the lymph node, potentially contributing to the false-positive node findings in this patient. Conclusion: This case highlights a clinically relevant interaction between tattoo ink and ICG during SLNB, which may influence the accuracy of lymphatic mapping and surgical outcomes. It demonstrates the need to expand current understanding of tattoo ink interference in breast cancer surgery guided by ICG fluorescence. Further exploration of the biochemical interactions between ICG and tattoo ink can refine surgical approaches and improve patient outcomes in the context of BCRL prevention. Citation Format: A. Vijay, B. Andrew, J. Anderson, M. Legenza, D. Krutzler-Berry. Tattoo Ink Fluorescence Interfering with Axillary Reverse Mapping Using Indocyanine Green in Breast Conservation Surgery [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS5-06-01.