Overstaged Rectal Cancer by MRI due to Fibrosis Induced by Tattoo Marker

Abstract

Endoscopic colorectal tattooing with carbon-based dyes is commonly employed in order to assist with later localization of the lesion. Although carbon is thought to be nontoxic, there usually is some inflammatory reaction with fibrosis and granuloma formation after tissue injection. The aim of this report is to alert to a possible underestimated, late consequence of colorectal carbon-based marker tattooing, namely pronounced fibrosis at the site of the injection that could lead to a blurring and misinterpretation of changes evaluated by radiological techniques. We describe a case of cT stage overestimation due to fibrosis of the rectal wall and perirectal fat, induced by carbon-based dye injection in a 66-year-old patient. In our case it was an overestimation of MR evaluation in the case of early invasive carcinoma. Although there have been some studies on tissue effect of carbon-based dyes, the possible scenario consequence of cancer stage overestimation due to fibrosis has not yet been described. Such a mistake could lead to inappropriate overtreatment. Clinicians must be aware of the possible consequences of dye injection and resultant overestimation of T stage of colorectal cancer. More histological studies concerning histological changes after carbon-based marker tattooing are needed to establish the extent of its significance.

Recommendations for Optimal Endoscopic Localization of Colorectal Neoplasms: A Delphi Consensus of National Experts

“…51 Tattoo material may cause lymph node uptake leading to false upstaging on imaging. 52 Falsely enlarged lymph nodes can be potentially clarified via PET scan, although entrained air and false upstage to perforated cancer can be more difficult to elucidate. Rectal tattoos have been reported to cause fibrosis, 53 disrupt tissue planes, and may make subsequent resection more difficult.…”

“…Anatomical landmarks and tattoo position in relation to the lesions, old tattoos, lesion before biopsy, postresection site Old scar site 30 ; postprocedure resection site 22,30 ; anatomical landmarks 17,22 ; tattoo injection 16,25 ; tattoo in relation to lesion 22,30 ; specimen 38 ; lesion before removal node uptake leading to false upstaging on imaging. 52 Falsely enlarged lymph nodes can be potentially clarified via PET scan, although entrained air and false upstage to perforated cancer can be more difficult to elucidate. Rectal tattoos have been reported to cause fibrosis, 53 disrupt tissue planes, and may make subsequent resection more difficult.…”

Colorectal Cancer: Preoperative Evaluation and Staging

“…Several case reports have also raised the issue of potential tumor implantation by improper endoscopic tattooing directly through the tumor, which obviously should be avoided [21]. In addition, tattooing may induce altered appearance of the rectal wall on MR or reactive lymphadenopathy, with possible resultant overstaging on MRI [22]. Thus, if a rectal tumor was not tattooed at diagnosis, it is optimal to obtain staging MRI and CT prior to marking the tumor endoscopically with ink.…”