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Life sciences · Journal article
The Thai Journal of Surgery · September 21, 2026
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Background: Neoadjuvant systemic therapy (NST) frequently achieves axillary downstaging in node-positive breast cancer. Targeted axillary dissection (TAD)—combining sentinel lymph node biopsy (SLNB) with removal of pre-NST marked metastatic nodes—provides accurate post-NST axillary restaging. While advanced wireless markers are standard in high-resource settings, carbon tattooing offers an economical, radiation-free visual alternative. This prospective study evaluates the feasibility, accuracy, and volume-optimized safety of carbon tattooing for TAD within Thailand's public health infrastructure. Materials and Methods: Patients with biopsy-proven axillary metastasis underwent dual marking (metallic clip + cortical carbon tattoo injection) prior to NST. We evaluated a refined injection volume (0.1 mL post-pilot) to minimize background spillage. After NST, we visually identified carbon-tattooed nodes intraoperatively and confirmed clip retrieval via specimen radiography. We performed SLNB using dual mapping with indocyanine green (ICG) fluorescence and blue dye to assess optical clarity between tracers. Primary endpoints were identification rate, accuracy (tattooed matching clipped node), and concordance (tattooed matching SLN). Results: Twelve patients completed TAD post-NST (mean tattoo-to-surgery interval: 156 days). We visually identified carbon-tattooed nodes in 11 of 12 patients (identification rate: 91.7%). Mean targeted node retrieval was 5.58 nodes. Clipped and tattooed nodes were identical in 11 cases (accuracy: 91.7%), whereas tattooed nodes matched SLNs in 6 cases (concordance: 50.0%). SLN detection was 100% with ICG fluorescence without carbon interference, and 83.3% with blue dye. Cutaneous staining occurred in one patient (8.3%) with no procedural complications. Conclusions: Carbon tattooing for TAD is a highly accurate, safe, and economical strategy post-NST. By optimizing injection volume and using real-time visual localization, this technique eliminates the need for expensive secondary radiologic localization procedures, providing a scalable TAD solution tailored to resource-constrained surgical oncology settings.