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Axillary lymphadenopathy, or swelling under the armpit, has been reported by women after receiving Pfizer-BioNTech and Moderna COVID-19 vaccines, but it is also a common symptom of breast cancer.
Therefore, clinicians should consider a history of COVID-19 vaccination in the differential diagnosis of patients with unilateral axillary lymphadenopathy, according to a new article.
“We have noticed an increasing number of patients with swollen lymph nodes on only one side / armpit who presented for a routine screening mammogram or ultrasound, and some women who actually felt these swollen nodes,” said author Katerina Dodelzon, MD, assistant professor of clinical radiology, Weill Cornell Medicine, New York.
“Historically, swollen lymph nodes on one side are relatively rare and infrequent on screening mammography – seen only 0.02% to 0.04% of the time – and this is a warning sign radiologist to rule out the presence of a malignant breast tumor on this side, ”she added.
In an article published in Clinical imaging, Dodelzon and colleagues describe four cases involving women who received a COVID-19 vaccine and then sought breast screening. In describing these cases, the authors sought “to inform the medical community to consider this benign and self-limiting diagnosis in the context of what may be an alarming presentation of unilateral axillary lymphadenopathy.”
They hope they will decrease unnecessary biopsies and help reassure patients.
Lymphadenopathy has been reported in association with other vaccines, such as Bacillus Calmette-Guérin vaccine, influenza vaccines and human papillomavirus vaccine, commented Jessica WT Leung, MD, president of the Society of Breast Imaging. (SBI).
“It’s too early to tell if there is anything different about COVID-19 vaccines,” said Leung, also professor of diagnostic radiology and vice president of breast imaging at the University of Texas MD Anderson Cancer Center, Houston, Texas.
“The two vaccines currently in use – Pfizer and Moderna – are both mRNA vaccines, and it is not known whether they will give a stronger immune response,” she said. “If the Johnson & Johnson and AstraZeneca vaccines become available, it will be interesting to see if they elicit such a strong response, as they are not mRNA vaccines. At the moment, we have no data to say one way or the other. “
Leung also noted that these latest vaccine reactions may get more attention because “they’re linked to COVID-19, and anything related to COVID-19 is getting more attention.
“It may also be more visible due to the large number of people getting vaccinated in a short period of time in an effort to contain the pandemic, and this is not the case with other vaccines,” he said. she declared.
New recommendations from SBI
The SBI recently issued recommendations to clinicians that women who have axillary lymphadenopathy and who were recently vaccinated on the same side where lymphadenopathy occurs be followed for a few weeks to see if the lymph nodes return to normal, rather than having a biopsy.
“Many practices are now regularly learning about the history of recent vaccination and from which side it was administered,” Dodelzon said. She stressed that women should feel empowered to share this story if they are not asked.
“Letting your mammography technologist or breast imager know that you were recently vaccinated and on which side will provide the breast imager with a more precise context in which to interpret the results,” she said.
In addition, the SBI recommends that, if possible, women schedule a routine screening mammogram either before the first dose of the COVID-19 vaccine or 4 to 6 weeks after the second dose to avoid a false positive.
“We want to emphasize that the screening mammogram is very important, and if possible, schedule it around the vaccine,” Leung commented. “But that may not be possible, because most of us don’t have a choice when to get the vaccine.”
If it is not possible to postpone the mammogram or vaccine, Leung recommends that women notify the facility that they have recently received a COVID-19 vaccine. “Currently we recommend a follow-up in 4 to 12 weeks,” she says. “The swelling might subside sooner, maybe even within 1 to 2 weeks, but we generally recommend waiting at least 4 weeks to capture the majority of women.”
Differences between vaccines?
The frequency with which axillary lymphadenopathy occurs as a side effect differs with the two COVID-19 vaccines, according to reports from the Centers for Disease Control and Prevention (CDC).
For Moderna vaccine, axillary lymphadenopathy ipsilateral to the vaccination arm was the second most frequently reported local reaction, with 11.6% of recipients aged 18 to 64 reporting it after the first dose and 16.0% after the second. The average duration of this lymphadenopathy was 1 to 2 days.
For the Pfizer-BioNTech COVID-19 vaccine, the CDC notes that reports of lymphadenopathy were imbalanced between the vaccine and the placebo groups and concluded that lymphadenopathy was likely related to the vaccine.
The average duration of lymphadenopathy was approximately 10 days.
Lymphadenopathy was reported within 2 to 4 days after vaccination for both groups of vaccines, notes the CDC.
However, the details of the cases reported by Dodelszon and his colleagues paint a somewhat different picture. For example, in case 1, the patient self-detected unilateral axillary lymphadenopathy 9 days after receiving the first dose of Pfizer-BioNTech vaccine. In case 3, the time between receipt of Moderna vaccine and detection of lymphadenopathy was 13 days.
In both of these cases, the duration was much longer than the average duration of 1 to 2 days noted by the CDC. The authors suggest that by taking the patient’s vaccination history, radiologists understand that the side effect can occur up to several weeks after the COVID-19 vaccination.
In cases 2 and 4, axillary lymphadenopathy was noted accidentally during the mammogram, so it is not known when the onset of this reaction occurred after receiving the COVID-19 vaccine.
The authors and Leung have disclosed no relevant financial relationship.
Clinical imaging. Published online January 18, 2021. Full text
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