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Axillary adenopathy, or swelling under the armpit, has been reported by women after receiving the Pfizer-BioNTech and Moderna COVID-19 vaccines, but it is also a common symptom for breast cancer.
Therefore, physicians should consider the recent history of vaccination against COVID-19 in the differential diagnosis of patients who have unilateral axillary adenopathy, according to a new article.
“We have seen an increasing number of patients with swollen lymph nodes on only one side / armpit who have undergone routine mammography or ultrasound, and some women who have actually experienced these swollen nodules,” said author Katerina Dodelzon, MD, assistant professor of clinical radiology , Weill Cornell Medicine, New York City.
“Historically, swollen lymph nodes on one side are relatively rare and an uncommon occurrence on screening mammography – seen only 0.02% to 0.04% of the time – and it is a sign that alerts the radiologist to exclude the presence of malignancy on that side, “she added.
In an article published in Clinical Image, Dodelzon and colleagues describe four cases involving women who received the COVID-19 vaccine and then sought breast screening. In describing these cases, the authors sought to “inform the medical community to consider this diagnosis benign and self-resolving in what can be an alarming presentation of unilateral axillary adenopathy”.
They hope to cut down on unnecessary biopsies and help reassure patients.
Adenopathy has been reported in association with other vaccines, such as the Calmette-Guérin bacillus vaccine, flu vaccines and the human papillomavirus vaccine, commented Jessica WT Leung, MD, president of the Society of Breast Imaging (SBI).
“It is too early to say if there is anything different about the COVID-19 vaccines,” said Leung, who is also a professor of diagnostic radiology and vice president of breast imaging at the MD Anderson Cancer Center at the University of Texas, Houston , Texas.
“The two vaccines that are currently in use – Pfizer and Moderna – are mRNA vaccines and it is not known whether they will give a stronger immune response,” she said. “If the Johnson & Johnson and AstraZeneca vaccines are available, it will be interesting to see if they elicit such a strong response, since they are not mRNA vaccines. At the moment, we have no data to say one thing or another. “
Leung also noted that these latest reactions to vaccines may be getting more attention because “it’s related to COVID-19, and everything related to COVID-19 gets more attention.
“It may also be more noticeable due to the large number of people vaccinated in a short period of time in an effort to contain the pandemic, and this is not the case with other vaccines,” she said.
New recommendations from SBI
The SBI recently issued recommendations to doctors that women who have axillary adenopathy and who have recently been vaccinated on the same side where adenopathy occurs should be followed up for a few weeks to see if the lymph nodes return to normal, rather than undergoing a biopsy.
“Many clinics are now asking about the recent vaccination history and which side it was applied to,” said Dodelzon. She emphasized that women should feel empowered to share this story if they are not questioned.
“Informing your mammography technician or breast imager that you have recently been vaccinated, and on which side, will provide the breast imager with a more accurate context for interpreting the results,” she said.
In addition, the SBI recommends that, if possible, women schedule routine screening mammograms before the first dose of the COVID-19 vaccine or 4 to 6 weeks after the second dose to avoid a false positive result.
“We want to emphasize that screening mammography is very important and, if possible, schedule it around the vaccine,” said Leung. “But that may not be possible, since most of us have no choice when to get the vaccine.”
If it is not possible to reschedule the mammogram or vaccine, Leung recommends that women inform the service that they have recently received the COVID-19 vaccine. “We currently recommend follow-up in 4 to 12 weeks,” she said. “The swelling may subside earlier, perhaps even within 1-2 weeks, but we generally recommend waiting at least 4 weeks to catch most women.”
Differences between vaccines?
The frequency with which axillary adenopathy occurs as a side effect differs with the two vaccines COVID-19, according to reports from the Centers for Disease Control and Prevention (CDC).
For the Modern vaccine, ipsilateral axillary adenopathy 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% reporting it after the first dose. the second. The average duration of this adenopathy was 1 to 2 days.
For the Pfizer-BioNTech COVID-19 vaccine, the CDC notes that reports of adenopathy were unbalanced between the vaccine and placebo groups and concluded that adenopathy was plausibly related to the vaccine.
The average duration of adenopathy was approximately 10 days.
Adenopathy has been 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 colleagues paint a slightly different picture. For example, in case 1, the patient self-detected unilateral axillary adenopathy 9 days after receiving the first dose of the Pfizer-BioNTech vaccine. In case 3, the time between the reception of the Moderna vaccine and the detection of adenopathy was 13 days.
In both cases, the time was much longer than the average duration of 1 to 2 days observed by the CDC. The authors suggest that when making the patient’s vaccination history, radiologists understand that the side effect can occur up to several weeks after vaccination with COVID-19.
In cases 2 and 4, axillary adenopathy was accidentally observed during mammography, so it is not clear when the onset of this reaction occurred after the administration of the COVID-19 vaccine.
The authors and Leung have disclosed no relevant financial relationships.
Clin Imaging. Published online January 18, 2021. Full text
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