Axillary lymphadenopathy at the time of COVID-19 vaccination: ten recommendations from the European Society of Breast Imaging (EUSOBI)

Abstract

Unilateral axillary lymphadenopathy is a frequent mild side effect of COVID-19 vaccination. European Society of Breast Imaging (EUSOBI) proposes ten recommendations to standardise its management and reduce unnecessary additional imaging and invasive procedures: (1) in patients with previous history of breast cancer, vaccination should be performed in the contralateral arm or in the thigh; (2) collect vaccination data for all patients referred to breast imaging services, including patients undergoing breast cancer staging and follow-up imaging examinations; (3) perform breast imaging examinations preferentially before vaccination or at least 12 weeks after the last vaccine dose; (4) in patients with newly diagnosed breast cancer, apply standard imaging protocols regardless of vaccination status; (5) in any case of symptomatic or imaging-detected axillary lymphadenopathy before vaccination or at least 12 weeks after, examine with appropriate imaging the contralateral axilla and both breasts to exclude malignancy; (6) in case of axillary lymphadenopathy contralateral to the vaccination side, perform standard work-up; (7) in patients without breast cancer history and no suspicious breast imaging findings, lymphadenopathy only ipsilateral to the vaccination side within 12 weeks after vaccination can be considered benign or probably-benign, depending on clinical context; (8) in patients without breast cancer history, post-vaccination lymphadenopathy coupled with suspicious breast finding requires standard work-up, including biopsy when appropriate; (9) in patients with breast cancer history, interpret and manage post-vaccination lymphadenopathy considering the timeframe from vaccination and overall nodal metastatic risk; (10) complex or unclear cases should be managed by the multidisciplinary team.

Frequency and Outcomes of Ipsilateral Axillary Lymphadenopathy After COVID-19 Vaccination

“…However, follow-up for patients with risk factors is important to identify the small number of malignant neoplasms reported by other authors. 2 , 5 , 6 …”

“… 1 , 2 , 3 Expert guidelines advise IAL management based on patient symptoms, imaging results, and risk factors. 2 , 4 , 5 We report on the frequency and outcomes of breast imaging–identified IAL after recent COVID-19 vaccination.…”

Regional Lymphadenopathy Following COVID-19 Vaccination in Patients with or Suspicious of Breast Cancer: A Quick Summary of Current Key Facts and Recommendations

“…In asymptomatic healthy women without risk of metastatic lymphadenopathy, imaging–detected unilateral axillary lymphadenopathy on the same side of the recent COVID-19 vaccination (i.e., within 12 weeks) should be classified as a benign finding, and no further workup should be recommended [ 11 ]. According to published articles on COVID-19 vaccine-associated lymphadenopathies, the most frequently observed morphological characteristics include enlarged lymph nodes with uniform cortical thickening > 3 mm and increased numbers of enlarged lymph nodes [ 12 13 ].…”

The Optimal Timing of Imaging Examinations in Patients With Newly Diagnosed Breast Cancer in the COVID-19 Pandemic Era

“…As Dr. Pathum Sookaromdee and colleague mentioned [ 2 ], the recommendation of avoiding imaging for the first 10 weeks after COVID-19 vaccination can be applied for healthy individuals without a high risk of metastatic lymphadenopathy since COVID-19 vaccine-associated lymphadenopathy spontaneously resolves with time, contrary to metastatic lymphadenopathy. The National Comprehensive Cancer Network recommends scheduling screening examinations before the first or 4–6 weeks after the second dose of the COVID-19 vaccine [ 5 ], and the European Society of Breast Imaging recommends imaging in cases of axillary lymphadenopathy at least 12 weeks from the second vaccine dose in patients without a history of breast cancer [ 6 ]. In the recent prospective investigation which evaluated temporal changes in COVID-19 vaccine-associated lymphadenopathy in healthy volunteers, persistent lymphadenopathy even after 12 weeks was observed in a significant number of women [ 7 ].…”

“…In conclusion, our study did not satisfactorily present clinical or imaging variables for the diagnosis of COVID-19 vaccine-associated reactive lymphadenopathy to be distinguished from malignant lymphadenopathy. We believe that necessary imaging examinations at breast clinics should be performed without delay owing to vaccination, and to avoid this diagnostic dilemma, patients with newly diagnosed breast cancer should be educated and encouraged to receive vaccination in the contralateral arm or thigh, according to the recent guidelines [ 5 6 ]. Clinicians should be aware of the overlapping image features of reactive and malignant lymphadenopathy.…”