A Pragmatic Approach: Harvard Breast Imagers Share Approach to COVID-19-Vaccine Adenopathies

February 24, 2021
Whitney J. Palmer

The approach, based on ACR guidance, is intended to promote vaccine use while reducing patient anxiety and unnecessary imaging.

It has been a month since Weill Cornell Medicine radiologists first reported swollen lymph nodes linked to the COVID-19 vaccine that mimic breast malignancies. In that time, there has been much discussion about how breast imagers should proceed when they encounter these findings.

In an article published Feb. 23 in the American Journal of Roentgenology, three radiologists from Harvard Medical School threw their hats into the ring, offering specifics about how they are approaching this issue. They have based their protocol on the American College of Radiology BI-RADS Atlas.

Their goal, they said, is to reassure women about the vaccine while limiting any unnecessary testing and continuing to provide the best care available.

Related Content: COVID-19 Vaccine-Linked Adenopathies Could Mimic Breast Malignancies

“In this setting,” said the team led by Constance D. Lehman, M.D., Ph.D., director of breast imaging at Harvard Medical School, “we believe our model can avoid reducing or delaying vaccinations and avoid further reduced or delayed breast cancer diagnoses based on confusion amongst patients and/or their providers.”

For patients who present at Harvard with these unilateral axillary adenopathies, the team said they based their approach on the patient’s unique circumstances. Is the patient asymptomatic at screening? Does she have a symptomatic breast or axilla for diagnosis or has she recently received a cancer diagnosis in the pre- or peri-phase of treatment? In addition, the technologist confirms and documents vaccination status, first or second dose with administration dates, as well as vaccination side and location.

For specific instances, Lehman’s team offered this advice:

  • For swollen lymph nodes visualized on the side of vaccination via screening mammography or MRI within six weeks of administration, the team reports the finding as benign with no need for follow-up if the adenopathy dissipates within six weeks of the second dose. Patients receive a lay-language letter alerting them that the finding is a common post-vaccine reaction.
  • For lymph nodes a provider can feel, they recommend clinical follow-up using BI-RADS 2 (benign). However, if the swollen node persists after six weeks post-second dose, they suggest an axillary ultrasound.
  • For patients who recently received breast cancer diagnoses in the pre- or peri-treatment setting, Lehman’s team recommended timely imaging regardless of vaccination status.

The team did note, however, that for all patients who have swollen lymph nodes that linger after the post-vaccine six-week mark, axillary ultrasound should be performed. And, as other institutions have recommended, they also advised providers to include all vaccine information on patient intake forms.

While this guidance is intended to help institutions schedule screening mammograms and MRIs at optimal times for women who have received the COVID-19 vaccine, the team said they anticipate their approach could changes as the vaccination process continues to unfold.

“As we navigate through this phase of the pandemic with vaccination programs expanding, and as more data become available, we will continue to refine our patient management paradigm to guide best practices for our patients,” they said.

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