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Breast Cancer

Axillary Lymphadenopathy After COVID-19 Vaccination in a Woman With Breast Cancer

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.

1 Credit CME

JAMA

Published Online: December 23, 2021

JAMA Clinical Challenge

Article Information and Disclosures

Diana L. Lam, MD¹;

Meghan R. Flanagan, MD, MPH²

Author Affiliations

¹Department of Radiology, University of Washington School of Medicine, Seattle
²Department of Surgery, University of Washington School of Medicine, Seattle

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A 39-year-old healthy woman without family history of malignancy found a mass in her right breast at 38 weeks of pregnancy. Prior to delivery, she underwent diagnostic ultrasound of the right breast, which showed a possible mass in the location of the palpable lesion that was most consistent with a normal island of fibroglandular tissue. Follow-up mammogram and ultrasound of the right breast (without axillary evaluation) were performed 6 months later, which showed an irregular 17-mm mass with associated pleomorphic calcifications in the same area. Ultrasound-guided biopsy was performed. Pathology showed high-grade, estrogen receptor–positive ductal carcinoma in situ (DCIS). On postbiopsy physical examination, the patient had a palpable 2.5-cm right breast mass at the 3-o’clock position without palpable axillary lymphadenopathy.

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A 39-year-old healthy woman without family history of malignancy found a mass in her right breast at 38 weeks of pregnancy. Prior to delivery, she underwent diagnostic ultrasound of the right breast, which showed a possible mass in the location of the palpable lesion that was most consistent with a normal island of fibroglandular tissue. Follow-up mammogram and ultrasound of the right breast (without axillary evaluation) were performed 6 months later, which showed an irregular 17-mm mass with associated pleomorphic calcifications in the same area. Ultrasound-guided biopsy was performed. Pathology showed high-grade, estrogen receptor–positive ductal carcinoma in situ (DCIS). On postbiopsy physical examination, the patient had a palpable 2.5-cm right breast mass at the 3-o’clock position without palpable axillary lymphadenopathy.

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Article Information

Corresponding Author: Diana L. Lam, MD, Department of Radiology, University of Washington, Seattle Cancer Care Alliance, 1144 Eastlake Ave E, LG2-216, Seattle, WA 98109 (dllam@uw.edu).

Published Online: December 23, 2021. doi:10.1001/jama.2021.20010

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share her information.

References

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Edmonds CE , Zuckerman SP , Conant EF . Management of unilateral axillary lymphadenopathy detected on breast MRI in the era of COVID-19 vaccination. AJR Am J Roentgenol. 2021;217(4):831-834. doi:10.2214/AJR.21.25604 PubMed Google Scholar Crossref

Özütemiz C , Krystosek LA , Church AL , et al. Lymphadenopathy in COVID-19 vaccine recipients: diagnostic dilemma in oncologic patients. Radiology. 2021;300(1):E296-E300. doi:10.1148/radiol.2021210275 PubMed Google Scholar Crossref

Washington T , Bryan R , Clemow C . Adenopathy following COVID-19 vaccination. Radiology. 2021;299(3):E280-E281. doi:10.1148/radiol.2021210236 PubMed Google Scholar Crossref

Bettini E , Locci M . SARS-CoV-2 mRNA vaccines: immunological mechanism and beyond. Vaccines (Basel). 2021;9(2):147. doi:10.3390/vaccines9020147 PubMed Google Scholar Crossref

Lederer K , Castaño D , Gómez Atria D , et al. SARS-CoV-2 mRNA vaccines foster potent antigen-specific germinal center responses associated with neutralizing antibody generation. Immunity. 2020;53(6):1281-1295. doi:10.1016/j.immuni.2020.11.009 PubMed Google Scholar Crossref

Moderna COVID-19 Vaccine: Vaccines and Related Biological Products Advisory Committee Meeting, December 17, 2020. Accessed September 28, 2021. https://www.fda.gov/media/144434/download

Polack FP , Thomas SJ , Kitchin N , et al; C4591001 Clinical Trial Group. Safety and efficacy of the BNT162b2 mRNA Covid-19 vaccine. N Engl J Med. 2020;383(27):2603-2615. doi:10.1056/NEJMoa2034577 PubMed Google Scholar Crossref

Adin ME , Isufi E , Kulon M , Pucar D . Association of COVID-19 mRNA vaccine with ipsilateral axillary lymph node reactivity on imaging. JAMA Oncol. 2021;7(8):1241-1242. doi:10.1001/jamaoncol.2021.1794 PubMed Google Scholar Crossref

Becker AS , Perez-Johnston R , Chikarmane SA , et al. Multidisciplinary recommendations regarding post-vaccine adenopathy and radiologic imaging: Radiology scientific expert panel. Radiology. 2021;300(2):E323-E327. doi:10.1148/radiol.2021210436 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.