Challenging Axillary Lymph Nodes on PET/CT in Cancer Patients throughout COVID-19 Vaccination Era


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Abstract

Background:The unexpected detection of axillary lymphadenopathy (AxL) in cancer patients (pts) represents a real concern during the COVID-19 vaccination era. Benign reactions may take place after vaccine inoculation, which can mislead image interpretation in patients undergoing F-18-FDG, F-18-Choline, and Ga-68-DOTATOC PET/CT. They may also mimic loco-regional metastases or disease. We assessed PET/CT findings after COVID-19 first dose vaccination in cancer patients and the impact on their disease course management.

Methods:We evaluated 333 patients undergoing PET/CT (257 F-18-FDG, 54 F-18-Choline, and 23 Ga-68 DOTATOC) scans after the first vaccination with mRNA vaccine (Pfizer-BioNTech) (study group; SG). The uptake index (SUVmax) of suspected AxL was defined as significant when the ratio was > 1.5 as compared to the contralateral lymph nodes. Besides, co-registered CT (Co-CT) features of target lymph nodes were evaluated. Nodes with aggregate imaging positivity were further investigated.

Results:Overall, the prevalence of apparently positive lymph nodes on PET scans was 17.1% during the vaccination period. 107 pts of the same setting, who had undergone PET/CT before the COVID-19 pandemic, represented the control group (CG). Only 3 patients of CG showed reactive lymph nodes with a prevalence of 2.8% (p < 0.001 as compared to the vaccination period). 84.2% of SG patients exhibited benign characteristics on co-CT images and only 9 pts needed thorough appraisal.

Conclusion:The correct interpretation of images is crucial to avoid unnecessary treatments and invasive procedures in vaccinated cancer pts. A detailed anamnestic interview and the analysis of lymph nodes’ CT characteristics, after performing PET/CT, may help to clear any misleading diagnosis.

About the authors

Alessia Giordano

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Rosj Gallicchio

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Mariarita Milella

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Rebecca Storto

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Anna Nardelli

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Teresa Pellegrino

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Antonio Nappi

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Email: info@benthamscience.net

Michele Di Cosola

Department of Head and Neck Pathology, University of Foggia,

Email: info@benthamscience.net

Giovanni Storto

Department of Nuclear Medicine, IRCCS CROB Referral Cancer Center of Basilicata

Author for correspondence.
Email: info@benthamscience.net

References

  1. Viscusi WK. Pricing the global health risks of the COVID-19 pandemic. J Risk Uncertain 2020; 61(2): 101-28. doi: 10.1007/s11166-020-09337-2 PMID: 33162671
  2. Jabłońska K, Aballéa S, Toumi M. The real-life impact of vaccination on COVID-19 mortality in Europe and Israel. Public Health 2021; 198: 230-7. doi: 10.1016/j.puhe.2021.07.037 PMID: 34482101
  3. Tanne JH. COVID-19: FDA approves Pfizer-BioNTech vaccine in record time. BMJ-Brit Med J 2021; 374: n2096.
  4. Iacobucci G. COVID-19: FDA set to grant full approval to Pfizer vaccine without public discussion of data. BMJ-Brit Med J 2021; 374: n2086.
  5. Su S, Du L, Jiang S. Learning from the past: Development of safe and effective COVID-19 vaccines. Nat Rev Microbiol 2021; 19(3): 211-9. PMID: 33067570
  6. Fanciullino R, Ciccolini J, Milano G. COVID-19 vaccine race: watch your step for cancer patients. Br J Cancer 2021; 124(5): 860-1. PMID: 33288844
  7. Rodríguez-Alfonso B, Ruiz Solís S, Silva-Hernández L, et al. 18F-FDG-PET/CT in SARS-CoV-2 infection and its sequelae. Rev Esp Med Nucl Imagen Mol 2021; 40: 299-309.
  8. Ahn RW, Mootz AR, Brewington CC, Abbara S. Axillary lymphadenopathy after mRNA COVID-19 vaccination. Radiol Cardiothorac Imaging 2021; 3(1): e210008. PMID: 33778667
  9. McIntosh LJ, Bankier AA, Vijayaraghavan GR, Licho R, Rosen MP. COVID-19 vaccination-related uptake on FDG PET/CT: An emerging dilemma and suggestions for management. AJR Am J Roentgenol 2021; 217(4): 975-83. doi: 10.2214/AJR.21.25728 PMID: 33646823
  10. Seely JM, Barry MH. The Canadian society of breast imaging/Canadian association of radiologists’ recommendations for the management of axillary adenopathy in patients with recent COVID-19 vaccination. Can Assoc Radiol J 2021; 72: 601-2. doi: 10.1177/0846537121998949 PMID: 34311551
  11. Lehman CD, D’Alessandro HA, Mendoza DP, Succi MD, Kambadakone A, Lamb LR. Unilateral lymphadenopathy after COVID-19 vaccination: A practical management plan for radiologists across specialties. J Am Coll Radiol 2021; 18(6): 843-52. doi: 10.1016/j.jacr.2021.03.001 PMID: 33713605
  12. Storto G, Nicolai E, Salvatore M. 18FFDG-PET-CT for early monitoring of tumor response: when and why. Q J Nucl Med Mol Imaging 2009; 53(2): 167-80. PMID: 19293765
  13. Storto G, De Renzo A, Pellegrino T, et al. Assessment of metabolic response to radioimmunotherapy with 90Y-ibritumomab tiuxetan in patients with relapsed or refractory B-cell non-Hodgkin lymphoma. Radiology 2010; 254(1): 245-52. doi: 10.1148/radiol.09090603 PMID: 20032155
  14. Treglia G. Diagnostic performance of 18F-FDG PET/CT in infectious and inflammatory diseases according to published meta-analyses. Contrast Media Mol Imaging 2019; 2019: 1-12. doi: 10.1155/2019/3018349 PMID: 31427907
  15. Casali M, Lauri C, Altini C, et al. State of the art of 18F-FDG PET/CT application in inflammation and infection: a guide for image acquisition and interpretation. Clin Transl Imaging 2021; 9(4): 299-339. doi: 10.1007/s40336-021-00445-w PMID: 34277510
  16. Oprea-Lager DE, Vincent AD, van Moorselaar RJA, et al. Dual-phase PET-CT to differentiate 18FFluoromethylcholine uptake in reactive and malignant lymph nodes in patients with prostate cancer. PLoS One 2012; 7(10): e48430. doi: 10.1371/journal.pone.0048430 PMID: 23119014
  17. Weiler-Sagie M, Half EE. 68GaGa-DOTA-TATE uptake due to COVID-19 vaccination. Eur J Nucl Med Mol Imaging 2021; 48(11): 3743-4. doi: 10.1007/s00259-021-05414-z PMID: 34021394
  18. Thomassen A, Lerberg Nielsen A, Gerke O, Johansen A, Petersen H. Duration of 18F-FDG avidity in lymph nodes after pandemic H1N1v and seasonal influenza vaccination. Eur J Nucl Med Mol Imaging 2011; 38(5): 894-8. doi: 10.1007/s00259-011-1729-9 PMID: 21340453
  19. Smith MV, Yang M. Reactive axillary lymphadenopathy to COVID-19 vaccination on 18 F-FDG PET/CT. J Nucl Med Technol 2021; 49(3): 286-7. doi: 10.2967/jnmt.121.262008 PMID: 33820864
  20. Nawwar AA, Searle J, Hopkins R, Lyburn ID. False-positive axillary lymph nodes on FDG PET/CT resulting from COVID-19 immunization. Clin Nucl Med 2021; 46(12): 1004-5. doi: 10.1097/RLU.0000000000003657 PMID: 33883486
  21. Schroeder DG, Jang S, Johnson DR, et al. Frequency and characteristics of nodal and deltoid FDG and (11)C-Choline uptake on PET performed after COVID-19 vaccination. AJR Am J Roentgenol 2021; 217(5): 1206-16. doi: 10.2214/AJR.21.25928 PMID: 34009000
  22. Eifer M, Eshet Y. Imaging of COVID-19 vaccination at FDG PET/CT. Radiology 2021; 299(2): E248. doi: 10.1148/radiol.2020210030 PMID: 33507123
  23. Cocco G, Delli Pizzi A, Fabiani S, et al. Lymphadenopathy after the anti-COVID-19 vaccine: multiparametric ultrasound findings. Biology (Basel) 2021; 10(7): 652. doi: 10.3390/biology10070652 PMID: 34356507
  24. Tan NJH, Tay KXJ, Wong SBJ, Nga ME. COVID‐19 post‐vaccination lymphadenopathy: Report of cytological findings from fine needle aspiration biopsy. Diagn Cytopathol 2021; 49(12): E467-70. doi: 10.1002/dc.24863 PMID: 34432391
  25. Albano D, Bertagna F, Alongi P, et al. Prevalence of interstitial pneumonia suggestive of COVID-19 at 18F-FDG PET/CT in oncological asymptomatic patients in a high prevalence country during pandemic period: a national multi-centric retrospective study. Eur J Nucl Med Mol Imaging 2021; 48(9): 2871-82. doi: 10.1007/s00259-021-05219-0 PMID: 33560453
  26. Shin M, Hyun CY, Choi YH, Choi JY, Lee KH, Cho YS. COVID-19 vaccination-associated lymphadenopathy on FDG PET/CT: Distinctive features in adenovirus-vectored vaccine. Clin Nucl Med 2021; 46(10): 814-9. doi: 10.1097/RLU.0000000000003800 PMID: 34115709
  27. Eshet Y, Tau N, Alhoubani Y, Kanana N, Domachevsky L, Eifer M. Prevalence of increased FDG PET/CT axillary lymph node uptake beyond 6 weeks after mRNA COVID-19 vaccination. Radiology 2021; 300(3): E345-7. doi: 10.1148/radiol.2021210886 PMID: 33904778
  28. Su N, Wiefels C, Klein R, Zeng W, Abbaspour F. Intensity of hypermetabolic axillary lymph nodes in oncologic patients in relation to timeline following COVID-19 vaccination. J Med Imaging Radiat Sci 2022; 53(2): 219-25. doi: 10.1016/j.jmir.2022.01.004 PMID: 35131216
  29. Weissman J, Bartel T. COVID-19 messenger ribonucleic acid vaccination and abnormal radiopharmaceutical uptake in the axilla visualized on 68Ga-DOTATATE positron-emission tomography/computed tomography. World J Nucl Med 2021; 20(4): 392-4. doi: 10.4103/wjnm.wjnm_54_21 PMID: 35018159
  30. Tsumura Y, Asakura K, Takahashi I, et al. New mimic of relapse or regional lymph node metastasis in a cancer survivor: A case of mRNA COVID-19 vaccine-induced lymphadenitis with high FDG uptake. Immunol Med 2021; 16: 1-3. PMID: 34915816
  31. Kirienko M, Biroli M, Pini C, Gelardi F, Sollini M, Chiti A. COVID-19 vaccination, implications for PET/CT image interpretation and future perspectives. Clin Transl Imaging 2022; 10(6): 631-42. doi: 10.1007/s40336-022-00521-9 PMID: 35992042
  32. Sollini M, Gelardi F, Biroli M, Chiti A. Patients’ findings after COVID-19 infection and vaccinations: What to expect from 18FFDG PET/CT. Eur J Nucl Med Mol Imaging 2022; 49(3): 791-5. doi: 10.1007/s00259-021-05652-1 PMID: 34928399
  33. Calabria F, Bagnato A, Guadagnino G, et al. COVID-19 vaccine related hypermetabolic lymph nodes on PET/CT: Implications of inflammatory findings in cancer imaging. Oncol Res 2023; 31(2): 117-24. doi: 10.32604/or.2023.027705 PMID: 37304242
  34. Zoughbor SH, AlRasbi Z, Yousif A, et al. Unilateral axillary lymphadenopathy in cancer patients post-COVID-19 vaccination: Review and case series. Case Rep Oncol 2023; 16(1): 188-203. doi: 10.1159/000529913 PMID: 37033700

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