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10th December 2021
The presence of subclinical axillary lymphadenopathy (sLAD) on mammography was significantly more likely among women who had received a COVID-19 vaccination, indicating that they should either delay screening or schedule visits before vaccination. This was the finding of a retrospective study by a team from the Baylor University Medical Center, Dallas, USA.
The term lymphadenopathy refers to lymph nodes that are abnormal in size and axillary lymphadenopathy, describes changes in the size and consistency of lymph nodes in the armpit. There are several potential causes of unilateral axillary lymphadenopathy including breast cancer and which therefore warrants further diagnostic investigations if these changes are observed during screening. Although the presence of sLAD has been observed in women who have received a COVID-19 vaccination, what remains uncertain, is the proportion of vaccinated women that will develop these lesions after either the Pfizer or Moderna vaccines.
Based on case reports of sLAD in vaccinated women, for the present study, the authors investigated the prevalence of the condition in all women who had attended a breast screening programme since December 2020 until April 2021. Data from medical records included the woman’s vaccination status, the vaccine received and the presence or absence of sLAD on mammography. The researchers cross-referenced prior imaging for all women to ensure that there was no baseline evidence of an axillary lymphadenopathy and excluded women who had presented for diagnostic mammography for a palpable axillary lump or pain and those with a history of breast cancer.
In total, 1027 women with a mean age range of 56.4 to 63.7 years were included in the analysis. There were 158 who received the Moderna vaccine, 144 (Pfizer) and 725 who had not been vaccinated. From these 1027 women, 43 (4.2%) had an sLAD; 3.3% of those who had been vaccinated compared to 0.9% who were unvaccinated and this difference was statistically significant (p < 0.01).
When comparing the two vaccines, the incidence of unilateral axillary lymphadenopathy was higher among those who received the Pfizer vaccination (13.2% vs 9.5%, Pfizer vs Moderna). Among the 43 women with sLAD and who were recalled after screening, vaccine induced sLAD was more likely to have resolved when re-scanned an average of 46.5 days since their COVID-19 vaccination.
The authors concluded that women who have received a COVID-19 vaccination within 8 weeks of their screening mammogram, were significantly more likely to present with a subclinical axillary lymphadenopathy and that this could result in unnecessary further diagnostic workload. They suggested that providers should either delay screening mammograms by 8 weeks in patients who have been vaccinated or that screening should be undertaken before vaccination to avoid unnecessary follow-up.
Raj S et al. COVID-19 vaccine-associated subclinical axillary lymphadenopathy on screening mammogram Acad Radiol 2021
21st September 2021
Detection of breast cancer requires that mammography scans are interpreted correctly and thus guidelines on screening require that robust quality control and quality assurance are in place. Although an assessment of performance against standards can be achieved through audits, such audits offer little insight of the diagnostic skills of individual radiologists. The use of on-line self-assessment, using pre-diagnosed mammograms, offers a means of identifying any knowledge gaps and could serve as an important educational tool.
An on-line self-assessment tool was adopted by the Italian Society of Medical Radiology in 2018 as part of a national on-line self-assessment program for interpretation of mammograms and the results have published. The test set was a collection of 24 pathology-confirmed cancers combined with 108 mammograms which were reported on as negative after double reading. All cases were acquired with full-field digital mammography and came from women aged 50 – 69 years, who represent those at average risk of breast cancer. For the assessment, the society determined a pass threshold for sensitivity of 62% (amounting to at least 15/24 cancers correctly identified) and 86% specificity (93/108 negative mammograms correctly identified). The on-line self-assessment was posted on a dedicated website and upon registration, radiologists provided information on demographics such as age, gender, place of work (public or private sector), years of breast imaging experience and a qualitative self-judgement of mammography interpretative skills as “beginner”, “average” and “expert”. As with usual mammography practice, the radiologists were required to submit a dichotomous diagnosis (i.e., positive/negative) for every case. In addition to reporting on the radiologist’s success in the test, the authors employed regression analysis and odds ratios to identify the most important predictor variables for diagnostic accuracy.
A total of 685 radiologists registered for the on-line self-assessment and 49.9% (342) with a mean age of 46 years (69% female), completed test. Among those completing, two-thirds (64%) self-judged their interpretative skills as “average” and respondents had a median of 8 years breast imaging experience although 38.3% reporting having more than 10 years’ experience. Participants reported a median number of 1501 mammographic interpretations per year and the majority (68.7%) worked in the public rather than private sector.
When examining the proportion who successfully completed the assessment, only 28.7% of radiologists (98/342) passed on their first attempt. After an initial failure, 138 of the remaining 244 radiologists, re-took the test of whom, only 35.5% (49/138) passed. In fact, the authors reported that overall, only 44.2% (151/342) of radiologists who completed the on-line self-assessment were successful.
Using regression analysis, a significant association for diagnostic accuracy was found only for the assessment of > 3,000 mammograms per year compared to < 1,000 (Odds ratio, OR = 3.88, 95% CI 1.07 – 14.14, p = 0.04) and working the in public rather than private sector (OR = 1.65). Other variables such as age, self-judged interpretative skills and years of breast imaging experience had no significant effect.
The authors concluded that their study suggested that breast imaging experience does not guarantee diagnostic accuracy in screening reading. They also noted that their on-line self-assessment test could be included as a criterion for the accreditation process of breast units.
Brancato B et al. Mammography self?evaluation online test for screening readers: an Italian Society of Medical Radiology (SIRM) initiative. Eur Radiol 2021