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SESSION TITLE: Using Imaging for Diagnosis Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaccine-related lymphadenopathy (VRL) is a local reaction like pain and swelling and has been associated with mRNA Pfizer/Moderna COVID-19 vaccines more than other vaccines (1). VRL can lead to false positives on nuclear imaging studies and confound the evaluation of patients during cancer screenings or treatments. The first COVID-19 VRL seen on imaging was reported in January 2021 in two patients undergoing breast mammogram (1). Since then, more cases have been reported in other nuclear imaging studies (1). Here, we report a case of subclinical unilateral VRL by FDG-PET 3 days after the patient received the Moderna COVID-19 booster. CASE PRESENTATION: 73-year-old male smoker returned for a 6 month follow up low dose CT for a 7 mm left upper lobe (LUL) nodule. He received the Moderna COVID-19 booster in the left deltoid the same day. The LUL nodule was found to be slightly larger at 8 mm and ipsilateral axillary nodes were not enlarged (Figure 1). He returned 3 days later for FDG-PET which showed mild uptake in the LUL nodule (SUV 1.8) and hypermetabolic left axillary nodes (Figure 2). COVID booster date/laterality was documented, and the FDG-PET summary included a comment about a possible inflammatory response to the booster. A repeat low dose chest CT in 3 months was recommended. DISCUSSION: After the first reported cases of COVID-19 VRL, recommendations were published to aid providers in evaluating clinical and imaging abnormalities. The Society of Breast Imaging recommended the "wait and watch” approach for unilateral COVID-19 VRL within the preceding 4 weeks only if appropriate in the clinical context;repeat exam in 4-12 weeks and lymph node sampling if VRL persists (1). All other screening exams should be scheduled prior to the first dose of the COVID-19 vaccine or 4-6 weeks after the second dose (1). Radiology experts recommended: 1) imaging screening exam to be scheduled at least 6 weeks after the final vaccination, 2) administer the vaccine in the arm contralateral to any primary or suspected cancer, and 3) record the vaccine date, injection site, and type (1). Months later, they recommended that in patients with a known vaccination history, ipsilateral VRL can be managed conservatively without further imaging (1). CONCLUSIONS: The current recommended COVID-19 Pfizer/Moderna vaccination consists of a two-dose primary series and a booster dose 5 months later. In a recent single-center study in oncologic patients in Israel who had FDG-PET after the Pfizer booster, the duration of unilateral axillary VRL was found to be shorter than the first and second dose (2). Therefore it has been suggested that FDG-PET can be scheduled 2 weeks after the third dose (3). Whether there will be any changes in the guidelines to accommodate this finding remains to be seen. More studies are needed to best inform clinicians because COVID-19 vaccinations will continue for the foreseeable future. Reference #1: 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):843-852. doi:10.1016/J.JACR.2021.03.001 Reference #2: Cohen D, Hazut Krauthammer S, Wolf I, Even-Sapir E. A sigh of relief: vaccine-associated hypermetabolic lymphadenopathy following the third COVID-19 vaccine dose is short in duration and uncommonly interferes with the interpretation of [18F]FDG PET-CT studies performed in oncologic patients. Eur J Nucl Med Mol Imaging. 2021. doi:10.1007/S00259-021-05579-7 Reference #3: Thaweerat W. Optimization of FDG PET study after mRNA COVID-19 vaccination to reduce the interference of vaccine-associated hypermetabolic lymphadenopathy. Ann Nucl Med 2021 363. 2022;36(3):327-328. doi:10.1007/S12149-021-01712-6 DISCLOSURES: No relevant relationships by Anh Nguyen No relevant relationships by Perry Nystrom
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Background-Aim: Vaccination is an established but uncommon cause of unilateral axillary lymphadenopathy. Early clinical experience with coronavirus disease (COVID-19) vaccination suggests that such vaccines cause a significantly higher incidence of lymphadenopathy detected on 18F-FDG PET/CT than other vaccines. Guidelines are needed to properly manage unilateral axillary lymphadenopathy in the era of COVID-19 vaccination and to avoid benign reactive node biopsies. The differential diagnosis for unilateral axillary lymphadenopathy is broad and includes benign and malignant etiologies: among the malignant causes, most cases are due to lymphoma or breast cancer. Methods: Shortly after the initiation of vaccination of frail cancer patients, a significant number of cases of unilateral axillary lymphadenopathy were incidentally detected in asymptomatic cancer patients who underwent 18F-FDG PET/CT for disease diagnosis or follow-up. Results: After deltoid vaccination, significant uptake of 18F-FDG can be observed in the axillary (level 1, 2 and 3), supraclavicular and cervical lymph nodes. The extent of FDG absorption varies with temporal proximity to vaccination, from intense immediately after administration to barely noticeable after a longer period of time (SUVmax range: 2.1-16.2). Also, after vaccination, lymph nodes may show variable morphology on CT, although they are usually normal or show only a slightly thickened cortex with retained fat hilum. In our department, we have added questions regarding the date and laterality of COVID-19 vaccine administration to our intake form prior to all PET/CT exams, to avoid misjudgment in cancer patients. Conclusions: We believe that isolated unilateral axillary lymphadenopathy detected on PET and associated with the ipsilateral vaccine arm is related to the COVID-19 vaccine, if within a few weeks of either dose. As data from clinical trials of the COVID-19 vaccine suggest that the first two FDA-approved vaccines are highly immunogenic, there is a higher percentage of patients who notice both local and systemic reactions than other vaccines. Careful management should avoid unnecessary biopsies of vaccine-related benign reactive lymphadenopathy. Vaccine ipsilateral axillary adenopathy of the arm should be considered as a potential reactive process that nuclear physicians should be familiar with. If a patient has known cancer with laterality, such as breast cancer, most melanomas, sarcoma of the extremities, lung cancer (particularly in the upper lobe), or head and neck cancer, the vaccine should be given in the arm. contralateral to avoid potentially confounding FDG uptake into lymph nodes on the cancer side. However, if active axillary lymph nodes are identified in the ipsilateral vaccinated arm, axillary ultrasound at 4 weeks is recommended.
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Introduction: Evaluation of the effectiveness of diagnostic computed tomography of the chest in differentiating between coronavirus 2019 (COVID-19) ground glass opacities and other reasons of ground glass opacities (GGO) not related to COVID-19. Place and Duration: In the department of Radiology, Miangul Abdul Haq Jahenzeb Kidney Hospital Swat for six-months duration from March 2021 to August 2021. Methods: 90 total covid-19 confirmed patients by RT-PCR having GGO (53 males and 37 females, with 47.20 ± 15.10 years mean age) and 110 patients (63 males and 47 males) who were confirmed GGO on chest CT but not due to Covid-19 were selected for the study. The experienced radiologists studied all chest CT scans after removing all descriptive information from the images. They tested negative or positive for COVID-19 and noted other features of CT of the lungs, including laterality, distribution pattern and lobe involvement. The laboratory results and clinical data were documented. Results: This study consisted of 90 COVID19 patients and 100 non-COVID-19 with ground glass opacities on CT chest. In terms of age;no statistically significant alteration was noted amid the 2 groups (p-value = 0.129). Non-COVID-19 cases with GGO;6 patients have atypical bacterial pneumonia, 42 patients have GGO after viral pneumonia, 14 patients have interstitial pneumonia, 5 patients have PJP, eosinophilic pneumonia in 3 patients, 9 patients have hypersensitivity pneumonia, 6 patients have drug-induced lung injury, 5 patients have pulmonary alveolar hemorrhage and pulmonary edema in 11 patients (cardiogenic and noncardiogenic). Conclusion: Chest CT is rational for distinguishing ground glass opacities form COVID-19 and non-COVID-19 reasons, with less specificity for distinguishing COVID-19 from viral pneumonia and intermediate specificity for distinguishing COVID-19 from other reasons of ground glass opacities.
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Background: Current research comparing CPR-associated injuries between those receiving LUCAS device and manual CPR has primarily focused on patients who suffered out-of-hospital cardiac arrest. During the SARS-CoV-2 pandemic, more hospitals leveraged mechanical CPR devices to provide distant yet high quality chest compressions for in-hospital cardiac arrest (IHCA) patients. We sought to investigate autopsy thoracic injury patterns in in-hospital non-traumatic cardiac arrests, comparing traditional manual compressions with the mechanical LUCAS device compressions. Design: Autopsies were screened for a history of in-hospital cardiopulmonary resuscitation in the absence of prior traumatic injuries at a single, large quaternary care center from 1/1/2018 to 06/30/2021. 20 received LUCAS compressions and 40 received manual compressions. Student's T-Tests were used to compare means for continuous variables, while chi-squared and Fischer's exact tests were used for categorical variables. An alpha of 0.05 was chosen as the threshold for statistical significance. Results: A statistically significant decrease in the rate of sternal fractures and rate of multiple sternal fractures during mechanical CPR was found. A statistically significant increase in other soft tissue injuries, such as pleural wall or lung injuries was seen in mechanical CPR cases, while an increased rate of bilateral rib fractures was noted in manual compression cases. Conversely, no difference in the number or laterality of rib fractures were noted. There was no significant difference in age, biological sex, or rate of scoliosis or kyphosis between cohorts. Results are listed in table 1. (Table Presented) Little research has looked at the injury patterns of mechanical CPR in the IHCA patient population. These results point to a potential difference in thoracic injury patterns from manual compressions when compared to LUCAS device compressions. The statistically significant decrease in sternal fractures with mechanical compressions is noteworthy. Conversely, the increase in other soft tissue injury demands further examination. The decrease in bilateral rib fractures with LUCAS use suggests that placement of the device may play a role in the epidemiology of rib injuries, but not in the number of ribs injured. Further research should examine rib injuries in more detail, and quantify additional comorbidities in both survivors and non-survivors of cardiac arrest.