COVID-19 VACCINATION-ASSOCIATED LYMPHADENOPATHY: A DIAGNOSTIC CONUNDRUM IN LUNG CANCER STAGING

ABSTRACT

SESSION TITLE Lung Cancer Imaging Case Report Posters 2 SESSION TYPE Case Report Posters PRESENTED ON 10/19/2022 1245 pm - 0145 pm INTRODUCTION: The Coronavirus disease 2019 (COVID-19) pandemic affected millions of people globally, prompting the emergent need for an effective vaccine. Lymphadenopathy associated with COVID-19 vaccine is a recognized phenomenon that can present a diagnostic dilemma for staging thoracic malignancies. We present a case of post COVID-19 vaccination axillary lymphadenopathy complicating the staging process for a patient with newly diagnosed lung adenocarcinoma. CASE PRESENTATION A 64-year-old-male with chronic obstructive pulmonary disease, former smoker with a 20-pack-year smoking history was found to have a 1.7 cm solid nodule in the left upper lobe with irregular margins on low dose computed tomography (CT) scan of the chest for lung cancer screening. Fine needle aspiration of the nodule was done, and histopathology results were consistent with the diagnosis of adenocarcinoma. Patient then underwent fluorodeoxyglucose-positron emission tomography (FDG-PET) scan that showed a 16 mm nodule in the left upper pulmonary lobe with maximum standardized uptake value (SUVmax) of 5.3 and left axillary nodes measuring up to 8 mm with SUVmax of 4.4 concerning for metastatic disease. On further history, patient had received the Pfizer mRNA vaccination booster three days prior to undergoing the FDG-PET scan. Patient was evaluated by oncology and decision was made to treat with a 7-day course of prednisone 20 mg daily and to repeat FDG-PET scan. FDG-PET scan done four weeks later showed resolution of axillary lymphadenopathy. Patient was clinically staged as T1bN0M0 stage 1A and underwent robotic left upper lobe lingular-sparing lobectomy. DISCUSSION: In patients with thoracic malignancies, lymphadenopathy related to COVID-19 vaccination with avid FDG uptake on PET scan was reported in 29% of patients (2). The presentation of FDG avid lymphadenopathy creates a clinical challenge by confounding accurate cancer staging and leading to unnecessary workup (3). More importantly, detection of lymphadenopathy while staging lung cancer has crucial implications in the process of triaging patients to oncologic management in terms of candidacy for surgical resection (3). Currently, no consensus is available to guide management for incidental lymphadenopathy associated with COVID-19 vaccination in lung cancer patients. For this patient, we chose to treat with steroids and to obtain repeat imaging within 4 weeks of the original FDG-PET to not delay treatment planning. Repeat imaging showed resolution of the axillary lymphadenopathy and patient was able to undergo definitive treatment promptly. CONCLUSIONS: This case highlights the diagnostic challenge posed by COVID-19 lymphadenopathy in patients with newly diagnosed lung cancer and delineates our approach to navigating this challenge to avoid malignancy up-staging and treatment delay. Reference #1 Polack FP, Thomas SJ, Kitchin N, et al. Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine. N Engl J Med. 2020;383(27)2603-2615. doi10.1056/NEJMoa2034577 Reference #2 Nishino M, Hatabu H, Ricciuti B, Vaz V, Michael K, Awad MM. Axillary Lymphadenopathy After Coronavirus Disease 2019 Vaccinations in Patients with Thoracic Malignancy Incidence, Predisposing Factors, and Imaging Characteristics. J Thorac Oncol. 2022;17(1)154-159. doi10.1016/j.jthoCH.2021.08.761 Reference #3 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 DISCLOSURES No relevant relationships by Hadya Elshakh No relevant relationships by Stephen Karbowitz No relevant relationships by Gina Villani