UCLA Radiological Sciences Proceedings

Background: In the setting of widespread COVID-19 vaccination and booster administration, there is an increased incidence of axillary lymphadenopathy identified during breast imaging.

Purpose: To investigate how breast imaging radiologists manage unilateral axillary lymphadenopathy (UAL) after a recent ipsilateral COVID-19 vaccination.

Methods: A 26-question survey was distributed to 12 California breast imaging facilities in June 2022.

Results: There were 10 responses to the survey (83% response rate). All respondents considered recent ipsilateral COVID-19 vaccination relevant to the interpretation of UAL. Seven respondents (70%) also  considered non-COVID-19 vaccinations relevant. All respondents documented recent COVID-19 vaccinations, but 4 (40%) had no information for other vaccines. Eight respondents (80%) delayed screening after COVID-19 vaccination during initial vaccination efforts, and 3 (30%) still required or suggested delaying screening at the time of the survey. Breast Imaging Reporting and Data System (BI-RADS) categorization for UAL with no abnormal findings in the ipsilateral breast varied by facility and modality. BI-RADS categorization for UAL previously assigned to BI-RADS 0 or associated with suspicious ipsilateral breast findings varied, but practices tended to demonstrate a high level of suspicion unless the UAL showed improvement on follow-up imaging. For unchanged UAL on initial follow-up, 7 (70%) assign BI-RADS 3, and 3 (30%) assign BI-RADS 4.

Conclusion: Despite available guidelines, there was no consensus approach to managing UAL after vaccination among academic and community-based breast imaging radiologists in California. Management was more uniform for a subset of patients perceived to be at higher risk for lymph node metastases, with most or all respondents recommending biopsy when there was  a suspicious finding in the ipsilateral breast, concurrent ipsilateral breast cancer, or concurrent malignant tumors not in the breast known to metastasize to the axilla.

We report a case of primary pulmonary anaplastic lymphoma kinase-positive anaplastic large cell lymphoma in a 38-year-old woman with a smoking and vaping history. The patient presented with hypoxemia and a history of shortness of breath, cough, and intermittent fevers. Initial imaging and pleural fluid studies suggested possible empyema. Despite being given antibiotics, her respiratory status continued to deteriorate and she was put on extracorporeal membrane oxygenation. Repeat imaging showed increased size of intrathoracic lymph nodes and perilymphatic pulmonary nodules. IV steroids were initiated after bronchoalveolar lavage revealed lipophages suggestive of e-cigarette, or vaping, product use-associated lung injury. A laboratory workup revealed no signs of rheumatologic disease, and negative cultures ruled out a bacterial or fungal cause of the disease. Because of these laboratory results and because the patient did not show clinical signs of improvement, a biopsy of the left lower lobe lymph node was performed. The patient was diagnosed with anaplastic lymphoma kinase-positive anaplastic large cell lymphoma based on the results of the biopsy. This case highlights the importance of suspecting pulmonary lymphoma in patients with a history of B-symptoms and compatible imaging findings, despite its rarity.

Kommerell diverticulum is the aneurysmal dilatation of the proximal descending aorta at the origin of an aberrant subclavian artery and may occur in either the left-sided or right-sided aortic arch. We report an unusual case of right-sided aortic arch with Kommerell diverticulum and concurrent agenesis of the left common carotid artery in a patient with progressive dysphagia to solid food. A brief overview of embryology, relevant anatomy, radiographic findings, and treatment options of Kommerell diverticulum are presented.

Soft tissue calcifications are a common imaging finding, but in the setting of a cosmetic augmentative injection and hypercalcemia, it may be pathognomonic for lipogranuloma, a delayed granulomatous inflammatory reaction to the injected foreign material. Although diagnosis of lipogranuloma is based on the results of histopathologic examination, the radiologist may play a key role in the clinical evaluation of challenging cases when patients do not report about nonmedical cosmetic procedures. If the treatment of granulomatosis-induced hypercalcemia is not timely, it may result in chronic renal disease and other comorbidities. We report a case of lipogranuloma with extensive subcutaneous calcification and hypercalcemia associated with cosmetic injection.