Implications for the Head and neck cancer services
The impact of CVAL on clinical services and patients should not be
underestimated. In the 12-weeks period of our study, cCVAL cases
accounted for around 15% of all fast-tracked lymphadenopathy referrals.
With the ongoing expansion of the vaccination programme in the UK to
cover younger individuals and more second dose vaccinations, as well as
the upcoming rollout the Moderna mRNA vaccine, we predict that the
number of referrals will increase exponentially.14,21
Moreover, awareness of clinical features and course of CVAL is also
crucial for the radiologists involved in cancer diagnosis and follow-up,
and it should nowadays be recognised in the differential diagnosis of
cervical or axillary lymphadenopathy.9,10Lymphadenopathy detected clinically or in routine surveillance scans
might create a diagnostic and management dilemma for oncology
patients.10,21 Not only that CVALs could exhibit
abnormal features on ultrasound scans, but they are also shown to be
metabolically active on positron emission tomographic (PET) images, with
intensities similar to malignant
lymphadenopathy.8-10,21 A recent study by Cohen et al.
on PET-positive supraclavicular and axillary lymphadenopathy in 728
oncology patients, following the Pfizer/BioNTech vaccine, the incidence
of overall and supraclavicular CVAL was 36.5% and 8% respectively,
with supraclavicular CVAL being more commonly encountered after the
second dose (9.1%) compared to the first dose
(5.5%).21
Recommendations for appropriate management of CVAL should aim to strike
a balance between avoiding delayed cancer diagnoses, and minimizing
patient harm by invasive biopsies, unnecessary scans, and heightened
anxiety.8,10,22,24 All requests for imaging in the
H&N and breast regions, and referrals to the fast-track cancer
services, should include full information about COVID-19 vaccine status,
especially the dates, the site, the side, and the type of the vaccine.
For patients with pre-existing history of H&N malignancy,
administration of the vaccine on the contra-lateral side is recommended.
Recently published recommendations from institutions in north America
have advised timing H&N and breast imaging for before, or 4-6 weeks
after COVID-19 vaccination, and recommended considering a follow-up scan
4-12 weeks after the second dose of the
vaccine.7,10,11,24 Moreover, evidence from our current
study and previously published data demonstrated that a good proportion
of cervical CVAL usually fully resolve within 3-6
weeks.12,13,21 Therefore, it is not unreasonable for
primary care physicians to rationalise referrals to specialist cancer
clinics, and to prioritise cases with persistent lymphadenopathy beyond
3-6 weeks, or patients with other concerning features of
malignancy.10 Until more data becomes available, H&N
cancer MDTs should carefully advise against delaying vaccine
administration, and should weigh the risks and the benefits of timing
any H&N imaging to before or 4-6 weeks after the COVID-19 vaccination.