Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies

L A Koehler, T C Haddad, D W Hunter, T M Tuttle, L A Koehler, T C Haddad, D W Hunter, T M Tuttle

Abstract

Axillary web syndrome (AWS) is a common condition occurring in up to 86% of patients following breast cancer surgery with ipsilateral lymphadenectomy of one or more nodes. AWS presents as a single cord or multiple thin cords in the subcutaneous tissues of the ipsilateral axilla. The cords may extend variable distances "down" the ipsilateral arm and/or chest wall. The cords frequently result in painful shoulder abduction and limited shoulder range of motion. AWS most frequently becomes symptomatic between 2 and 8 weeks postoperatively but can also develop and recur months to years after surgery. Education about and increased awareness of AWS should be promoted for patients and caregivers. Assessments for AWS should be performed on a regular basis following breast cancer surgery especially if there has been associated lymphadenectomy. Physical therapy, which consists of manual therapy, exercise, education, and other rehabilitation modalities to improve range of motion and decrease pain, is recommended in the treatment of AWS.

Keywords: Mondor’s disease; axillary lymphadenectomy; cording; rehabilitation.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Axillary web syndrome of the left axilla. Note: Multiple cords are visible in the mid axilla.
Figure 2
Figure 2
Axillary web syndrome of the right extremity. Note: Multiple cords are visible in the axilla and medial upper extremity with extension into the antecubital fossa.
Figure 3
Figure 3
(A) In order to make an accurate diagnosis of the presence or absence of AWS. The physical examination should be performed in a manner that is designed to facilitate the search for the problem. The first step is to gently but maximally extend the arm at the elbow and then gently but maximally abduct the affected arm at the shoulder. The person performing the evaluation both visualizes and palpates for cords in the locations indicated in (B). (B) This figure illustrates the locations (see black lines) in which a cord or cords may be found, including the axilla, down the upper arm from the axilla to and across the antecubital space, and rarely down the forearm to the base of the thumb. Abbreviation: AWS, axillary web syndrome.

References

    1. Koehler LA, Blaes AH, Haddad TC, Hunter DW, Hirsch AT, Ludewig PM. Research report movement, function, pain, and postoperative edema in axillary web syndrome. Phys Ther. 2015;95(10):1345–1353.
    1. Koehler LA, Hunter DW, Blaes AH, Haddad TC. Function, shoulder motion, pain, and lymphedema in breast cancer with and without axillary web syndrome: an 18-month follow-up. Phys Ther. 2018;98(6):518–527.
    1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg. 2001;181(5):434–439.
    1. Leidenius M, Leppänen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185(2):127–130.
    1. Koehler LA, Hunter DW. Lymphspiration: the axillary web and its lymphatic origin. Lymphology. 2016;49(4):185–191.
    1. Severeid K, Simpson J, Templeton B, York R, Hummel-Berry K, Leiserowitz A. Lymphatic cording among patients with breast cancer of melanoma referred to physical therapy. Rehabil Oncol. 2007;25(4):8–13.
    1. O’Toole J, Miller CL, Specht MC, et al. Cording following treatment for breast cancer. Breast Cancer Res Treat. 2013;140(1):105–111.
    1. Torres Lacomba M, Mayoral Del Moral O, Coperias Zazo JL, Yuste Sánchez MJ, Ferrandez JC, Zapico Goñi A. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat. 2009;117(3):625–630.
    1. Lauridsen MC, Overgaard M, Overgaard J, Hessov IB, Cristiansen P. Shoulder disability and late symptoms following surgery for early breast cancer. Acta Oncol. 2008;47(4):569–575.
    1. Bergmann A, Mendes VV, de Almeida Dias R, do Amaral E Silva B, da Costa Leite Ferreira MG, Fabro EA. Incidence and risk factors for axillary web syndrome after breast cancer surgery. Breast Cancer Res Treat. 2012;131(3):987–992.
    1. Baggi F, Nevola Teixeira LF, Gandini S, et al. Axillary web syndrome assessment using a self-assessment questionnaire: a prospective cohort study. Support Care Cancer. 2018;26(8):2801–2807.
    1. Lewis PA, Cunningham JE. Dynamic angular petrissage as treatment for axillary web syndrome occurring after surgery for breast cancer: a case report. Int J Ther Massage Bodywork. 2016;9(2):28–37.
    1. Figueira PVG, Haddad CAS, de Almeida Rizzi SKL, Facina G, Nazario ACP. Diagnosis of axillary web syndrome in patients after breast cancer surgery: epidemiology, risk factors, and clinical aspects: a prospective study. Am J Clin Oncol. 2018;41(10):992–996.
    1. Wyrick SL, Waltke LJ, Ng AV. Physical therapy may promote resolution of lymphatic coding in breast cancer survivors. Rehabil Oncol. 2006;24(1):29–34.
    1. Koehler LA. Axillary web syndrome and lymphedema, a new perspective. Natl Lymphedema Netw. 2006;18(3):9–10.
    1. Reedijk M, Boerner S, Ghazarian D, McCready D. A case of axillary web syndrome with subcutaneous nodules following axillary surgery. Breast. 2006;15(3):4101–413.
    1. Josenhans E. Physiotherapeutic treatment for axillary cord formation following breast cancer surgery. Pt Zeitschriftfür Physiother. 2007;59(9):868–878.
    1. Wariss BR, Costa RM, Pereira AC, Koifman RJ, Bergmann A. Axillary web syndrome is not a risk factor for lymphoedema after 10 years of follow-up. Support Care Cancer. 2017;25(2):465–470.
    1. Huang HC, Liu HH, Yin LY, Yeh CH, Tu CW, Yang CS. The upper-limb volumetric changes in breast cancer survivors with axillary web syndrome. Eur J Cancer Care (Engl) 2017;26(2):e12637.
    1. Cho Y, Do J, Jung S, Kwon O, Jeon JY. Effects of a physical therapy program combined with manual lymphatic drainage on shoulder function, quality of life, lymphedema incidence, and pain in breast cancer patients with axillary web syndrome following axillary dissection. Support Care Cancer. 2016;24(5):2047–2057.
    1. Furlan C, Matheus CN, Jales RM, Derchain S, Sarian LO. Vascular alterations in axillary and brachial vessels in patients with axillary web syndrome after breast cancer surgery. Lymphat Res Biol. 2018;16(3):287–293.
    1. Koehler L. Axillary Web Syndrome Ongoing Medical Evaluation [dissertation] Minnesota: University of Minnesota; 2013.
    1. Salmon RJ, Berry MG, Hamelin JP. A novel treatment for postoperative mondor’s disease: manual axial distraction. Breast J. 2009;15(4):381–384.
    1. Koehler LA, Hunter DW, Haddad TC, Blaes AH, Hirsch AT, Ludewig PM. Characterizing axillary web syndrome: ultrasonographic efficacy. Lymphology. 2014;47(4):156–163.
    1. Leduc O, Fumière E, Banse S, et al. Identification and description of the axillary web syndrome (AWS) by clinical signs, MRI and US imaging. Lymphology. 2014;47(4):164–176.
    1. Rashtak S, Gamble GL, Gibson LE, Pittelkow MR. From furuncle to axillary web syndrome: shedding light on histopathology and pathogenesis. Dermatology. 2012;224(2):110–114.
    1. Fourie WJ, Robb KA. Physiotherapy management of axillary web syndrome following breast cancer treatment: discussing the use of soft tissue techniques. Physiotherapy. 2009;95(4):314–320.
    1. Kepics JM. Physical therapy treatment of axillary web syndrome. Rehabil Oncol. 2004;22(1):21–22.
    1. Luz CMD, Deitos J, Siqueira TC, Palú M, Heck APF. Management of axillary web syndrome after breast cancer: evidence-based practice. Rev Bras Ginecol Obstet. 2017;39(11):632–639.
    1. Zuther JE, Norton S. Lymphedema Management The Comprehensive Guide for Practitioners. Vol. 4. New York, NY: Thieme; 2017.
    1. Thompson Buum HA, Koehler L, Tuttle TM. Venturing out on a limb: axillary web syndrome. Am J Med. 2017;130(5):e209–e210.
    1. Cheville AL, Tchou J. Barriers to rehabilitation following surgery for primary breast cancer. J Surg Oncol. 2007;95(5):409–418.

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