Axillary web syndrome is not a risk factor for lymphoedema after 10 years of follow-up

[Update of indications and techniques for the management of lymphedema after breast cancer surgery]

OBJECTIVES

Upper limb lymphedema secondary to breast cancer treatment is the leading cause of lymphedema in France. Despite improved surgical practices and de-escalation of radiotherapy, the risk of lymphedema after breast cancer still affects 5-20% of patients, with this variation depending on the measurement method used and the population studied. Lymphedema has a negative impact on quality of life and body image, and their possible occurrence remains a major concern for all women treated for breast cancer. The Sénologie Commission of the Collège national des gynécologues et obstétriciens français (CNGOF) asked four specialists in breast surgery or lymphology to prepare a summary on the prevention, medical and surgical management of lymphedema after breast cancer treatment, and to discuss the medical and surgical innovations currently being evaluated.

METHODS

This synthesis was based on national and international guidelines on the management of upper limb lymphedema after breast surgery and a recent review of the literature focusing on the years 2020-2023.

RESULTS

From a preventive point of view, the restrictive instructions imposed for a long time (reduction in physical activity or the carrying of loads, air travel, exposure to the sun or cold, etc.) have altered patients' quality of life and should no longer be recommended. A good understanding of risk factors enables us to target preventive actions. Examples include obesity, a sedentary lifestyle, axillary clearance, radiotherapy of the axillary fossa in addition to axillary clearance, total mastectomy, taxanes or anti-HER-2 therapies in the adjuvant phase. Resumption of physical activity, minimally invasive axillary surgery, de-escalation of radiotherapy and breast-conserving surgical procedures have all demonstrated their preventive value. When lymphedema does occur, early management, through complete decongestive physiotherapy, can help reduce its volume and prevent its long-term worsening.

CONCLUSION

Surgical (lymph node transplants, lympho-vascular anastomoses) and medical (prolymphangiogenic growth factors) approaches to lymphedema treatment are numerous, but require long-term evaluation of their efficacy and adverse effects.

The efficacy in shoulder range of motion of a snapping manual maneuver added to a standardized exercise protocol in axillary web syndrome: a randomized controlled trial

PURPOSE

Axillary Web Syndrome (AWS) is a common sequela after surgical axillary lymph node dissection (ALND) often manifesting with reduced range of motion (ROM) of the limb, which requires rehabilitation. Notwithstanding, a standardized rehabilitation protocol is currently lacking in clinical practice. Our primary objective was therefore to evaluate the effectiveness of the use of a snapping manual maneuver (SMM, used in our clinical practice) to increase ROM during abduction (ABD) when compared with a standardized stretching exercise (SSE) protocol. A three-year follow-up of the enrolled patients was also carried out to determine the incidence of Breast Cancer-Related Lymphedema (BCRL).

MATERIALS AND METHODS

Between July 2013 and January 2019, we conducted a single-blinded randomized clinical trial. A total of 60 patients, who underwent ALND in our hospital, came to our clinic under medical advice or on voluntary access and reported AWS symptoms. The patients were randomly assigned into two equally divided groups. The treatment of group one consists in the execution of a supervised SSEs protocol, while group two additionally received a manual snapping maneuver. Patients of both groups received two treatment sessions within two weeks. At the end of the session, they were asked to continue the exercises autonomously on a daily basis, three times per day, for one month.

RESULTS

There were no statically significant differences in ROM at our one-month follow-up and the incidence of BCRL was equally distributed after three years.

CONCLUSIONS

The use of the manual snapping maneuver in addition to stretching once per week for two weeks does not appear to improve the outcome of the patients in comparison with stretching alone and does not appear to be related to lymphedema in our 3 years follow-up.

Randomised clinical trial of a manual therapy programme to reduce the evolution time of axillary web syndrome in women affected by breast cancer: study protocol

INTRODUCTION

Breast cancer is the most common malignant tumour in women, with more than 2 million new cases annually worldwide. One of the most frequent and well-known surgical and post-actinic sequelae is post-mastectomy lymphoedema. The axillary web syndrome is another sequela that limits the functionality of the patient and delays the protocol time of administering cancer treatments; and in many cases, this sequela is misdiagnosed. This surgical sequela usually disappears spontaneously after the third month of appearance, but this implies a long period of discomfort and limitations for the patient, at the same time, it may delay the application of radiotherapy within the indicated protocol deadline (due to a need for body posture).

METHODS AND ANALYSIS

With the present quasi-experimental study, we intend to show the application of physiotherapy and stretching from the beginning of the appearance of the axillary cord, in a controlled and scheduled way by the physiotherapist. It is possible to reduce the time in which the lymphatic thrombus is present and, therefore, recover functionality and mobility, reduce pain and be able to apply treatments within the established deadline. We intend to apply this therapy into the intervention group and compare thrombus evolution time with the control group.

ETHICS AND DISSEMINATION

This trial has the approval of the Andalucía Ethics Committee (PEIBA code 1909-N1-21, reg. number 171.21).

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05115799).

A Risk Factor Analysis of Axillary Web Syndrome in Patients After Breast Cancer Surgery: A Single Center Study in Korea

OBJECTIVE

To investigate the prevalence and risk factors of axillary web syndrome (AWS) in Korean patients.

METHODS

This retrospective study included a total of 189 women who underwent breast cancer surgery and received physical therapy between September 2019 and August 2020. We analyzed AWS and the correlation between the patients' demographics, underlying disease, type of surgery and chemotherapy or radiation therapy, and lymphedema.

RESULTS

The prevalence of AWS was found to be 30.6%. In the univariable analysis, age, chemotherapy, and hypertension were related to AWS. Finally, the multivariable logistic regression revealed that chemotherapy (odds ratio [OR]=2.84; 95% confidence interval [CI], 1.46-5.53) and HTN (OR=2.72; 95% CI, 1.18-6.30) were the strongest risk factors of AWS.

CONCLUSION

To the best of our knowledge, this was the first study that explored the risk factors of AWS in a Korean population after breast cancer surgery. As almost one-third of patients suffer from AWS after breast cancer surgery, it is essential to closely monitor the development of AWS in patients with hypertension or undergoing chemotherapy.

Web Axillary Pain Syndrome-Literature Evidence and Novel Rehabilitative Suggestions: A Narrative Review

Axillary web syndrome (AWS) is defined as a visible and palpable network of cords in the skin of the axillary cavity that are tensed by shoulder abduction following surgery for breast cancer, causing significant functional limits of the ipsilateral upper limb (UL) and pain. The purpose of this narrative review is to discuss rehabilitation approaches for greater efficacy with respect to pain and novel suggestions. AWS is a frequent complication of axillary lymphadenectomy that necessitates a thorough follow-up in the medium to long term. Physiotherapy is effective in the treatment of functional limb deficits, the management of pain, and the treatment of upper limb disability. The best management approach involves the use of soft tissue techniques to slow the natural course of the syndrome, in association with therapeutic exercises for functional recovery and muscle strengthening. AWS is linked secondary lymphedema, requiring integration with manual lymphatic drainage. The physiotherapy management of AWS is currently fragmented, and insufficient information is available on the nature of the disease. Thus, randomized and controlled studies that compare rehabilitation approaches in AWS are desirable, including the possibility of using mesotherapy in the treatment of axillary and upper limb pain.

Patients who report cording after breast cancer surgery are at higher risk of lymphedema: Results from a large prospective screening cohort

OBJECTIVES

To identify the association between cording and breast cancer-related lymphedema (BCRL); describe time course, location, symptoms and functional impairments.

METHODS

A total of 1181 patients were prospectively screened for BCRL after breast cancer (BC) surgery, including patient-reported outcome measures (4193) and perometric arm volume measurements (BCRL defined as relative or weight-adjusted volume change [RVC or WAC] ≥10% ≥3 months postoperatively).

RESULTS

A total of 374/1181 patients (31.7%) reported cording first a median of 4.5 months postoperatively, and were more likely to: have body mass index less than 30 kg/m² ; be less than 55 years of age; have had mastectomy, axillary lymph node dissection, regional lymph node radiation, neoadjuvant chemotherapy (all P < .001), or RVC/WAC ≥10% (P = .002). Patients who reported cording had 2.4 times the odds of developing BCRL compared to those who did not (odds ratio = 2.40; 95% confidence interval = 1.40-4.11; P = .002), and most frequently reported these symptoms: tenderness (61.2%), aching (60.7%), and firmness/tightness (59.8%). On multivariable analysis, cording was significantly correlated with functional difficulty for 17 actions.

CONCLUSIONS

Patients frequently present with cording, potentially months after BC surgery. Risk factors for and symptoms of cording are identified, and treatment is recommended. Patients reporting cording are at higher risk of BCRL, therefore, cording should be incorporated into BCRL risk stratification.

Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study

PURPOSE

Axillary web syndrome (AWS) presents as a common postsurgical complication in individuals with breast cancer. Breast cancer-related lymphedema (BCRL) contributes to the shoulder and arm morbidity common in breast cancer survivors and often associated to cancer treatment. A paucity of literature exists evaluating the risk factors for developing AWS and the association between AWS and BCRL. The purposes of this study were (1) to identify risk factors for AWS in individuals with breast cancer, (2) to examine the association between BCRL and AWS, and (3) to determine if AWS increases the risk for developing BCRL.

METHODS

A retrospective study of 354 women who underwent breast cancer treatment and received physical therapy was included.

RESULTS

Axillary web syndrome developed in a third of women and predominately occurred in the first 8 postoperative weeks. The odds of AWS development were 73% greater for participants over the age of 60 (OR = 1.73, CI 95% 1.05-2.84). Women with AWS had 44% greater risk to develop lymphedema during the first postoperative year (RR = 1.44, CI 95% 1.12-1.84, p = 0.002). If AWS developed within the first postoperative month, women were almost 3 times more likely to develop lymphedema within the first 3 postoperative months compared with other women with AWS (RR = 2.75, CI 95% 1.199-6.310, p = 0.007).

CONCLUSIONS

Our findings suggest that 30% of breast cancer survivors will have AWS during the first year of survivorship. As institutions prioritize screening efforts, early postoperative prospective surveillance is needed for women over 60 due to high risk for AWS development and any women with AWS for increased risk of lymphedema development based on our findings.

Risk factors for the development of oedema and lymphoedema

An important symptom of ill health in clinical medicine is the development of oedema, which represents an imbalance in the amount of fluid entering and leaving the tissues of the body. Although medical treatment for the underlying cause of oedema is required, in both cancer and non-cancer settings risk factors that may increase or decrease the potential for oedema to develop or worsen can be identified. For the patient who has risk factors for the development of oedema, advice and education can enable the risk to be modified. Reducing the risk of oedema formation will help avoid long-term problematic oedema and complex skin conditions, as well as maintaining the patient's quality of life. This article discusses some of the risk factors for oedema and lymphoedema and concludes with an outline of how the risk can be managed.

Review of axillary web syndrome: What the radiologist should know

Axillary web syndrome is common after axillary surgery, frequently affecting breast cancer patients. In this condition, patients develop one or more linear bands of firm tissue, also known as "cords", in the axilla and arm, associated with pain and limited range of motion of the shoulder and arm. Radiologists may encounter this syndrome in patients referred for axillary or upper extremity ultrasound, and should be aware of the physical examination and ultrasound findings for accurate diagnosis. However, there are currently limited articles about this syndrome published in radiology journals, suggesting that radiologists may be unaware of this entity. In this work, axillary web syndrome will be discussed, including background knowledge, incidence, clinical presentation, possible etiology, and ultrasound appearance.

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

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.

Axillary Web Syndrome in Breast Cancer: A Prevalent But Under-Recognized Postoperative Complication

The purpose of this review is to define axillary web syndrome (AWS) and describe its diagnosis and management. The following databases were searched through July 2017: PubMed, EMBASE (OvidSP), Cumulative Index for Nursing and Allied Health Literature, Physiotherapy Evidence Database, and Cochrane Database of Systematic Reviews. Search terms included 'axillary web syndrome', 'axillary cording', and 'lymphatic cording'. 49 articles were identified; 8 did not relate to breast cancer, and 3 were not in English. Of the remaining articles, the majority were case reports, case series, or descriptive reviews. 2 systematic reviews were located as well as 1 randomized trial, 6 prospective cohort studies, and 2 retrospective cohort studies. Although a common sequela after axillary surgery for breast cancer staging, AWS has been poorly described in the medical literature as to the underlying pathophysiology, diagnosis, and management. Interventions range from patient education and simple reassurance that the syndrome will resolve spontaneously to active physical or manual therapies to maintain upper extremity range-of-motion, especially adequate motion for undergoing radiation therapy. Oncologists, breast surgeons, family physicians, and oncology nurse practitioners that work with patients with breast cancer should educate them about this prevalent complication and inform them preoperatively about what to anticipate.

Axillary web syndrome assessment using a self-assessment questionnaire: a prospective cohort study

BACKGROUND

Surgical procedure for breast cancer is not without its side effects and one such side effect is axillary web syndrome (AWS), characterized by palpable fibrotic-like cords in the operated arm. As physical evaluation is the only gold standard method used, our study aims to assess the incidence and early detection of AWS with a self-assessment questionnaire.

METHODS

From July 2013 to July 2014, 370 breast cancer patients were enrolled. AWS incidence was 51.1%, with 94.1% onset in the first 4 weeks after surgery; 43.5% of the patients did not recover in the first 8 weeks. Univariate analysis showed that BMI (P < 0.001), age (P < 0.001), educational level (P = 0.01), and exercise frequency in the eighth week of follow-up (P < 0.001) were significantly associated with the AWS detection, and multivariate analyses confirmed that younger patients (age < 50) have significantly higher AWS detection (OR = 2.38 (95%CI 1.53, 3.71) and that BMI is associated with AWS, with normal weight patients (BMI ≤ 25) having a significantly greater AWS detection with an odds ratio of 2.11 (95%CI 1.33, 3.36).

CONCLUSION

Our findings indicated that the incidence of AWS is high in breast cancer patients, particularly in the first month after surgery. Not all patients achieved recovery during our 8 week follow-up, suggesting that evaluation and treatment should be longer. Double AWS detection was found for patients who were younger (age < 50) and with normal weight.