A case of axillary web syndrome with subcutaneous nodules following axillary surgery

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.

'Patience is a virtue' - Post-traumatic Axillary Web Syndrome - resolution without intervention

The current case report showcases an atypical symptomatic post-traumatic Axillary Web Syndrome in a 63-year-old Caucasian male patient with complete resolution of symptoms with no intervention. Axillary web syndrome is a condition where the skin area under the axilla becomes taut and on palpation there is a cord-like feeling similar to a guitar string, usually bound together as spider web appearance. The case report highlights the importance of appropriate physical examination and also the need for Community Diagnostic Centres and Point of Care Ultrasound services to help provide patients with timely diagnosis, reduce patient anxiety, and enhance patient experience and outcomes. The current case study is specifically useful for healthcare professionals working in primary care, especially in the National Health Service, where resources are already stretched to avoid unnecessary referrals, interventions and investigations. The case report is atypical since axillary web syndrome is typically and largely seen in cancer patients, specifically post breast cancer surgery in females and very rarely seen as a post traumatic presentation in acute setting.

Lymphoscintigraphic Investigations for Axillary Web Syndromes

Background: Axillary web syndrome (AWS) is a frequent complication after surgery for breast cancer, but its lymphatic involvement is not definitively established. Here we report the results of lymphoscintigraphic investigations in patients with AWS. Methods and Findings: We conducted a retrospective, single-center review of lymphoscintigraphic investigations performed in 46 patients with AWS that was either clinically obvious or suspected. Of this group, 23 patients had two investigations with a mean interval of 19 weeks between them (range, 6-98 weeks). Results of the lymphoscintigraphic investigations, which were performed according to a well-standardized protocol, were classified into four patterns: normal; functional lymphatic insufficiency only (no lymphatic vascular morphologic abnormality); lymphovascular blockade without collateralization; and vascular collateralization and/or dermal backflow. Of the 46 patients, on the first lymphoscintigraphic investigation, four (8.6%) had a normal pattern, seven (15.2%) had functional lymphatic insufficiency only, four (8.6%) had lymphovascular blockade without collateralization, and 31 (67.3%) had vascular collateralization and/or dermal backflow. Among patients who underwent two investigations, four of the five who had only functional lymphatic insufficiency at the first investigation had developed vascular collateralization and/or dermal backflow by the second. The three patients who had lymphovascular blockade without collateralization at the first examination had also progressed to collateralization and/or dermal backflow at the second. None of the 15 patients who initially had vascular collateralization and/or dermal backflow showed any reversal at the second examination. Conclusions: Our analysis confirms the lymphatic nature of AWS and shows the lymphoscintigraphic patterns and evolutions of the lymphatic lesions with potential therapeutic implications. The retrospective review of our database is approved by the institutional ethics committee under number 2048.

Quality of Life Interventions in Breast Cancer Survivors: State of the Art in Targeted Rehabilitation Strategies

Breast cancer is the most common malignant tumor and the most prevalent cause of mortality in women. Advances in early diagnosis and more effective adjuvant therapies have improved the long-term survival of these patients. Pharmacotherapies and intrinsic tumor-related factors may lead to a wide spectrum of treatment-related disabling complications, such as breast cancer-related lymphedema, axillary web syndrome, persistent pain, bone loss, arthralgia, and fatigue. These conditions have a detrimental impact on the health-related quality of life of survivors. Here, we sought to provide a portrait of the role that rehabilitation plays in breast cancer survivors. Particular emphasis has been placed on recovering function, improving independence in activities of daily living, and reducing disability. This complex scenario requires a precision medicine approach to provide more effective decision-making and adequate treatment compliance.

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.

Axillary Web Syndrome: Evidence for Lymphatic Origin with Thrombosis

Background: The axillary web syndrome (AWS) occurs in the axilla and on the frontal side of the upper arm and sometimes along the forearm to the thumb. The cord is painful, particularly on movement, and can therefore be very distressing for the patient. Although the phenomenon has been examined and discussed for decades, no evidence for the origin has been found until now. The aim of this study was to perform a histopathologic analysis of cords taken between 1996 and 1998 in the Surgical Clinic, Skane University Hospital, Lund, Sweden. Methods and Results: In seven patients, biopsies of the AWS cords were obtained 4-5 weeks after axillary node surgery for breast cancer and examined with standard hematoxylin and eosin and D2-40 (lymphatic endothelial cell) staining. In one biopsy, there was a dilated vessel with a thickened wall, which was confirmed by D2-40 immunostaining to represent a lymphatic vessel. The lumen was occluded by organized thrombus, within which new vessels were being formed, indicating recanalization. In two other biopsies, similar lymphatic vessels with thickened walls were present, although the lumen of the vessels was not visualized in the planes of the section. The other four biopsies do not show specific features. Conclusion: Although only one case, this is the first pathological evidence of thrombosis within a confirmed lymphatic vessel from a case of cording. We propose that the axillary cord represents lymphatic vessel thrombosis. Recanalization of the thrombus may eventually restore lymphatic flow consistent with the transient nature of the condition.

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.

Vascular Alterations in Axillary and Brachial Vessels in Patients with Axillary Web Syndrome After Breast Cancer Surgery

BACKGROUND

Surgical manipulations of the axilla may cause a condition known as Axillary Web Syndrome (AWS). The systems compromised and the sequence of events leading to this syndrome remains unknown. This study evaluated clinical, surgical, and vascular factors associated with onset and duration of AWS after breast cancer surgery.

METHODS AND RESULTS

In this prospective study, 155 women were included. They were submitted to a physical examination that consisted of ultrasound Doppler of axillary and brachial vessels and the evaluation of AWS in 1, 3, and 6 months after breast cancer surgery. Women with advanced disease had a significantly higher incidence of AWS than those with early stage breast cancer (p = 0.02). In addition, women who underwent mastectomy or axillary lymph node dissection (ALND) had a significantly higher incidence of AWS in the 1-month (p < 0.01; p < 0.01) and 3-months (p < 0.01; p = 0.02) assessment rounds, respectively. The cross-sectional area of brachial artery was significantly smaller (p = 0.04) in women with AWS at the 3-months postoperative visit. The peak systolic velocity and the blood flow of the axillary artery was significantly higher in women with AWS 6 months after surgery (p < 0.03 and p = 0.02 respectively).

CONCLUSION

Our study confirm the combined changes of lymphatic and vascular systems in woman with AWS, since AWS was associated with more extensive dissection of axillary lymph nodes, compromised lymph nodes, and with abnormalities of the vascular parameters.

Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction

PURPOSE

There is a paucity of research that investigates physical therapy management for patients with axillary web syndrome (AWS) and thoracic rotation dysfunction. The purpose of this case report is to describe the management of a patient with AWS and thoracic rotation dysfunction using an impairment-based approach that includes instrument assisted soft tissue mobilization (IASTM), thoracic manipulation, and stretching.

CASE DESCRIPTION

The patient was a 48-year-old female with a past medical history of bilateral breast cancer with a bilateral latissimus dorsi flap reconstruction. The patient was referred to physical therapy with chief complaints of right shoulder pain with reaching and an inability to resume running due to right shoulder and scapula pain. The patient was seen in outpatient physical therapy for four visits over four weeks. Treatment consisted of IASTM, thoracic manipulation, stretching exercises, and home exercise program instruction.

OUTCOMES

Upon discharge, the patient had improved right shoulder and thoracic range of motion, decreased pain, and improved function on the patient specific functional scale (PSFS).

CONCLUSION

Utilization of an impairment-based physical therapy approach to treat a patient with AWS and thoracic dysfunction yielded positive outcomes. Further research on the efficacy of IASTM and physical therapy management of AWS is warranted.

Axillary Web Syndrome: Current Understanding and New Directions for Treatment

BACKGROUND

Axillary web syndrome (AWS) is a poorly understood but common cause of significant morbidity after axillary lymph node dissection for breast cancer. It is characterized by painful scar tissue formation and contracture extending from the axilla down the medial arm which limits shoulder and arm mobility. We sought to gain a better understanding of its pathophysiology and available treatments. Additionally, we present our preliminary experience with 2 novel treatment methods: (1) percutaneous needle cord disruption with fat grafting, (2) Xiaflex injection to the cording.

METHODS

In order to gain better understanding of current treatment modalities, we performed a literature search to identify articles that described axillary cording after axillary dissection exclusively for breast cancer. We performed operative percutaneous cord disruption and immediate autologous fat grafting in 18 patients. Xiaflex injection was performed in one patient. Details from the 2 new treatment modalities are described.

RESULTS

Described treatments in the literature include physical therapy, nonsteroidal anti-inflammatories, moist heat, and 1 case of Ascueven Forte. Typically, symptoms lasted from 1 week to 2 years, and most cases resolved by 3 months postoperatively with return to preoperative functionality. We found our 2 new treatment modalities markedly improved arm and shoulder range of motion, overall daily functioning, and pain. Aesthetic outcomes were also improved with softening of the cords.

CONCLUSIONS

Axillary web syndrome remains an incompletely understood postoperative phenomenon, which warrants further research. Those patients who develop severe cording often do not respond to traditional therapy and may require more aggressive treatment. Our 2 novel techniques provide alternative options for treating this condition.

Dynamic Angular Petrissage as Treatment for Axillary Web Syndrome Occurring after Surgery for Breast Cancer: a Case Report

BACKGROUND

In the context of breast cancer, axillary web syndrome (AWS), also called lymphatic cording, typically presents in the weeks after axillary surgery. This painful condition, likely lymphofibrotic in origin, restricts upper extremity range of motion (ROM). There is no established treatment, although physical therapy and other approaches have been used to variable effect. This report describes treatment of a female client with AWS, who had recently undergone a unilateral simple mastectomy with sentinel node biopsy plus axillary dissection.

METHODS

The client presented with pain upon movement (self-reported as 5 on the 0-10 Oxford Pain Scale), visible cording and restricted use of the ipsilateral upper extremity. Clinical assessment included determining the extent of AWS cording (taut, from axilla to wrist) and measuring glenohumeral joint ROM (140° flexion by goniometer). A therapeutic massage with movement protocol, termed dynamic angular petrissage, was administered over two sessions: Swedish massage combined with dynamically taking the limb through all possible angles of movement (passive ROM), controlling stretch and tension while simultaneously and segmentally applying petrissage and non-petrissage techniques to the underlying soft tissue. Careful attention was taken to not break the cord. Home care consisted of prescribed exercises performed by the patient.

RESULTS

After Session One, pain was reduced (to 0/10), ROM improved (to 170° flexion), and cording was visibly reduced. After Session Two the cord was residually apparent only on hyperextension, with no ROM restrictions in glenohumeral joint flexion. Follow-up at three months revealed absence of visual or palpable evidence of cording, unrestricted glenohumeral joint ROM, and absence of movement-associated pain.

CONCLUSION

The signs and symptoms of AWS were quickly and effectively eliminated, without causing any pain or discomfort to the client. We propose that dynamic angular petrissage may be an efficient and safe treatment approach for reducing the pain, mobility restrictions, and cording of AWS.

A systematic review of axillary web syndrome (AWS)

INTRODUCTION

Axillary web syndrome (AWS) can result in early post-operative and long-term difficulties following lymphadenectomy for cancer and should be recognised by clinicians. This systematic review was conducted to synthesise information on AWS clinical presentation and diagnosis, frequency, natural progression, grading, pathoaetiology, risk factors, symptoms, interventions and outcomes.

METHODS

Electronic searches were conducted using Cochrane, Pubmed, MEDLINE, CINAHL, EMBASE, AMED, PEDro and Google Scholar until June 2013. The methodological quality of included studies was determined using the Downs and Black checklist. Narrative synthesis of results was undertaken.

RESULTS

Thirty-seven studies with methodological quality scores ranging from 11 to 26 on a 28-point scale were included. AWS diagnosis relies on inspection and palpation; grading has not been validated. AWS frequency was reported in up to 85.4 % of patients. Biopsies identified venous and lymphatic pathoaetiology with five studies suggesting lymphatic involvement. Twenty-one studies reported AWS occurrence within eight post-operative weeks, but late occurrence of greater than 3 months is possible. Pain was commonly reported with shoulder abduction more restricted than flexion. AWS symptoms usually resolve within 3 months but may persist. Risk factors may include extensiveness of surgery, younger age, lower body mass index, ethnicity and healing complications. Low-quality studies suggest that conservative approaches including analgesics, non-steroidal anti-inflammatory drugs and/or physiotherapy may be safe and effective for early symptom reduction.

CONCLUSIONS

AWS appears common. Current evidence for the treatment of AWS is insufficient to provide clear guidance for clinical practice.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors should be informed about AWS. Further investigation is needed into pathoaetiology, long-term outcomes and to determine effective treatment using standardised outcomes.

Complication rates in patients with negative axillary nodes 10 years after local breast radiotherapy after either sentinel lymph node dissection or axillary clearance

BACKGROUND

We assess complication rates in node negative breast cancer patients treated with breast radiotherapy (RT) only after sentinel lymph node dissection (SLND) or axillary lymph node dissection (ALND).

MATERIALS AND METHODS

Between 1995 and 2001, 226 women with AJCC stage I-II breast cancer were treated with lumpectomy, either SLND or SLND+ALND, and had available toxicities in follow-up: 111/136 (82%) and 115/129 (89%) in SLND and ALND groups, respectively. RT targeted the breast to median dose of 48.2 Gy (range, 46.0 to 50.4 Gy) without axillary RT. Chi-square tests compared complication rates of 2 groups for axillary web syndrome (AWS), seroma, wound infection, decreased range of motion of the ipsilateral shoulder, paresthesia, and lymphedema.

RESULTS

Median follow-up was 9.9 years (range, 8.3-15.3 y). Median number of nodes assessed was 2 (range, 1-5) in SLND and 18 (range, 7-36) in ALND (P < 0.0001). Acute complications occurred during the first 2 years and were AWS, seroma, and wound infection. Incidences of seroma 5/111 (4.5%) in SLND and 16/115 (13.9%) in ALND (P < 0.02, respectively) and wound infection 3/111 (2.7%) in SLND and 10/115 (8.7%) in ALND (P < 0.05, respectively) differed significantly. AWS was not statistically different between the groups. At 10 years, the only chronic complications decreased were range of motion of the shoulder 46/111 (41.4%) in SLND and 92/115 (80.0%) in ALND (P < 0.0001), paresthesia 12/111 (10.8%) in SLND and 39/115 (33.9%) in ALND (P < 0.0001), and lymphedema assessed by patients 10/111 (10.0%) in SLND and 39/115 (33.9%) in ALND (P < 0.0001). Chronic lymphedema, assessed by clinicians, occurred in 6/111 (5.4%) in SLND and 21/115 (18.3%) in ALND cohorts, respectively (P < 0.0001).

CONCLUSIONS

Our mature findings support that in patients with negative axillary nodal status SLND and breast RT provide excellent long-term cure rates while avoiding morbidities associated with ALND or addition of axillary RT field.

Axillary Web Syndrome after Sentinel Node Biopsy

BACKGROUND: Axillary web syndrome (AWS) is a self-limiting cause of morbidity in the early postoperative period after axillary surgery, but it is encountered also after sentinel lymph node biopsy. The syndrome is characterized by cords of subcutaneous tissue extending from the axilla into the medial arm. CASE REPORT: Here, we report a patient presenting with AWS several weeks after sentinel lymph node biopsy. CONCLUSION: AWS has been reported to be resolved spontaneously in all patients 8-16 weeks after axillary surgery, and shoulder movements improve in this period. There is no definitive treatment modality for AWS. Patients should be reassured and informed that this condition will improve even without treatment.

Axillary web syndrome after axillary dissection in breast cancer: a prospective study

The axillary web syndrome is a self-limiting and frequently overlooked cause of significant morbidity in the early post-operative period after breast cancer axillary surgery, which is characterized by axillary pain that runs down the medial arm, limited shoulder range of motion affecting mainly shoulder abduction, and cords of subcutaneous tissue extending from axilla into the medial arm, made visible or palpable and painful by shoulder abduction. We evaluated the incidence of axillary web syndrome after axillary lymph-node dissection. Altogether 116 patients who underwent axillary lymph-node dissection were assessed for axillary web syndrome. Range of shoulder abduction, pain, and the subjective feeling of tightness along the arm were recorded. Axillary web syndrome was found in 56 patients, which means an incidence of 48.3% (CI95%: 38.9, 57.7). Axillary web syndrome is a significant self-limited cause of morbidity of axillary surgery ocurring not only in the early post-operative period.