Axillary web syndrome following breast cancer surgery.
Treatment for breast cancer can lead to long-term complications such as reduced shoulder and arm function, reduced ROM, pain, and lymphedema.
Axillary web syndrome (AWS) or cording is another complication that often develops within weeks following breast cancer surgery and may present as one or more visible or palpable tight cords of tissue in the axilla, sometimes extending into the upper extremity or chest wall.
Risk factors include the removal of more lymph nodes (extensive surgery) and a lower BMI.
The etiology and natural history of AWS is still poorly understood, but centres around iatrogenic damage to the lymphatic and/ or venous system, resulting in local stasis, hypercoagulation, and inflammation of the involved supercial vein or lymphatic vessel.
AWS was previously thought to be self-limiting after 3 months, but recent research showed a 60% prevalence at 12 weeks.
This prospective cohort study tracked 36 women for 18 months following breast cancer surgery with visits at 2, 4, and 12 weeks and 18 months after surgery.
Inclusion criteria were:
- Early stage breast cancer surgery, with a minimum of 1 axillary lynph node removed;
- No history of shoulder dysfunction, DVT or previous breast cancer
Clinical outcome measures were ROM (flexion, abduction), lymphedema (UE circumference, bioimpedance, tissue dielectric constant), pain (VAS), function (DASH), AWS (visible or palpable cords in axilla, UE or trunk at maximal abduction).
No intervention was performed, but participants received the usual care: light ROM exercises and lymphedema education.
The period prevalence of AWS was 33%, 42%, 47%, and 50% at 2, 4, and 12 weeks and 18 months, respectively - making it a surprisingly common condition with a proportional distribution over time.
AWS disappeared, developed and reoccurred during those months in some women. Women with sentinel node biopsy (1-2 lymph nodes removed) had a 43% prevalence, in those with ALND (axillary lymph node dissection) this was 75%.
AWS accounted for statistically reduced function and reduced aROM (not pROM!), but had no effect on pain or lympedema.
Future research should focus on long term association of AWS and physical impairments, and effective treatment strategies.
> From: Koehler et al., Phys Ther 98 (2018) 518-527. All rights reserved to American Physical Therapy Association. Click here for the online summary.