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Axillary web syndrome is a poorly understood cause of morbidity after lymph node surgery characterized by visible or palpable cords in the involved axilla extending down into the medial arm and forearm, often accompanied by a sensation of tightness, limitation of movement, and pain. Axillary web syndrome was first described in 2001 as a complication of axillary clearance.
The cumulative incidence at 18 months has been reported as 50% and is higher in patients who underwent axillary lymph node dissection (72%-75%) versus sentinel node biopsy (20%-41%).
Reduced shoulder motion, functional impairment, and increased arm volume all have been associated with axillary web syndrome.
Objective
Given the overall prevalence of breast cancer, there is a need to recognize axillary web syndrome as a potential complication. Clinicians should be aware that axillary web syndrome can occur weeks to months after even minimally invasive surgery, and thin females are at higher risk of developing this condition. Early recognition and prompt referral to physical therapy can improve outcomes.
Case Report
A 44-year-old otherwise healthy woman with a body mass index of 18.2 underwent right simple mastectomy and sentinel lymph node biopsy for node-negative early-stage breast cancer in April 2016. The patient was discharged to home the same day and had an uneventful postoperative recovery. She did not receive chemotherapy or radiotherapy. She returned to work after 2 weeks and resumed usual fitness routine after 4 weeks.
Approximately 5 weeks post mastectomy, the patient began to experience a tightening sensation and a decrease in range of motion of the right arm. At 6 weeks, the patient observed visible cording involving the ipsilateral axilla, extending down into the forearm, with prominent cords noted in the antecubital fossa (Figure). After contacting the care team, the diagnosis of axillary web syndrome was made, prompting a referral to physical therapy for evaluation and treatment.
FigureAxillary web syndrome, with prominent cording in the involved axilla extending down into the medial forearm. This cording occurs after trauma to the lymph system and is presumed to be of lymphatic origin based on histologic and radiographic findings.
Physical therapy assessment revealed that right arm flexion was limited to 115° and abduction limited to 92°, with a pain score of 2/10 and functional limitations. Treatment consisted of manual lymph drainage, myofascial release, and stretching in addition to a home exercise regimen. The patient regained full range of motion and was discharged from physical therapy after 4 sessions.
Discussion
The exact pathogenesis of axillary web syndrome is unknown, however, there is histologic and radiographic evidence of a lymphatic origin.
Features of this case suggest that younger age and low body mass index are strong predictors of axillary web syndrome and it can be associated with reduced range of motion and function. While the optimal treatment is not defined, the benefits of noninvasive approaches such as physical therapy have been described in numerous reports.
Axillary web syndrome is likely under-recognized, given the cumulative incidence noted above together with data collected regarding referrals to physical therapy (Koehler et al, unpublished data, 2017). Breast cancer patients, particularly thin females, should be educated about signs and symptoms. Increasing collaboration among surgeons, oncologists, physical therapy and other health professionals can help facilitate diagnosis and treatment of axillary web syndrome.
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