A systematic review of axillary web syndrome (AWS)
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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.
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.
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.
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.
KeywordsAxillary web syndrome Axillary lymphadenectomy Breast cancer Melanoma Post-operative morbidity Pain
Conflicts of interest
W M Yeung, S M McPhail and S S Kuys declare that they have no conflict of interest.
- 5.Johansson K, Ingvar C, Albertsson M, Ekdahl C. Arm lymphoedema, shoulder mobility and muscle strength after breast cancer treatment—a prospective 2-year study. Adv Physiother. 2001;3:55–66.Google Scholar
- 12.Ferrandez J-C, Serin D. Rééducation et cancer du sein. 1st ed. Paris: Masson; 1996.Google Scholar
- 15.Kepics J. Physical therapy treatment of axillary web syndrome. Rehabil Oncol. 2004.http://www.highbeam.com/doc/1P3-626819761.html. Accessed 10 Jan 2013.
- 17.Wernicke AG, Shamis M, Sidhu KK, Turner BC, Goltser Y, Khan I, et al. Complication rates in patients with negative axillary nodes 10 years after local breast radiotherapy after either sentinel lymph node dissection or axillary clearance. Am J Clin Oncol. 2013;36:12–9.PubMedCentralCrossRefPubMedGoogle Scholar
- 19.Lattanzi JB, Zimmerman A, Marshall LM. Case report of axillary web sydnrome. Rehabil Oncol. 2012;30:18–21.Google Scholar
- 25.Sarri AJ, Moriguchi SM. Evidence-based usefulness of physiotherapy techniques in breast cancer patients. In: Ozdemir PO, editor. Current cancer treatment - novel beyond conventional approaches: InTech; 2011. pp. 751–66.http://www.intechopen.com/books/current-cancer-treatment-novel-beyond-conventional-approaches. Accessed 10 Jan 2013.
- 26.Koehler L. Axillary web syndrome and lymphedema, a new perspective. Lymph Link. 2006;18:9–10.Google Scholar
- 27.Severeid K, Simpson J, Templeton B, York R, Hummel-Berry K, Leiserowitz A. Lymphatic cording among patients with breast cancer or melanoma referred to physical therapy. Rehabil Oncol. 2007;25:8–13.Google Scholar
- 28.Wyrick SL, Waltke LJ, Ng AV. Physical therapy may promote resolution of lymphatic coding in breast cancer survivors. Rehabil Oncol. 2006;24:29–34.Google Scholar
- 31.Hummel-Berry K, Leiserowitz A. Functional evaluation and rehabilitation for musculosekeltal problems resulting from cancer or its treatment. Formos J Phys Ther. 2009;34:95–105.Google Scholar
- 34.Villamiel Campos E, Ramallo Alcover A, Killing Rodriguez I. Axillary web syndrome. Prog Obstet Ginecol. 2008;51(12):745–8. http://zl.elsevier.es/es/revista/progresos-obstetricia-ginecologia-151/axillary-web-syndrome-13129624-casos-clinicos-2008 Accessed 19 Dec 2014.
- 39.Josenhans E. Physiotherapeutic treatment for axillary cord formation following breast cancer surgery. Pt_Zeitschrift für Physiotherapeuten. 2007;59:868–78.Google Scholar
- 40.National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. National Health and Medical Research Council. Canberra 2009.Google Scholar
- 47.Koehler L. Axillary web syndrome ongoing medical evaluation [Dissertation]: University of Minnesota; 2013. http://conservancy.umn.edu/bitstream/144876/1/Koehler_umn_0130E_13456.pdf. Accessed 10 Apr 2014.
- 48.Bergmann A, Mendes VV, de Almeida Dias R, do Amaral e Silva B, da Costa Leite Ferreira MG, Fabro EAN. Incidence and risk factors for axillary web syndrome after breast cancer surgery. Breast Cancer Res Treat. 2011;131:987–92.Google Scholar
- 49.Davies S, Logan K. Cording following breast cancer surgery: a retrospective analysis and discussion of current literature. 8th Australasian Lymphology Association Conference, Melbourne, Victoria. 2010. Google Scholar
- 53.Bergmann A, Mattos IE, Koifman RJ, Ribeiro MJ, Nogueira EA, Ribeiro EP, et al. Axillary web syndrome after lymph node dissection: results of 1004 breast cancer patients. Lymphology. 2007;40(Suppl):198–203.Google Scholar
- 54.Bergmann A, Bourrus N, de Carvalho CM, Dias RA, Fabro EAN, Sales NS, et al. Arm symptoms and overall survival in brazilian patients with advanced breast cancer. Asian Pac J Cancer. 2011;12:2939-42.Google Scholar
- 55.Moreau A, Leduc O, Tinlot A, Clement A, Parijs T, Strappaert J, et al. Axillary web syndrome: its features and the physical treatment plan of care. EJLRP. 2010;21:25–8.Google Scholar
- 56.Fabro EAN, Bergmann A, do Amaral e Silva B, Padula Ribeiro AC, de Souza Abrahão K, da Costa Leite Ferreira MG, et al. Post-mastectomy pain syndrome: incidence and risks. Breast. 2012;21:321–5.Google Scholar
- 59.Winicour J. What is cording? Lymph Link. 2013;25(2). http://www.lymphnet.org/membersOnly/dl/reprint/Vol_25/Vol_25-N2_What_is_cording.pdf. Accessed 09 Feb 2015.
- 60.The Lymphoedema Framework. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd; 2006.Google Scholar
- 65.Torres Lacomba M, Yuste Sánchez MJ, Zapico Goñi A, Prieto Merino D, Mayoral del Moral O, Cerezo Téllez E, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010;340:b5396.PubMedCentralCrossRefPubMedGoogle Scholar