Journal of Cancer Survivorship

, Volume 9, Issue 4, pp 576–598 | Cite as

A systematic review of axillary web syndrome (AWS)

  • W. M. YeungEmail author
  • S. M. McPhail
  • S. S. Kuys



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.


Axillary 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.

Supplementary material

11764_2015_435_MOESM1_ESM.docx (17 kb)
Supplementary 1 (DOCX 17 kb)
11764_2015_435_MOESM2_ESM.docx (23 kb)
Supplementary 2 (DOCX 22 kb)


  1. 1.
    Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe RE. Axillary web syndrome after axillary dissection. Am J Surg. 2001;181:434–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Tilley A, Thomas-MacLean R, Kwan W. Lymphatic cording or axillary web syndrome after breast cancer surgery. Can J Surg. 2009;52:E105–6.PubMedCentralPubMedGoogle Scholar
  3. 3.
    Morehead-Gee AJ, Pfalzer L, Levy E, McGarvey C, Springer B, Soballe P, et al. Racial disparities in physical and functional domains in women with breast cancer. Support Care Cancer. 2012;20:1839–47.CrossRefPubMedGoogle Scholar
  4. 4.
    Rashtak S, Gamble GL, Gibson LE, Pittelkow MR. From furuncle to axillary web syndrome: shedding light on histopathology and pathogenesis. Dermatology. 2012;224:110–4.CrossRefPubMedGoogle Scholar
  5. 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
  6. 6.
    Craythorne E, Benton E, Macfarlane S. Axillary web syndrome or cording, a variant of Mondor disease, following axillary surgery. Arch Dermatol. 2009;145:1199–200.CrossRefPubMedGoogle Scholar
  7. 7.
    Wei P, Zhu L, Chen K, Jia W, Hu Y, Su F. Axillary web syndrome following secondary breast-conserving surgery: a case report. World J Surg Oncol. 2013;11:8.PubMedCentralCrossRefPubMedGoogle Scholar
  8. 8.
    Torres Lacomba M, Mayoral del Moral O, Coperias Zazo JL, Yuste Sanchez MJ, Ferrandez J-C, Zapico Goñi A. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat. 2009;117:625–30.CrossRefPubMedGoogle Scholar
  9. 9.
    Marcus RT, Pawade J, Vella EJ. Painful lymphatic occlusion following axillary lymph node surgery. Br J Surg. 1990;77:683.CrossRefPubMedGoogle Scholar
  10. 10.
    Eastcott H. Antecubital strings—a new physical sign? Br J Surg. 1960;47:629–35.CrossRefPubMedGoogle Scholar
  11. 11.
    Ashken M. String phlebitis. Br J Surg. 1963;50:689–93.CrossRefPubMedGoogle Scholar
  12. 12.
    Ferrandez J-C, Serin D. Rééducation et cancer du sein. 1st ed. Paris: Masson; 1996.Google Scholar
  13. 13.
    de Oliveira RR, Pinto e Silva M, Gurgel MS, Pastori-Filho L, Sarian LO. Immediate breast reconstruction with transverse latissimus dorsi flap does not affect the short-term recovery of shoulder range of motion after mastectomy. Ann Plast Surg. 2010;64:402–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Box RC, Hildegard MR-H, Bullock-Saxton JE, Furnival CM. Shoulder movement after breast cancer surgery: results of a randomised controlled study of postoperative physiotherapy. Breast Cancer Res Treat. 2002;75:35–50.CrossRefPubMedGoogle Scholar
  15. 15.
    Kepics J. Physical therapy treatment of axillary web syndrome. Rehabil Oncol. 2004. Accessed 10 Jan 2013.
  16. 16.
    Springer BA, Levy E, McGarvey C, Pfalzer LA, Stout NL, Gerber LH, et al. Pre-operative assessment enables early diagnosis and recovery of shoulder function in patients with breast cancer. Breast Cancer Res Treat. 2010;120:135–47.PubMedCentralCrossRefPubMedGoogle Scholar
  17. 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
  18. 18.
    Fourie WJ, Robb KA. Physiotherapy management of axillary web syndrome following breast cancer treatment: discussing the use of soft tissue techniques. Physiotherapy. 2009;95:314–20.CrossRefPubMedGoogle Scholar
  19. 19.
    Lattanzi JB, Zimmerman A, Marshall LM. Case report of axillary web sydnrome. Rehabil Oncol. 2012;30:18–21.Google Scholar
  20. 20.
    Levy EW, Pfalzer LA, Danoff K, Springer BA, McGarvey C, Shieh CY, et al. Predictors of functional shoulder recovery at 1 and 12 months after breast cancer surgery. Breast Cancer Res Treat. 2012;134:315–24.CrossRefPubMedGoogle Scholar
  21. 21.
    Leduc O, Sichere M, Moreau A, Rigolet J, Tinlot A, Darc S, et al. Axillary web syndrome: nature and localization. Lymphology. 2009;42:176–81.PubMedGoogle Scholar
  22. 22.
    Stout NL, Pfalzer LA, Levy E, McGarvey C, Springer B, Gerber LH, et al. Segmental limb volume change as a predictor of the onset of lymphedema in women with early breast cancer. PM&R. 2011;3:1098–105.CrossRefGoogle Scholar
  23. 23.
    McNeely ML, Binkley JM, Pusic AL, Campbell KL, Gabram S, Soballe PW. A prospective model of care for breast cancer rehabilitation: postoperative and postreconstructive issues. Cancer. 2012;118(8 suppl):2226–36.CrossRefPubMedGoogle Scholar
  24. 24.
    Young A. The surgical management of early breast cancer. Int J Clin Pract. 2001;55:603–8.PubMedGoogle Scholar
  25. 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. Accessed 10 Jan 2013.
  26. 26.
    Koehler L. Axillary web syndrome and lymphedema, a new perspective. Lymph Link. 2006;18:9–10.Google Scholar
  27. 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. 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
  29. 29.
    Hase K, Kamisako M, Fujiwara T, Tsuji T, Liu M. The effect of zaltoprofen on physiotherapy for limited shoulder movement in breast cancer patients: a single-blinded before-after trial. Arch Phys Med Rehabil. 2006;87:1618–22.CrossRefPubMedGoogle Scholar
  30. 30.
    Paiva DM, Rodrigues VO, Cesca MG, Palma PV, Leite IC. Prevalence of lymphedema in women undergoing treatment for breast cancer in a referral center in southeastern brazil. BMC Womens Health. 2013;13:6.PubMedCentralCrossRefPubMedGoogle Scholar
  31. 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
  32. 32.
    Lyman GH, Giuliano AE, Somerfield MR, Benson 3rd AB, Bodurka DC, Burstein HJ, et al. American society of clinical oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23:7703–20.CrossRefPubMedGoogle Scholar
  33. 33.
    Ferreira Rezende L, Laier Franco R, Costa Gurgel MS. Axillary web syndrome: practical implications. Breast J. 2005;11:531.CrossRefPubMedGoogle Scholar
  34. 34.
    Villamiel Campos E, Ramallo Alcover A, Killing Rodriguez I. Axillary web syndrome. Prog Obstet Ginecol. 2008;51(12):745–8. Accessed 19 Dec 2014.
  35. 35.
    Yang EJ, Park W-B, Seo KS, Kim S-W, Heo C-Y, Lim J-Y. Longitudinal change of treatment-related upper extremity dysfunction and its impact on late dysfunction in breast cancer survivors: a prospective cohort study. J Surg Oncol. 2010;101:84–91.CrossRefPubMedGoogle Scholar
  36. 36.
    Cheville AL, Tchou J. Barriers to rehabilitation following surgery for primary breast cancer. J Surg Oncol. 2007;95:409–18.CrossRefPubMedGoogle Scholar
  37. 37.
    Aydogan F, Belli AK, Baghaki S, Karabulut K, Tahan G, Uras C. Axillary web syndrome after sentinel node biopsy. Breast Care. 2008;3:277–8.PubMedCentralCrossRefPubMedGoogle Scholar
  38. 38.
    Lauridsen MC, Christiansen P, Hessov IB. The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer: a randomized study. Acta Oncol. 2005;44:449–57.CrossRefPubMedGoogle Scholar
  39. 39.
    Josenhans E. Physiotherapeutic treatment for axillary cord formation following breast cancer surgery. Pt_Zeitschrift für Physiotherapeuten. 2007;59:868–78.Google Scholar
  40. 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
  41. 41.
    Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52:377–84.PubMedCentralCrossRefPubMedGoogle Scholar
  42. 42.
    Tan L, Wang M, Modini M, Joyce S, Mykletun A, Christensen H, et al. Preventing the development of depression at work: a systematic review and meta-analysis of universal interventions in the workplace. BMC Med. 2014;12(1):74.PubMedCentralCrossRefPubMedGoogle Scholar
  43. 43.
    Sutcliffe P, Martin S, Sturt J, Powell J, Griffiths F, Adams A, et al. Systematic review of communication technologies to promote access and engagement of young people with diabetes into healthcare. BMC Endocr Disord. 2011;11(1):1.PubMedCentralCrossRefPubMedGoogle Scholar
  44. 44.
    Benjamin DR, van de Water ATM, Peiris C. Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014;100(1):1–8.CrossRefPubMedGoogle Scholar
  45. 45.
    Park JE, Jang HJ, Seo KS. Quality of life, upper extremity function and the effect of lymphedema treatment in breast cancer related lymphedema patients. Ann Rehabil Med. 2012;36:240–7.PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Stout Gergich NL, Pfalzer LA, McGarvey C, Springer B, Gerber LH, Soballe P. Preoperative assessment enables the early diagnosis and successful treatment of lymphedema. Cancer. 2008;112:2809–19.CrossRefPubMedGoogle Scholar
  47. 47.
    Koehler L. Axillary web syndrome ongoing medical evaluation [Dissertation]: University of Minnesota; 2013. Accessed 10 Apr 2014.
  48. 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. 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
  50. 50.
    Leidenius M, Leppanen E, Krogerus L, von Smitten K. Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer. Am J Surg. 2003;185:127–30.CrossRefPubMedGoogle Scholar
  51. 51.
    Huh SJ, Yang J-H, Park W, Nam SJ, Kim JH. Axillary web syndrome after sentinel node biopsy and axillary lymph node dissection during the conservative treatment of early breast cancer. J Breast Cancer. 2005;8:94–8.CrossRefGoogle Scholar
  52. 52.
    Reedijk M, Boerner S, Ghazarian D, McCready D. A case of axillary web syndrome with subcutaneous nodules following axillary surgery. Breast. 2006;15:411–3.CrossRefPubMedGoogle Scholar
  53. 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. 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. 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. 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
  57. 57.
    Alvarez-Garrido H, Garrido-Rios AA, Sanz-Munoz C, Miranda-Romero A. Mondor’s disease. Clin Exp Dermatol. 2009;34:753–6.CrossRefPubMedGoogle Scholar
  58. 58.
    Lippi G, Favaloro EJ, Cervellin G. Hemostatic properties of the lymph: relationships with occlusion and thrombosis. Semin Thromb Hemost. 2012;38:213–21.CrossRefPubMedGoogle Scholar
  59. 59.
    Winicour J. What is cording? Lymph Link. 2013;25(2). Accessed 09 Feb 2015.
  60. 60.
    The Lymphoedema Framework. Best practice for the management of lymphoedema. International consensus. London: MEP Ltd; 2006.Google Scholar
  61. 61.
    Caban ME, Yadav R. Rehabilitation of breast cancer-related functional deficits. Crit Rev Phys Rehabil Med. 2008;20:1–23.CrossRefGoogle Scholar
  62. 62.
    Mabry H, Giuliano AE. Sentinel node mapping for breast cancer: progress to date and prospects for the future. Surg Oncol Clin N Am. 2007;16:55–70.CrossRefPubMedGoogle Scholar
  63. 63.
    Vitug AF, Newman LA. Complications in breast surgery. Surg Clin N Am. 2007;87:431–51.CrossRefPubMedGoogle Scholar
  64. 64.
    Torres Lacomba M, Mayoral del Moral O, Coperias Zazo JL, Gerwin RD, Zapico Goñi A. Incidence of myofascial pain syndrome in breast cancer surgery: a prospective study. Clin J Pain. 2010;26:320–5.CrossRefPubMedGoogle Scholar
  65. 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
  66. 66.
    Teixeira L, Veronesi P, Lohsiriwat V, Luini A, Schorr M, Garusi C, et al. Axillary web syndrome self-assessment questionnaire: initial development and validation. Breast. 2014;23(6):836-43.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of PhysiotherapyPrincess Alexandra Hospital, Metro South Hospital and Health ServiceBrisbaneAustralia
  2. 2.Principal Research Fellow, School of Public Health and Social WorkQueensland University of TechnologyBrisbaneAustralia
  3. 3.Centre for Functioning and Health ResearchMetro South Hospital and Health ServiceBrisbaneAustralia
  4. 4.Allied Health Research CollaborativeMetro North Hospital and Health ServiceBrisbaneAustralia
  5. 5.School of Allied Health Sciences, Griffith Health InstituteGriffith UniversityGold CoastAustralia

Personalised recommendations