Axillary Web Syndrome: a Poorly Understood Side Effect of Lymph Node Removal

When it comes to the various side-effects of cancer therapy, Axillary Web Syndrome is probably less well known, and less understood than even lymphedema.  Occasionally called “cording lymphedema”, “syndrome of the axillary cords”, “syndrome of axillary adhesion”, or a variant of “Mondor’s disease”, Axillary Web Syndrome is a surprisingly common lymphatic condition arising from lymph node dissection during cancer therapy.

The origin, presentation, and course of Axillary Web Syndrome are still poorly defined.  Breast cancer patients undergoing lymph node dissection surgery may initially experience normal pain-free arm function and range of motion immediately following surgery.  However, over the course of a few weeks post surgery some of these patients will develop a rope-like cord of tissue that is palpable under the skin of their armpit, and exhibit associated pain and tension that limits arm function and range of motion.  Time of onset may also be delayed.  This condition can occur without associated lymphedema, and no redness or irritation may be visible.  While Axillary Web Syndrome may resolve on its own after about 3 months (although timing is variable), it can significantly impact patient quality of life.

Thanks to recent clinical studies, the incidence of Axillary Web Syndrome is becoming clearer, but larger more detailed studies are still needed.  One study from 2009 reported 48% of patients experienced Axillary Web Syndrome following axillary lymph-node dissection (Torres Lacomba, M., et al. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat. 2009 Oct;117(3):625-30.), while another study in 2011 reported an incidence rate of 28% in the early postoperative period (45 days) (Bergmann, A., et al. Incidence and risk factors for axillary web syndrome after breast cancer surgery. Breast Cancer Res Treat. 2012 Feb;131(3):987-92.).  The incidence rate will certainly vary based on characteristics of the patients themselves, as well with the type of lymph node procedure performed.  Less invasive axillary surgeries are likely to exhibit a smaller incidence rate.  In the Bergmann study, women who underwent sentinel lymph node biopsy appeared to have a 68% reduction in risk of Axillary Web Syndrome compared with patients who underwent the more invasive procedure of axillary node dissection.

Although a gold-standard of care is not yet established, various physiotherapy protocols have been reported in a handful of studies to be beneficial for improving limb function and range of motion in patients with this Axillary Web Syndrome (for example: Lauridsen M.C., et al. The effect of physiotherapy on shoulder function in patients surgically treated for breast cancer: a randomized study. Acta Oncol. 2005;44:449-57.).  Our own anecdotal experience at Toronto Physiotherapy also suggests good success with manual therapy approaches.  Although Axillary Web Syndrome may be painful, functionally limiting, and alarming given the lack of available information, patients can take comfort in knowing that the condition is generally self-limiting, and that viable manual therapy options do exist.