Abstract

Axillary Web Syndrome: Evidence for Lymphatic Origin with Thrombosis

Karin Johansson, RPT, PhD,1 Heung Chong, PhD, FRCPath,2 Cristina-Daria Ciornei, MSc, PhD,3 Ha˚kan Brorson, MD,4,5 and Peter S. Mortimer, MD, FRCP6. Lymphatic Research Biology 2019.

Background: The axillary web syndrome (AWS) occurs in the axilla and on the frontal side of the upper arm and sometimes along the forearm to the thumb. The cord is painful, particularly on movement, and can therefore be very distressing for the patient. Although the phenomenon has been examined and discussed for decades, no evidence for the origin has been found until now. The aim of this study was to perform a histopathologic analysis of cords taken between 1996 and 1998 in the Surgical Clinic, Skane University Hospital, Lund, Sweden.

Methods and Results: In seven patients, biopsies of the AWS cords were obtained 4–5 weeks after axillary node surgery for breast cancer and examined with standard hematoxylin and eosin and D2–40 (lymphatic endothelial cell) staining. In one biopsy, there was a dilated vessel with a thickened wall, which was confirmed by D2–40 immunostaining to represent a lymphatic vessel. The lumen was occluded by organized thrombus, within which new vessels were being formed, indicating recanalization. In two other biopsies, similar lymphatic vessels with thickened walls were present, although the lumen of the vessels was not visualized in the planes of the section. The other four biopsies do not show specific features.

Conclusion: Although only one case, this is the first pathological evidence of thrombosis within a confirmed lymphatic vessel from a case of cording. We propose that the axillary cord represents lymphatic vessel thrombosis. Recanalization of the thrombus may eventually restore lymphatic flow consistent with the transient nature of the condition.

Main findings

• N = 7
• It is a reasonable hypothesis that the cording represents lymphatic thrombosis because (a) the phenomenon occurs after severance of lymphatic vessels and (b) lymph does clot.
• The ability to snap the cords is consistent with a thrombosed vessel.
• Axillary node surgery can clearly account for disruption and stasis in lymphatic flow and damage to lymphatic vessels.
• The finding of thrombotic occlusion of the dilated lymphatic vessel with recanalization of the organized thrombus by angiogenesis corresponds to the transient nature of the axillary cord. The cord resolves as the vessel gradually recanalizes. This agrees with the natural history of AWS, showing a reduction of symptoms and normalization of ROM within 3 months postoperatively. Thus, the patients with an axillary cord should be reassured and informed that this condition will improve, even without treatment.
• Although only one case, this is the first pathological evidence of thrombosis within a confirmed lymphatic vessel from a case of cording. We propose that AWS represents lymphatic vessel thrombosis. Recanalization of the thrombus and its resolution are consistent with the transient nature of the condition.