Function, Shoulder Motion, Pain, and Lymphedema in Breast Cancer With and Without Axillary Web Syndrome: An 18-Month Follow-Up

Linda A. Koehler, David W. Hunter, Anne H. Blaes, Tufia C. Haddad. Physical Therapy Volume 98 Number 6 June 2018

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Function, Shoulder Motion, Pain, and Lymphedema in Breast Cancer With and Without Axillary Web Syndrome: An 18-Month Follow-Up

Linda A. Koehler, David W. Hunter, Anne H. Blaes, Tufia C. Haddad. Physical Therapy Volume 98 Number 6 June 2018

Background. Axillary web syndrome (AWS) can develop following breast cancer surgery and presents as a tight band of tissue in the axilla with shoulder abduction.

Objective. The objectives were to determine the prevalence and natural history of AWS and the association between AWS and function, range of motion, pain, lymphedema, and body mass index (BMI).

Design. This study was a longitudinal prospective cohort study utilizing a repeated measures design.

Methods. Axillary web syndrome, function, shoulder range of motion, pain, and lymphedema (using circumference, bioimpedance spectroscopy, tissue dielectric constant) were assessed in women at 2, 4, and 12 weeks and 18 months following breast cancer surgery. Prevalence of AWS and the association with the measured outcomes were analyzed.

Results. Thirty-six women agreed to participate in the study. The cumulative prevalence of AWS was 50% (18/36) at 18 months following breast cancer surgery. AWS was identified as a risk factor for reduced function. Women with AWS had statistically reduced range of motion, lower BMI, and higher number of lymph nodes removed compared to the non AWS group. Forty-one percent (13/32) of women had AWS at 18 months. AWS reoccurred in 6 women following resolution, and a new case developed beyond the early postoperative period. The overall prevalence of physical impairments ranged from 66% to 97% within the first 18 months following surgery regardless of AWS.

Limitations. Limitations include a small sample size and potential treatment effect.

Conclusion. AWS occurs in approximately 50% of women following breast cancer surgery. It can persist for 18 months and potentially longer, develop beyond the early postoperative time period, and reoccur after resolution. Clinicians need to be aware of the chronicity of AWS and its association with reduced range of motion and function.

Main findings

  • Small sample size.
  • Growing body of evidence that appears to support the hypothesis that AWS results from a local pathophysiological injury to the lymphatic system
  • AWS was once thought to be a self-limiting condition, which resolved spontaneously by 3 months after surgery. This has been disproved as it has been demonstrated that AWS can persist at 12 weeks following breast cancer surgery. Early postoperative decrease in shoulder ROM was significantly worse in individuals with AWS, and that women with lower BMI were at higher risk of AWS.
  • The period prevalence of AWS was 33%, 42%, 47%, and 50% at 2, 4, and 12 weeks and 18 months, respectively. Thirteen women (41%) had AWS at 18 months. A new case of AWS was discovered at 18 months that was not present at previous visits. AWS returned in 6 women at 18 months following no identifiable signs of AWS at 12 weeks.
  • Women with sentinel node biopsy (SNB) had a 43% prevalence, and those with axillary lymph node dissection (ALND) had a 75% prevalence. Visible cords were detected in 48% of women. Fifty-two percent of the women had cords that were palpable but not visible, requiring careful palpation of the axilla in the abducted position for detection.
  • AWS have reduced ROM, lower BMI, and a higher number of lymph nodes removed, and AWS was identified as a risk factor for long-term reduced function.
  • A larger sample size may be needed to provide evidence as to whether or not there is an association between AWS and other physical impairments such as lymphoedema.
  • Previous studies have suggested AWS may go undetected because it is hidden by excess adipose tissue present in women with a higher BMI. It has also been suggested that AWS may be related to scar formation, and the thick layer of subcutaneous adipose tissue in obese individuals may prevent adhesions from developing.
  • The authors of this study the pathophysiology of AWS is part of the body’s natural response to lymphatic injury and may be suppressed in women with a higher BMI. When the lymphatic system has been injured, the body responds with a cascade of events, including inflammation, leakage of lymphatic fluid into the interstitial space, and coagulation. In order to remove lymphatic fluid and re-establish lymphatic flow, the  lymphatic vessels attempt to recanalize and reconnect by forming lymphatic connections to existing lymph vessels (ie, lymphangiogenesis). The newly forming lymphatic vessels may become adhered to the underlying tissue during the attempt to make a lymphatic connection.