THIEME

632 Systematic Review

Management of Axillary Web Syndrome after

Breast Cancer: Evidence-Based Practice
Tratamento da síndrome de rede axilar pós-câncer de
mama: prática baseada em evidências
Clarissa Medeiros da Luz1 Julia Deitos1 Thais Cristina Siqueira1 Marina Palú1
Ailime Perito Feiber Heck1

1 Physiotherapy Postgraduate Program, Center of Health and Sport Address for correspondence Clarissa Medeiros da Luz, PhD, Programa
Sciences, Universidade do Estado de Santa Catarina (Udesc), de Pós-Graduação em Fisioterapia, Universidade do Estado de Santa
Florianópolis, SC, Brazil Catarina (Udesc), Rua Pascoal Simone, 358-Coqueiros, 88080-350 -
Florianópolis–SC, Brazil (e-mail: [Link]@[Link]).
Rev Bras Ginecol Obstet 2017;39:632–639.

Abstract Axillary web syndrome is characterized as a physical-functional complication that

impacts the quality of life of women who have undergone treatment for breast cancer.
The present study aims to verify the physiotherapy treatment available for axillary web
syndrome after surgery for breast cancer in the context of evidence-based practice. The
selection criteria included papers discussing treatment protocols used for axillary web
syndrome after treatment for breast cancer. The search was performed in the MEDLINE,
Scopus, PEDro and LILACS databases using the terms axillary web syndrome,
lymphadenectomy and breast cancer, focusing on women with a previous diagnosis of
breast cancer who underwent surgery with lymphadenectomy as part of their
Keywords treatment. From the 262 studies found, 4 articles that used physiotherapy treatment
► physiotherapy were selected. The physiotherapy treatment was based on lymphatic drainage, tissue
► axillary web mobilization, stretching and strengthening. The four selected articles had the same
syndrome outcome: improvement in arm pain and shoulder function and/or dissipation of the
► conservative axillary cord. Although axillary web syndrome seems to be as frequent and detrimental
treatment as other morbidities after cancer treatment, there are few studies on this subject. The
► rehabilitation publications are even scarcer when considering studies with an interventional ap-
► cording proach. Randomized controlled trials are necessary to support the rehabilitation
► lymphadenectomy resources for axillary web syndrome.

Resumo A síndrome da rede axilar (ou cordão axilar) é uma complicação físico-funcional que
interfere na qualidade de vida de mulheres que foram submetidas a tratamento para o
câncer de mama. O objetivo do presente estudo foi verificar os tratamentos fisiote-
rapêuticos disponíveis para a síndrome da rede axilar após o tratamento cirúrgico do
câncer de mama no contexto da prática clínica baseada em evidências. Utilizou-se
como critério de inclusão artigos que discutissem protocolos de tratamento para a
síndrome da rede axilar após o tratamento para o câncer de mama. A pesquisa foi

received DOI [Link] Copyright © 2017 by Thieme Revinter

January 25, 2017 10.1055/s-0037-1604181. Publicações Ltda, Rio de Janeiro, Brazil
accepted ISSN 0100-7203.
May 5, 2017
published online
July 12, 2017
 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al. 633

realizada nas bases de dados MEDLINE, Scopus, PEDro e LILACS, utilizando como
palavras-chave síndrome da rede axilar linfadenectomia e câncer de mama, com foco em
mulheres com diagnóstico de câncer de mama que realizaram cirurgia com linfade-
nectomia como parte do tratamento. Dos 262 estudos encontrados, foram selecio-
Palavras-chave nados 4 artigos que utilizaram fisioterapia, os quais incluíram drenagem linfática,
► fisioterapia mobilização tecidual, alongamento e fortalecimento. Os quatro artigos selecionados
► síndrome da rede tiveram desfechos similares: melhora da dor no membro superior e na função do
axilar ombro e/ou desaparecimento do cordão axilar. Embora a síndrome da rede axilar seja
► tratamento tão frequente e prejudicial quanto as outras morbidades após tratamento para o
conservador câncer, existem poucos estudos sobre esse tema. As publicações são ainda mais
► reabilitação escassas quando se considera uma abordagem intervencionista. Estudos randomiza-
► cordão axilar dos controlados são necessários para embasar as técnicas de reabilitação na síndrome
► linfadenectomia da rede axilar após tratamento para o câncer de mama.

Introduction
to the stasis and tissue damage caused by the axillary surgery.
Breast cancer is the most common cancer that affects women, According to recent publications, all of these factors could
with
1.050.000 new diagnoses per year worldwide. It result in thrombosis of the axillary vessels, the large superficial
represents the leading cause of death by cancer among wom- vessels, or the upper limb lymphatic vessels, originating
en1 in developing countries.2 Surgery is the treatment of choice palpable cords.4,10,18
for this disease, and many times it includes sentinel lymph The studies by Moskovitz et al5 and Leidenius et al10
node biopsy (SLNB) or axillary lymph node dissection (ALND). showed that AWS has spontaneous resolution in a period
These procedures are important to predict prognosis, reduce of three to six months. However, it is known that during this
recurrence, and to plan an adequate treatment program.3 phase the patients experience significant pain and reduced
However, the axillary surgical approach leads to significant ROM in the compromised extremity, with a negative impact
short or long-term complications,4 such as pain, paresthesia, on or even preventing the use of radiation as an adjuvant
lymphedema and decreased range of motion (ROM).5,6 therapy in the cases it would be indicated.6
Recently, the literature has pointed out a condition whose Previous studies suggested that physiotherapy could alter
occurrence had been previously neglected. This condition is the natural course of AWS, with full remission in a period of
responsible for significant morbidity in the postoperative six to eight weeks.14,18 Therefore, physiotherapy has an
stage.4,6–8 Axillary web syndrome (AWS), or cording, is a important role in reducing the patients’ exposure to com-
dysfunction that usually occurs between the first and fifth plications caused by cording, improving their quality of life.
weeks following breast cancer surgery. It is characterized by Nevertheless, the treatment management and protocols are
the presence of a visible and palpable stretched band under not yet precise in these cases.
the skin, which is taut and painful during shoulder flexion or Thereby, the search for data about evidence-based practices
abduction.4,5,8–13 The cords are always present in the axilla, on the treatment of AWS after breast cancer surgery seems
and may extend down into the medial ipsilateral arm. These timely. Thus, the objective of this review was to determine the
cords frequently extend across the antecubital fossa and into current evidence of available physiotherapy treatments for
the forearm, and occasionally to the radial aspect of the wrist axillary web syndrome after breast cancer surgery.
and into the base of the thumb.5
In general, AWS is observed with the occurrence of two or
Methods
three palpable cords under the skin, with no hyperemia,
increased local temperature, or systemic symptoms. Howev- The planning for the present review was based on the
er, the patients may present significant loss in ROM, numb- Cochrane Handbook for Systematic Reviews of Interven-
ness, pain and tightness on the surgical ipsilateral upper tions,19 and adapted according to the recommendations of
limb, mainly when performing the shoulder abduction the Preferred Reporting Items for Systematic Reviews and
movement.5,6,12,14,15 Meta-Analysis (PRISMA) statement.20
Ferrandez and Serin16 initially described the presence of
cords in 1996 as lymphatic thrombosis. Later, the term axillary Eligibility Criteria
web syndrome was chosen to describe this phenomenon.5,17,18 Studies published on the MEDLINE, LILACS, PEDro or Scopus
The etiology of AWS is unknown; however, Moskovitz et al5 and databases that explored AWS or its treatments were selected
Ferrandez and Serin16 proposed that the pathogenesis would for this review, with no date restrictions.
be related to the damage in the venous/lymphatic system, to All studies that explored physiotherapy treatment for
the superficial venous/lymphatic hypercoagulability, as well as AWS as a single therapy associated with other techniques

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017

634 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al.

or compared with other interventions or to placebo were

Studies idenfied aer

Idenficaon
included. Studies with no clear description of the interven- database search:
tions or techniques were excluded. n = 262

Search Strategy
The electronic search was performed on the Medline, Scopus,

Screening
Selected studies aer removal
of duplicated publicaons:
LILACS, and PEDro databases using Medical Subject Headings n = 232
(MeSH) terms, with most common descriptors and expressions Total of publicaons excluded by
tle
found in the literature. Scottish Intercollegiate Guidelines Net- n = 138
work21 search filters were combined with an strategy developed
Selecon by tle
by the authors to enable the search of clinical trials that included n = 94
AWS treatment. This strategy was used for all databases, and Total of publicaons excluded by

Eligibility
adapted according to their specificities. The search was per- abstract
n = 57
formed until September 14th, 2016. ►Table 1 describes the
Complete scripts analyzed
specific search strategies on the selected databases. based on eligibility Total of publicaons excluded in
n = 37 full n = 33
• Studies that did not address
Study Selection axillary web syndrome n = 29
• Studies that did not treat
All titles and summaries retrieved from each database were axillary web syndrome n = 03

Included
imported to a free bibliographical package (Mendeley Reference Studies included in the • Studies with inaccuracy in the
qualitave synthesis treatment of the axillary web
Manager, Elsevier, Amsterdam, Netherlands) and compiled in a n=4 syndrome n = 01
central database in which four reviewers independently ana-
lyzed all the titles, keywords and summaries for relevance. Fig. 1 Flowchart of the studies included after the selection process.
When an agreement was not reached, a fifth reviewer was
consulted to decide on the eligibility of the study. Studies that
did not meet the inclusion criteria were not selected, and only 11 on LILACS, and 64 on Scopus. A total of 30 titles were found in
those meeting the selection criteria were fully analyzed. more than one database and excluded, and 232 tittles were left
for analysis. Subsequently, 94 and 37 manuscripts were
Evaluation of the Methodological Quality of the considered potentially relevant for summary review and full
Selected Studies manuscript review respectively. The studies had been pub-
The Strengthening the Reporting of Observational Studies in lished in English, Portuguese, Spanish, French, German, Dutch
Epidemiology (STROBE)22,23 statement was used to verify and Chinese. Finally, four studies published in English were
the methodological quality of the selected studies. It has a selected. ►Fig. 1 shows the detailed selection process.
scale that consists of 22 items, which were independently Among the excluded studies, the majority did not men-
verified by 4 reviewers. Each study was classified as follows: tion the axillary cord as one of the post-breast cancer surgery
A (studies that met 80% of the criteria), B (studies that met 50 morbidities, and some were limited to the identification of
to 80% of the criteria), and C (studies that met less than 50% of the axillary cord, with no therapeutic approach. The four
the criteria).23 selected studies had their main focus on physiotherapy
treatment for axillary cord after breast cancer surgery.
Two case reports conducted in England and China, and
Results
two randomized controlled clinical trials (RCCTs) from
Upon completion of the search with the applicable database Denmark and South Korea were included. The mean age
filters, 262 titles were identified, 45 on PEDro, 142 on MEDLINE, observed in all studies varied from 39 to 60 years. On the case

Table 1 Search strategies for the selected databases: MEDLINE, Scopus and PEDro

Search strategies
MEDLINE
((Axillary dissection OR axillary lymph node dissection OR axillary surgery OR axillary web syndrome OR axillary clearance
OR axillary cording OR cording OR lymphatic cording) AND (breast cancer OR breast neoplasm) AND (physical therapy
modalities))
SCOPUS
Breast neoplasm AND axillary web syndrome OR cording AND physical therapy OR physiotherapy
LILACS
(tw:((mh:(“breast cancer”)) AND (mh:(“physiotherapy (techniques)”)) AND (mh:(“axilla/surgery”)) AND (tw:(axillary web
syndrome)) OR (tw:(axillary cording)) OR (tw:(cording)) OR (tw:(lymphatic cording))))
PEDro
In the Problem field: muscle shortening, reduced joint compliance; in the Body Part field: upper arm, shoulder or shoulder
girdle; in the Subdiscipline field: oncology; in the Method field: clinical trial; when searching: match all search terms AND.

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017

 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al. 635

reports, the duration of the treatment varied between two weeks, and group B, after the 26th postoperative week. There
and four weeks. In one RCCT, the subjects underwent 12 was a significant improvement in shoulder function in group
sessions with a frequency of 2 sessions per week and follow- A compared with group B starting at the seventh postopera-
ups at 7, 13, 26 and 56 postoperative weeks. In the other one, tive week. Besides, the development of AWS was similar in
there were three weekly sessions for four weeks. All selected both groups, with no changes based on the type of surgery or
studies showed the same outcome: axillary cords resolved radiation therapy. The number of cording cases decreased
after treatment/follow-up, or improvement in pain and throughout the follow-up period, affecting 57% of the
shoulder function. Only the two RCCTs were categorized as participants on the 7th week, 31% on 13th week, 15% on
A studies based on the evidence hierarchy by the STROBE 26th week, and none after the 56th postoperative week.
classification22,23 (►Table 2). The aim of the study by Fourie and Robb14 was to report
On the RCCT by Lauridsen et al,24 139 patients who the treatment of a 47-year-old patient who developed AWS
underwent levels I and II lymph node dissections followed on the 22nd day after modified radical mastectomy with
by radiation (45%) and/or modified radical mastectomy with unilateral axillary dissection. Due to progressive loss of
or without levels I and II axillary dissections (55%) were shoulder movements upon the onset of AWS, which was
enrolled to evaluate the effects of physiotherapy on shoulder visible from the axilla to the wrist, the patient started
function. For such, 12 physiotherapy sessions of 60 minutes axillary cord stretching in abduction, self-mobilization, as
each were performed, including mobilization, relaxation and well as slight circular mobilization and soft tissue mobiliza-
strength training of the shoulder, vein pump therapy, as well tion of the chest wall. The treatment was performed over 10
as scar tissue mobilization and patient encouragement to sessions of 30 to 45 minutes each. After 26 days of treatment,
perform the exercises at home. The difference between the the patient returned to work and had complete resolution of
groups was related to the onset of the treatment: group A the syndrome, including an improvement in the pain and
started the treatment between the 6th and 8th postoperative shoulder mobility 16 weeks postoperatively. Thus, the

Table 2 Criteria for the evaluation of the methodological quality of the selected studies according to the Strengthening the
Reporting of Observational Studies in Epidemiology (STROBE) statement22

Section/topic Lauridsen et al24 Fourie and Robb14 Wei et al15 Cho et al25
(2005) (2009) (2013) (2016)
1 Title and abstract Y Y Y Y
Introduction 3 Background/rationale Y Y Y Y
4 Objectives Y N N Y
Methods 5 Study design Y N N Y
6 Participants Y Y N Y
7 Variables Y Y Y Y
8 Data sources/measurement Y Y Y Y
9 Bias N N Y Y
10 Study size Y N N Y
11 Quantitative variables Y N N Y
12 Statistical methods Y N N Y
Results 13 Participants Y N N Y
14 Descriptive data Y N Y Y
15 Outcome data Y Y Y Y
16 Main results Y Y Y Y
17 Other analysis Y N N N
Discussion 18 Key results Y Y Y Y
19 Limitations N N N Y
20 Interpretation Y Y N Y
21 Generalizability N N N Y
Other information 22 Funding N N N N
Total 18/22–81% 10/22–45% 9/22–40% 20/22–90%
Final classification A C C A

Abbrreviations: Y, yes; N, no.

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017

636 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al.

physiotherapy intervention was considered efficient. How- and manual therapy with massages and tissue mobilization
ever, the authors acknowledge the need for further inves- composed the treatment for AWS. The physiotherapy inter-
tigations to develop a standard physiotherapy treatment for ventions in these studies varied from 10 to 12 sessions. The
this syndrome. results show evidence of improvements in the ROM of the
The study by Wei et al15 described the treatment of a case shoulder and patient well-being, and the resolution of pain
of AWS secondary to breast-conserving surgery and negative and reduction of cords during the physical examination, with
SLNB. On the third day after her second procedure for margin the exception of the study by Cho et al,25 an RCCT in which
excision, with no axillary dissection, the patient developed the authors did not observe differences between the groups
axillary cords. During her follow-up, the cords extended to for visible cords at the end of the treatment.
her elbow and the superior external quadrant of the ipsilat- Although the study by Cho et al25 reports the incidence of
eral breast. The authors report that besides the pharmaco- visible cords in 28.5% of the patients who underwent exer-
logical treatment, she underwent massage sessions on the cises combined with manual lymphatic drainage, and in 35%
cord area, and performed shoulder abduction exercises. of the patients who only performed exercises, without
However, there are no details about the recommended making it clear if there were any differences in inspection
exercises. After two weeks of treatment, she presented and palpation of the cords compared to the initial param-
decreased pain and increased ROM on shoulder abduction, eters, the significant improvement in arm pain in the group
as well as an improvement in the axillary cording. On the that underwent manual lymphatic drainage, and the im-
third week follow-up, a physical exam showed full recovery provement in shoulder function after interventions observed
of ROM and absence of pain. Moreover, the axillary cords in both groups indicate a possible improvement in AWS itself.
were visible but no longer palpable, even though the patient Therefore, the results of the four studies show the efficacy
still reported numbness and tightness. of physiotherapy as a conservative intervention for AWS after
Recently, Cho et al25 designed a randomized clinical trial breast cancer treatment. However, these results should be
to evaluate the effects of physiotherapy combined with carefully analyzed, as the scientific evidence level of two of
manual lymphatic drainage on shoulder function, pain and the selected studies did not present appropriate methodo-
lymphedema compared with isolated physical therapy in logical accuracy.
breast cancer patients with AWS. The 48 participants re- The axillary surgical approach has been important in the
cruited for the study had pain in the arm area and presented treatment of breast cancer. However, the dissection of
palpable or visible cords on the arm for at least four weeks lymph nodes may lead to comorbidities such as AWS.26
after surgery. They were submitted to three weekly sessions The incidence of AWS is different among women who
of a physiotherapy program for four weeks, which consisted underwent breast surgery and SLNB and those who under-
of stretching and strengthening exercises for upper limb went ALND; it varies from 11.7 to 20%, and from 38 to 72%
tissue mobilization, scapular mobilization and shoulder respectively.6,18,27,28 The development of cords occurs from
ROM exercises, and a specific program for AWS. The partic- two to six weeks after surgery and is, therefore, associated
ipants were divided into two groups: the first group only with the initial phases of postoperative wound healing. The
performed the exercise program, and the second underwent literature suggests that adhesion formed around the lym-
the exercise program and 30 minutes of manual lymphatic phatic veins could be responsible for AWS and venous
drainage daily 5 times for 1 week, with instructions to thrombosis. Yet, there is still little evidence to support
perform it at home themselves for the other two to four this theory.14
weeks of the program. There was a significant improvement Fourie and Robb14 mention studies that point AWS as a
in pain and arm volume in the group that performed manual self-limiting comorbidity, with spontaneous resolution in
lymphatic drainage. In addition, both groups showed im- about three months.10,14 However, the study by Torres
provements in quality of life, strength and shoulder function Lacomba et al18 indicates that physiotherapy for AWS could
after the interventions. There was no significant difference shorten the natural course of the syndrome to six to eight
related to visible cording between the groups, and it was weeks.
present in 28.5% of the patients who underwent exercises Several studies indicate the use of physiotherapy for the
combined with manual lymphatic drainage, and in 35% of the treatment of AWS in the form of active exercises, Kabat
patients who only performed exercises. diagonals, pendulum exercises, stretching, myofascial techni-
►Table 3 details the main methodological aspects and the ques, manual therapy, cryotherapy, thermotherapy14,29,30 and
results of the studies selected for the present systematic active and passive exercises that should be implemented
review. early.18 When the limitation is severe and the pain level is
high, it is suggested that the treatment begin with mild gravity
assisted exercises, such as Codman pendulum exercises. With
Discussion
the improvement in the limiting symptoms, active mobiliza-
According to the results of the present systematic review, all tion of the shoulder in flexion, abduction, and internal and
four studies showed that AWS developed between one and external rotations should be implemented.29
six months postoperatively. Exercises for shoulder ROM and The myofascial techniques and manual therapy are also
for strengthening and relaxation, instruction for lymphatic used on lymphatic cords. The study conducted by Cheville
drainage and mobilization of scar tissue, as well as stretching and Tchou29 instructs therapists and patients to perform

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017

 Table 3 Description of the main methodological aspects and results of the selected studies

Lauridsen et al24 (2005) Fourie and Robb14 (2009) Wei et al15 (2013) Cho et al25 (2016)
Title/Country The effect of physiotherapy on shoulder function Physiotherapy management of axillary web syn- Axillary web syndrome following secondary Effects of a physical therapy program combined
in patients surgically treated for breast cancer: A drome following breast cancer treatment: Discuss- breast-conserving surgery: a case report/China. with manual lymphatic drainage on shoulder
randomized study/Denmark. ing the use of soft tissue techniques/England. function, quality of life, lymphedema incidence,
and pain in breast cancer patients with axillary
web syndrome following axillary dissection/
South Korea.
Mean age (SD) Group A: MRM þ RT ¼ 49 years, MRM ¼ 60 47 years. 39 years. PTMLD group ¼ 46.6 years; PT group ¼ 50.7
years, BCT ¼ 54 years; Group B: MRM þ RT¼ years.
51 years, MRM¼ 63 years, BCT¼ 54 years.
Number of 139 1 1 48
participants
Study design Randomized controlled clinical trial Case report Case report Randomized controlled clinical trial
Participants’ Patients with breast cancer who underwent uni- Patient who underwent left MRM and axillary Patient diagnosed with breast cancer who un- Breast cancer patients who underwent surgery
characteristics lateral surgery planned according to the Danish dissection. On the 22nd day post-surgery, she derwent conservative surgery and sentinel lymph with pain and visible or palpable cords in the arm
Breast Cancer Cooperative Group (DBCG) guide- developed severe headache and nausea asso- node biopsy. Seventeen days after the first sur- for at least four weeks. Exclusion criteria: lym-
lines. Exclusion criteria: comorbidities that would ciated with the development of tight and painful gery, a second procedure was needed for margin phedema, thrombosis, skin infection and mus-
affect the upper limbs prior to surgery. subcutaneous cords extending from the medial excision. Three days after the second surgery, the culoskeletal disorders.
aspect of the inner arm into the cubital tunnel and patient reported severe pain in the ipsilateral
the medial aspect of the left wrist, with pro- axilla, limitation on shoulder abduction, and ax-
gressive restriction of all shoulder movements. illary cords.
Intervention Group intervention with shoulder mobilization Patient instructions and a booklet with home- Aescuven (Cesra Arzneimittel GmbH & Co., Baden- PT group: exercise program consisting of
exercise program, relaxation, strength training, based exercises. Physiotherapy sessions including Baden, Germany) was prescribed twice a day for one stretching and strengthening exercises for upper
venous pump therapy, and instruction on mobi- axillary cord stretching in abduction, self-mobili- week, and the patient was instructed to perform limb tissue mobilization, scapular mobilization,
lization of the scar tissue. The patients were zation, as well as slight circular mobilization of shoulder exercises, including shoulder abduction, and shoulder ROM exercises. Specifically for AWS:
encouraged to perform the exercises on a regular the shoulder and soft tissue mobilization of the and cord massage twice a day for 30 minutes. 1) soft tissue mobilization techniques and
basis at home. chest wall. stretching for tight tissue cords; 2) shoulder
abduction, elbow extension, and wrist supination
and extension stretching exercises; 3) shoulder
girdle mobilization; and 4) passive ROM exercises.
PTMLD group: the same exercise program in
addition to 30 minutes of manual lymphatic
drainage for 1 week, with instructions to perform
it at home themselves for the other 2-4 weeks of
the program.
Treatment Group A: 12 physiotherapy sessions of 60 min- Ten sessions over 26 days. Two weeks Both groups: three sessions a week for four weeks
duration utes, twice a week. The treatment started be-
tween the sixth and eighth postoperative weeks.
Group B: 12 sessions of 60 minutes each, twice a
week, but they only started after the 26th post-
operative week. The patients were evaluated 4
times during the first postoperative year (at
weeks 7, 13, 26 and 56).
Results Significant improvement in shoulder function on the Improvement in shoulder mobility and well- Increased ROM from 90° to 170°, and resolution No significant difference regarding visible cord-
surgical side on group A compared to group B being, enabling the participant to resume her of pain. The tightness and numbness sensation on ing between the groups. Improvement in pain
starting at the second assessment (6 weeks on fulltime activities 26 days after the onset of the arm was still present, but improved. The cords and arm volume in the group that performed

Rev Bras Ginecol Obstet

treatment). At the fourth evaluation, both groups cording. After the completion of the physiother- were no longer visible or palpable at the end of manual lymphatic drainage. Both groups showed
presented a significant improvement. The number apy sessions, the participant was instructed to the treatment. improvements in quality of life, strength and
Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice

decreased to 43 (31%) patients on the second continue with the self-mobilization and exercises. shoulder function after the interventions.

Vol. 39
follow-up, and to 21 (15%) on the third follow-up,
6 months after surgery. Complete remission in all
cases in the follow-up after 1 year.

Abbreviations: AWS, axillary web syndrome; BCT, breast-conserving therapy; MRM, modified radical mastectomy; PT, physiotherapy; PTMLD, physiotherapy þ manual lymphatic drainage; ROM, range of motion;
Luz et al.

No. 11/2017
RT, radiation therapy; SD, standard deviation.
637
638 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al.

manual techniques to release the cords. Torres Lacomba AWS and its treatment, the studies selected in this review
et al18 mention specific manual lymphatic drainage using showed the efficacy of physiotherapy as a conservative
the thumb to make the lymphatic cords more flexible. Still, technique for the treatment of AWS following breast cancer
there is no evidence that such techniques contribute to the surgery. The studies included programs with exercises to
improvement of AWS. increase shoulder ROM, relaxation, strengthening, and
Although suggested by Cheville and Tchou,29 thermother- instructions for lymphatic drainage, stretching and manual
apy should be used with caution. Heat makes collagen more therapy, such as massage and tissue mobilization. These
flexible, consequently improving shoulder ROM, but the interventions lead to improvements in ROM, resolution of
extensive exposure to heat increases vasodilatation and, pain, reduction of cords on inspection and, consequently,
therefore, the risk of lymphedema.31 Besides, patients pre- improvements in the well-being of women.
senting intercostobrachial nerve lesion, another common The lack of scientific interest on this subject suggests that
morbidity related to breast cancer treatment, have increased this complication may be underestimated or neglected on
risk of skin burning due to reduced sensitivity in the area.29 the clinical practice. Therefore, new prospective controlled
It is possible that the lack of studies on this subject could studies with high methodological accuracy would be valu-
be explained by the relatively short period since this mor- able to support the evidence-based practice. This is particu-
bidity has been described in the literature. As Fukushima larly important, as AWS affects the functionality of women
et al26 mentioned, AWS has not yet had a complete review of with progressive pain that evolves into partial or complete
its complications and treatments and, until a few years ago, it immobility of the affected extremity.
had no proper definition. Despite the deficiency in studies
describing the pathophysiology of AWS, there is a tendency
of recent publications to describe its etiology and character-
istics using complementary exams such as ultrasonography References
and magnetic resonance imaging.8,9 A recent study is pro- 1 DeSantis C, Ma J, Bryan L, Jemal A. Breast cancer statistics, 2013.
posing the use of a new self-assessment questionnaire to CA Cancer J Clin 2014;64(01):52–62
improve diagnosis and patient education to evaluate the 2 Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global
cancer statistics, 2012. CA Cancer J Clin 2015;65(02):87–108
presence of AWS.28
3 Nogueira PVG, Guirro ECO, Guirro RRJ, Palauro VA. [Effects of
Previous studies suggesting the lack of efficacy of physio- proprioceptive neuromuscular facilitation on functional perfor-
therapy on the treatment of AWS have not specified the mance of mastectomized women]. Fisioter Bras 2005;6(01):
proposed exercise protocol.29,32 Furthermore, the remaining 28–35 Portuguese
studies excluded from the present review had no description 4 Reedijk M, Boerner S, Ghazarian D, McCready D. A case of axillary
of the methods used, the AWS examination, or the selected web syndrome with subcutaneous nodules following axillary
surgery. Breast 2006;15(03):411–413
type and frequency of the treatment. Other studies described
5 Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ, Moe
the treatment but not the efficacy analysis on the results RE. Axillary web syndrome after axillary dissection. Am J Surg
following intervention or patient education. 2001;181(05):434–439
It is important to point out the quality of the selected 6 Koehler LA, Blaes AH, Haddad TC, Hunter DW, Hirsch AT, Ludewig
studies, as the level of scientific evidence on the manuscripts PM. Movement, function, pain, and postoperative edema in
axillary web syndrome. Phys Ther 2015;95(10):1345–1353
was not quite accurate in terms of methodology. Only two
7 Bernas MJ. Axillary web syndrome, the lost cord, and lingering
studies were classified as STROBE category A, and the other
questions. Lymphology 2014;47(04):153–155
two were classified as category C, as it applies to case reports. 8 Leduc O, Fumière E, Banse S, et al. Identification and description of
None of these two studies with lower levels of scientific the axillary web syndrome (AWS) by clinical signs, MRI and US
evidence described the study design, the variables used, and/ imaging. Lymphology 2014;47(04):164–176
or the research limitations. Nevertheless, these studies are 9 Koehler LA, Hunter DW, Haddad TC, Blaes AH, Hirsch AT, Ludewig
PM. Characterizing axillary web syndrome: ultrasonographic
still important to understand this morbidity, considering
efficacy. Lymphology 2014;47(04):156–163
that the lack of publications on this subject contributes to the 10 Leidenius M, Leppänen E, Krogerus L, von Smitten K. Motion restric-
low evidence on this matter. tion and axillary web syndrome after sentinel node biopsy and
axillary clearance in breast cancer. Am J Surg 2003;185(02):127–130
11 Torres Lacomba M, Yuste Sánchez MJ, Zapico Goñi A, et al.
Conclusion Effectiveness of early physiotherapy to prevent lymphoedema
after surgery for breast cancer: randomised, single blinded,
Surgeries are often the first treatment choice for breast
clinical trial. BMJ 2010;340:b5396
cancer, and may result in several complications, including 12 Leduc O, Sichere M, Moreau A, et al. Axillary web syndrome:
AWS, which causes pain and ROM limitation on the ipsilat- nature and localization. Lymphology 2009;42(04):176–181
eral upper limb. The complete or partial mobility limitation 13 Fukushima KF, Carmo LA, Borinelli AC, Ferreira CW. Frequency
of the arm may delay the beginning of the radiation therapy. and associated factors of axillary web syndrome in women who
Thus, it is extremely important to recognize all available had undergone breast cancer surgery: a transversal and retro-
spective study. Springerplus 2015;4:112
resources to treat this complication, enabling the early
14 Fourie WJ, Robb KA. Physiotherapy management of axillary
initiation of adjuvant therapies. web syndrome following breast cancer treatment: discussing
Although AWS has spontaneous resolution within a few the use of soft tissue techniques. Physiotherapy 2009;95(04):
weeks, and besides the lack of methodological evidence on 314–320

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017

 Management of Axillary Web Syndrome after Breast Cancer: Evidence-Based Practice Luz et al. 639

15 Wei P, Zhu L, Chen K, Jia W, Hu Y, Su F. Axillary web syndrome 24 Lauridsen MC, Christiansen P, Hessov I. The effect of physiother-
following secondary breast-conserving surgery: a case report. apy on shoulder function in patients surgically treated for breast
World J Surg Oncol 2013;11:8 cancer: a randomized study. Acta Oncol 2005;44(05):449–457
16 Ferrandez J, Serin D. Rééducation et cancer du sein. Paris: Masson; 25 Cho Y, Do J, Jung S, Kwon O, Jeon JY. Effects of a physical therapy
1996. program combined with manual lymphatic drainage on
17 Aydogan F, Belli AK, Baghaki S, Karabulut K, Tahan G, Uras C. shoulder function, quality of life, lymphedema incidence, and
Axillary web syndrome after sentinel node biopsy. Breast Care pain in breast cancer patients with axillary web syndrome
(Basel) 2008;3(04):277–278 following axillary dissection. Support Care Cancer 2016;
18 Torres Lacomba M, Mayoral Del Moral O, Coperias Zazo JL, Yuste 24(05):2047–2057
Sánchez MJ, Ferrandez JC, Zapico Goñi A. Axillary web syndrome 26 Fukushima KFP, Silva HJ, Ferreira CWS. Alterações vasculares
after axillary dissection in breast cancer: a prospective study. resultantes da abordagem cirúrgica da axila: uma revisão da
Breast Cancer Res Treat 2009;117(03):625–630 literatura. Rev Bras Mastologia. 2011;21(02):91–98
19 Higgins J, Green S. Cochrane handbook for systematic reviews of 27 Bergmann A, Mendes VV, de Almeida Dias R, do Amaral E Silva B,
interventions [Internet]. Chichester: Wiley; 2011 [cited 2012 Mar da Costa Leite Ferreira MG, Fabro EA. Incidence and risk factors for
20]. Available from: [Link] axillary web syndrome after breast cancer surgery. Breast Cancer
[Link] Res Treat 2012;131(03):987–992
20 Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for 28 Nevola Teixeira LF, Veronesi P, Lohsiriwat V, et al. Axillary web
reporting systematic reviews and meta-analyses of studies that syndrome self-assessment questionnaire: Initial development
evaluate healthcare interventions: explanation and elaboration. and validation. Breast 2014;23(06):836–843
BMJ 2009;339:b2700 29 Cheville AL, Tchou J. Barriers to rehabilitation following surgery
21 Scottish Intercollegiate Guidelines Network [Internet]. Search for primary breast cancer. J Surg Oncol 2007;95(05):409–418
filters. 2014 [cited 2015 Feb 17]. Available from: [Link] 30 Pou Chaubron M, Almendáriz Juárez A, Peñalva Padial G, Case-
[Link]/methodology/fi[Link] rmeiro Cortés J. El síndrome axillary-web, frecuente, pero infra-
22 Malta M, Cardoso LO, Bastos FI, Magnanini MM, Silva CM. STROBE diagnosticado. Rehabilitación. 2012;46(02):175–178
initiative: guidelines on reporting observational studies. Rev 31 International Society of Lymphology. The diagnosis and treat-
Saude Publica 2010;44(03):559–565 ment of peripheral lymphedema: 2013 Consensus Document of
23 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vanden- the International Society of Lymphology. Lymphology 2013;
broucke JP; STROBE Initiative. The Strengthening the Reporting of 46(01):1–11
Observational Studies in Epidemiology (STROBE) statement: 32 Craythorne E, Benton E, Macfarlane S. Axillary web syndrome or
guidelines for reporting observational studies. Int J Surg 2014; cording, a variant of mondor disease, following axillary surgery.
12(12):1495–1499 Arch Dermatol 2009;145(10):1199–1200

Rev Bras Ginecol Obstet Vol. 39 No. 11/2017