ARTICLE IN PRESS

The Breast (2006) 15, 411–413

THE BREAST

www.elsevier.com/locate/breast

CASE REPORT

A case of axillary web syndrome with subcutaneous

nodules following axillary surgery
Michael Reedijka,, Scott Boernerb, Danny Ghazarianb, David McCreadya

a
Department of Surgical Oncology, Princess Margaret Hospital, University Health Network and the
University of Toronto, 610 University Avenue, Toronto, Ont., Canada M5G 2M9
b
Department of Pathology, Princess Margaret Hospital, University Health Network and the University of
Toronto, 610 University Avenue, Toronto, Ont., Canada M5G 2M9

Received 5 May 2005; received in revised form 20 July 2005; accepted 21 September 2005

KEYWORDS Summary Axillary web syndrome (AWS) is a cause of morbidity in the early
Axillary web syndrome; postoperative period following axillary surgery, which is characterized by cords of
Lymphatics; subcutaneous tissue extending from the axilla into the medial arm. Few reports have
Thrombosis; been published describing this entity, which results in pain and a limitation of
Axillary dissection shoulder abduction. Here, we report a case of AWS that was accompanied with sub-
cutaneous nodules mimicking recurrence of breast cancer.
& 2005 Elsevier Ltd. All rights reserved.

Introduction include bleeding, wound dehiscence, infection at

the operative site, and seroma formation. The
The potential benefits of performing axillary potential long-term complications of ALND include
surgery in breast cancer include its well-estab- pain, numbness, swelling, weakness and reduced
lished prognostic purpose, contribution to adjuvant range of motion (ROM).
therapy planning, and a reduction in the risk of The axillary web syndrome (AWS) is a self-
axillary recurrence. The surgical assessment of limiting and frequently over-looked cause of
axillary lymph nodes for metastatic spread con- significant morbidity occurring in approximately
tinues to be a significant source of breast cancer 6% of patients in the early post-operative period
treatment morbidity. Early complications of ALND following surgery of the axilla.1 Although AWS has
most frequently been reported in patients follow-
ing axillary lymph node dissection in breast cancer
Corresponding author. Tel.: +416 946 4432;
we have also observed this morbidity following
fax: +416 946 6590. axillary staging in melanoma (confirmed by patho-
E-mail addresses: michael.reedijk@uhn.on.ca (M. Reedijk),
scott.boerner@uhn.on.ca (S. Boerner),
logical examination). The syndrome is character-
danny.ghazarian@uhn.on.ca (D. Ghazarian), ized by axillary pain that radiates down the arm,
david.mccready@uhn.on.ca (D. McCready). limited shoulder ROM and cords of tissue extending

0960-9776/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.breast.2005.09.005
 ARTICLE IN PRESS
412 M. Reedijk et al.

right-sided 4.5 cm breast cancer. Pathological in-

vestigation of the primary tumor revealed an
invasive ductal carcinoma with a modified Bloom
and Richardson histologic grade III/III and positive
estrogen and progesterone receptor expression.
Through a standard level I and II axillary lymph node
dissection, 31 metastases-negative lymph nodes
were retrieved. The initial postoperative course
included decreased ROM of the ipsilateral arm that
improved with physiotherapy and time. After sur-
gery the patient was started on a six-cycle course of
cyclophosphamide/epirubicin/5-flurouracil (CEF)
chemotherapy with a plan for breast radiation
therapy after completion of chemotherapy.
Approximately 7 weeks after surgery this patient
presented with a several-week history of right-
sided arm pain, reduced ROM and findings on
physical exam consistent with AWS. Furthermore,
inspection of the epitrochlear area of the right arm
revealed multiple subcutaneous nodules. The re-
mainder of the physical exam did not reveal any
evidence of loco-regional or systemic recurrence.
Staging work-up with chest X-ray, abdominal ultra-
sound and bone scan were negative.
By 11 weeks after surgery the subcutaneous
nodules had grown in number (total of four) and
Figure 1 (A) Patient demonstrating axillary web syn-
in size (the largest nodule was 2 cm). The nodules
drome in left arm. Taut cords extending from the axilla
were described as painless and mobile. The
and beyond the anticubital fossa is seen. The patient is
unable to fully extend the left elbow. Inset shows a close- possibility that these nodules may represent evi-
up of the cords. This patient did not develop subcuta- dence of stage IV disease was raised and so fine
neous nodules as is described in the case reported in the needle aspiration followed by excisional biopsy was
text. (B) This photomicrograph shows the central portion undertaken for pathological assessment. The fine
of a subcutaneous nodule filled with thrombotic material needle aspirate of the lesion was limited by low
and evidence of recanalization of the lumen. The fibrosis cellularity and revealed reactive mesenchymal
involving the wall of the lesion is seen extending into the cells. Following excision of the lesion, gross
adjacent adipose tissue. Note the absence of smooth examination revealed a solitary white nodule
muscle and elastic lamina in the wall of the lesion (elastic surrounded by adipose tissue and measuring
trichrome stain, magnification  25).
1.3 cm in maximum dimension. Microscopically,
the nodule was composed of a non-muscular
from the axilla into the medial arm visible on arm fibrotic wall infiltrated by scattered mixed inflam-
abduction (Fig. 1A). Typically, the syndrome pre- matory cells. The nodule’s center was filled with
sents after an initial postoperative delay of about 1 thrombotic material undergoing organization and
week and resolves spontaneously within 3 months recanalization (Fig. 1B). A small number of ery-
of onset. Currently, no mode of therapy has proven throcytes were present within the thrombus, but no
useful in shortening the duration or changing the significant hemorrhage or hemosiderin was evident.
self-limited course of this morbidity. Here, we The fibrosis extended from the main lesion into the
report an extreme case of AWS accompanied by adjacent adipose tissue (Fig. 1). An elastic lamina
subcutaneous nodules in the ipsilateral upper arm was not identified in the wall of the nodule.
and discuss the relevant pathological findings The histopathologic findings of the nodules
associated with this morbidity. evoked a differential diagnoses including an orga-
nizing hematoma, pseudo-aneurysm or thrombotic
occlusion and recanalization of a blood or lympha-
Case report tic vessel. The paucity of blood and hemosiderin
argued against a hematoma or pseudoaneurysm and
The patient is a 41-year-old female status post- the absence of an elastic lamina excluded a blood
lumpectomy and axillary lymph node dissection for a vessel. Therefore, the presumed pathogenesis was
 ARTICLE IN PRESS
A case of axillary web syndrome with subcutaneous nodules following axillary surgery 413

thrombotic occlusion of a lymphatic vessel followed et al.1 may reflect the prospective nature of this
with recanalization, explaining clinical resolution study and the thorough postoperative assessment
of the nodules over time (the nodules described in of each patient that was enrolled.
this case report resolved by 15 weeks post-surgery). In summary, AWS is a significant source of
morbidity in patients who have undergone ALND
and also occurs, albeit with reduced incidence in
Discussion patients who have undergone SLND. Occasionally,
AWS is associated with the development of sub-
The pathogenesis of the subcutaneous nodules cutaneous nodules. The pathogenesis of these
described in this report is consistent with the nodules is similar to the described pathogenesis of
pathogenesis of AWS as described by Moskovitz et the palpable cords after which this syndrome has
al.1: lymphovenous injury, stasis and hypercoagul- been named. When associated with subcutaneous
ability in axillary vessels resulting in thrombosis of nodules, AWS can present a source of anxiety for
large superficial veins or lymphatics of the arm, both physician and patient until metastases as a
giving rise to palpable cords. Although trauma to cause, are ruled out.
the axilla (in the form of axillary surgery) is the
most common initiating event for AWS, this
syndrome has also been observed in patients with
extensive fixed malignant nodal disease in the References
axilla.
AWS usually resolves within 12 weeks of onset 1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ,
Moe RE. Axillary web syndrome after axillary dissection. Am
and no specific therapy has been proven effective J. Surg 2001;181:434–9.
in altering this course. Reassuring the patient of the 2. Guiliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic
self-limiting nature of the syndrome is in order. mapping and sentinel lymphadenectomy for breast cancer.
Recently, sentinel lymph node dissection (SLND) Ann Surg 1994;220:391–401.
3. Krag D, Weaver D, Ashikaga T, et al. The sentinel node in
was introduced to improve axillary staging and to
breast cancer—a multicenter validation study. N Engl J Med
avoid ALND in selected patients, thereby reducing 1998;339:941–6.
treatment morbidity.2–4 A recent prospective study 4. Burak WE, Hollenbeck ST, Zervos EE, Hock KL, Kemp LC, Young
evaluated AWS in patients undergoing either SLND DC. Sentinel lymph node biopsy results in less post-operative
or ALND and identified a significant reduction in the morbidity compared with axillary lymph node dissection for
prevalence of this syndrome from 72% in the ALND breast cancer. Am J Surg 2002;183:23–7.
5. Leidenuis MD, Leppanen E, Krogerus L, von Smitten K. Motion
group to 20% in the SLND group.5 The high restriction and axillary web syndrome after sentinel node
prevalence of AWS in both groups in this report biopsy and axillary clearance in breast cancer. Am J Surg
compared with the 6% figure described by Moskovitz 2003;185:127–30.