THE AXILLARY WEB AND ITS LYMPHATIC ORIGIN

Abstract

Axillary web syndrome (AWS) is a
frequently overlooked problem that causes
morbidity in the early post-operative period
following cancer surgery with axillary lymph
node removal (1-3). AWS, also known as
“cording” was first described in 2001 by
Moskovitz as “a visible web of axillary skin
overlying palpable cords of tissue that are
made taut by shoulder abduction” (1). Over a
decade has passed since Moskovitz’s seminal
article was published, and we still lack a good
understanding of AWS. This condition has
been suboptimally studied using widely
differing criteria. This has resulted in almost
meaningless data such as the incidence of the
problem, which varies from 6 to 72% following
cancer surgery with axillary lymph node dissection
(ALND) or sentinel node biopsy (SNB)
(1-5). AWS continues to perplex the medical
and scientific community. For instance, there
is no explanation for the observation that
individuals with a lower body mass index
(BMI) are at higher risk for AWS (1-3). There
are differing views on the physiological and
etiological aspects of AWS. Some believe
there is a vascular component involving the
lymphatic and/or venous system (1, 6-11).
Others consider the cord to be composed of
fascial tissue (12). The terminology used to
describe the cord varies dependent on the
researcher’s opinions, which are based on
their speculations as to the underlying
pathophysiology of the condition.
The purpose of this paper is to present a
new perspective that supports the theory that
AWS is associated with the lymphatic system.
Based on our clinical experience including
more in-depth analysis of specific cases, our
clinical research, and the accumulated
literature, we present our proposal to explain
the pathophysiology of AWS, define the
period of onset and duration of AWS, outline
possible reasons for the association between
AWS and BMI, and postulate why we occasionally
see cases of AWS that are associated
with conditions that disturb normal lymphatic