There are many well-known side effects from breast cancer treatments; for example, the scars left behind from surgery, burned skin from radiation, and the loss of hair with chemotherapy. However, there are just as many side effects that aren't as recognized or understood. In this blog post, we focus on axillary web syndrome (or cording), which is a common side effect that is not as well-known among patients, researchers, and health-care providers alike.
What is Axillary Web Syndrome?
Axillary cording is characterized by a "web" or "cord" of tissue extending from the armpit/axilla down the inside of the arm into the bend of the elbow or even the wrist, hand, and fingers.
How does it develop?
This is a condition that can develop after a mastectomy and more often with the removal of lymph nodes from the axilla or underarm. The origin of the cords is still uncertain; however, it is theorized that lymphatic vessels, blood vessels, and nerves become damaged during surgery and cause inflammation to occur. The connective tissue surrounding these structures then scars and becomes firm developing into cords.
This condition can appear almost immediately following surgery or up to several months later when the healing process seems to be complete. Its most commonly seen in women who have undergone a mastectomy with lymph node removal. However, it can occur even in women who have undergone a less invasive lumpectomy, but it is less common.
Who is at risk?
Research varies on the prevalence of axillary cording, likely due to lack of knowledge of health care providers and late diagnosis. Some research finds this condition is present in as many as 86% of women after having undergone a mastectomy with lymph node removal. Interestingly, it seems more common in women with lower body mass index's (normal body weight), women who are younger in age at time of diagnosis, and is more common in women who have undergone extensive surgery as is the case with axillary lymph node dissections.
What are the signs and symptoms?
Axillary web syndrome or cording make take only days to appear or may be a somewhat delayed response to surgery, but the presentation and restrictions are always very similar. Women with this condition present in the clinic with a string or rope like cord under their arm on the same side they have had surgery. This cord or string will be tender to touch and limit the women's full range of motion in that arm. It can involve just a portion of the axilla or arm pit or it can extend from the rib cage into the arm and all the way into the wrist and hand. This cording isn't usually visible in a position of rest. It is most noticeable when reaching overhead or when moving the arm out and away from the body. In these positions, the cord will "pop" out just under the surface of the skin creating a pulling, tight sensation that limits the woman's ability to fully use her arm and can be a source of pain and discomfort. Many women think this cord is an overly tight or an injured tendon and/or just a previously unnoticed, part of their own normal anatomy that is now causing them pain.
How can it be treated?
Several woman have been seen in our clinic afraid to move and use their arm for normal daily activities, such as dressing, bathing, and reaching. Many are worried they might further aggravate this condition by moving. The good news is that it is usually very easily treated. In most cases, the resolution of this common side effect is only a few sessions of physical and/or occupational therapy. The therapist will perform manual techniques to break up the cording and prescribe a specific home stretching and strengthening program. A simple exercise to complete is the wall stretch exercise.
Most women have some relief from this condition on the first visit with a well-trained physical and/or occupational therapist. A typical course of treatment is about 6 visits and many can be pain free and back to regular daily tasks quickly. To prevent loss of range of motion, it is important to continue the home stretching program after finishing with therapy.
Breastcancer.org. (2019 March 9). Axillary Web Syndrome (cording). Retrieved from https://www.breastcancer.org/treatment/side_effects/aws.
Koehler LA, Haddad TC, Hunter DW, Tuttle TM: Axillary web syndrome following breast cancer surgery: symptoms, complications, and management strategies. Breast Cancer - Targets and Therapy. 2019; 11: 13-19.
Harris, SR. Axillary Web Syndrome in Breast Cancer: A prevalent but under-recognized postoperative complication. Breast Care. 2018; 13:132-135.
The Ohio State University Comprehensive Cancer Center. (2019 March 5). Axillary Web Syndrome Exercise Program. Retrieved from https://patienteducation.osumc.edu/Documents/AxillaryWebSyndromeExercises.pdf.