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 potential benefits of performing axillary
surgery in breast cancer include its well-estab-
lished prognostic purpose, contribution to adjuvant
therapy planning, and a reduction in the risk of
axillary recurrence. The surgical assessment of
axillary lymph nodes for metastatic spread con-
tinues to be a significant source of breast cancer
treatment morbidity. Early complications of ALND
Corresponding author. Tel.: +416 946 4432;
fax: +416 946 6590.
E-mail addresses: michael.reedijk@uhn.on.ca (M. Reedijk),
scott.boerner@uhn.on.ca (S. Boerner),
danny.ghazarian@uhn.on.ca (D. Ghazarian),
david.mccready@uhn.on.ca (D. McCready).
the operative site, and seroma formation. The
potential long-term complications of ALND include
pain, numbness, swelling, weakness and reduced
range of motion (ROM).
The axillary web syndrome (AWS) is a self-
limiting and frequently over-looked cause of
significant morbidity occurring in approximately
6% of patients in the early post-operative period
following surgery of the axilla.1 Although AWS has
most frequently been reported in patients follow-
ing axillary lymph node dissection in breast cancer
we have also observed this morbidity following
axillary staging in melanoma (confirmed by patho-
logical examination). The syndrome is character-
ized by axillary pain that radiates down the arm,
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
Figure 1 (A) Patient demonstrating axillary web syn-
drome in left arm. Taut cords extending from the axilla
and beyond the anticubital fossa is seen. The patient is
unable to fully extend the left elbow. Inset shows a close-
up of the cords. This patient did not develop subcuta-
neous nodules as is described in the case reported in the
text. (B) This photomicrograph shows the central portion
of a subcutaneous nodule filled with thrombotic material
and evidence of recanalization of the lumen. The fibrosis
involving the wall of the lesion is seen extending into the
adjacent adipose tissue. Note the absence of smooth
muscle and elastic lamina in the wall of the lesion (elastic
trichrome stain, magnification  25).
from the axilla into the medial arm visible on arm
abduction (Fig. 1A). Typically, the syndrome pre-
sents after an initial postoperative delay of about 1
week and resolves spontaneously within 3 months
of onset. Currently, no mode of therapy has proven
useful in shortening the duration or changing the
self-limited course of this morbidity. Here, we
report an extreme case of AWS accompanied by
subcutaneous nodules in the ipsilateral upper arm
and discuss the relevant pathological findings
associated with this morbidity.
Case report
The patient is a 41-year-old female status post-
lumpectomy and axillary lymph node dissection for a
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
in size (the largest nodule was 2 cm). The nodules
were described as painless and mobile. The
possibility that these nodules may represent evi-
dence of stage IV disease was raised and so fine
needle aspiration followed by excisional biopsy was
undertaken for pathological assessment. The fine
needle aspirate of the lesion was limited by low
cellularity and revealed reactive mesenchymal
cells. Following excision of the lesion, gross
examination revealed a solitary white nodule
surrounded by adipose tissue and measuring
1.3 cm in maximum dimension. Microscopically,
the nodule was composed of a non-muscular
fibrotic wall infiltrated by scattered mixed inflam-
matory cells. The nodule’s center was filled with
thrombotic material undergoing organization and
recanalization (Fig. 1B). A small number of ery-
throcytes were present within the thrombus, but no
significant hemorrhage or hemosiderin was evident.
The fibrosis extended from the main lesion into the
adjacent adipose tissue (Fig. 1). An elastic lamina
was not identified in the wall of the nodule.
The histopathologic findings of the nodules
evoked a differential diagnoses including an orga-
nizing hematoma, pseudo-aneurysm or thrombotic
occlusion and recanalization of a blood or lympha-
tic vessel. The paucity of blood and hemosiderin
argued against a hematoma or pseudoaneurysm and
the absence of an elastic lamina excluded a blood
vessel. Therefore, the presumed pathogenesis was
 ARTICLE IN PRESS
A case of axillary web syndrome with subcutaneous nodules following axillary surgery
thrombotic occlusion of a lymphatic vessel followed
with recanalization, explaining clinical resolution
of the nodules over time (the nodules described in
this case report resolved by 15 weeks post-surgery).
Discussion
The pathogenesis of the subcutaneous nodules
described in this report is consistent with the
pathogenesis of AWS as described by Moskovitz et
al.1: lymphovenous injury, stasis and hypercoagul-
ability in axillary vessels resulting in thrombosis of
large superficial veins or lymphatics of the arm,
giving rise to palpable cords. Although trauma to
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
axilla.
AWS usually resolves within 12 weeks of onset
and no specific therapy has been proven effective
in altering this course. Reassuring the patient of the
self-limiting nature of the syndrome is in order.
Recently, sentinel lymph node dissection (SLND)
was introduced to improve axillary staging and to
avoid ALND in selected patients, thereby reducing
treatment morbidity.2–4 A recent prospective study
evaluated AWS in patients undergoing either SLND
or ALND and identified a significant reduction in the
prevalence of this syndrome from 72% in the ALND
group to 20% in the SLND group.5 The high
prevalence of AWS in both groups in this report
compared with the 6% figure described by Moskovitz
413
et al.1 may reflect the prospective nature of this
study and the thorough postoperative assessment
of each patient that was enrolled.
In summary, AWS is a significant source of
morbidity in patients who have undergone ALND
and also occurs, albeit with reduced incidence in
patients who have undergone SLND. Occasionally,
AWS is associated with the development of sub-
cutaneous nodules. The pathogenesis of these
nodules is similar to the described pathogenesis of
the palpable cords after which this syndrome has
been named. When associated with subcutaneous
nodules, AWS can present a source of anxiety for
both physician and patient until metastases as a
cause, are ruled out.
References
1. Moskovitz AH, Anderson BO, Yeung RS, Byrd DR, Lawton TJ,
Moe RE. Axillary web syndrome after axillary dissection. Am
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2. Guiliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic
mapping and sentinel lymphadenectomy for breast cancer.
Ann Surg 1994;220:391–401.
3. Krag D, Weaver D, Ashikaga T, et al. The sentinel node in
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1998;339:941–6.
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DC. Sentinel lymph node biopsy results in less post-operative
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