Lymphspiration: The Axillary Web and Its Lymphatic Origin

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 function but are unrelated to surgery.