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Management of Early Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • National Comprehensive Cancer Network (NCCN) guidelines:
    • Recommend surgical management:
      • For local control for women with early stage invasive breast cancer
    • Several studies have shown an equivalence in overall and / or breast cancer-specific survival rates:
      • For breast conservation with radiation compared to mastectomy among early stage breast cancer patients
    • For patients with ER positive disease:
      • Endocrine therapy with tamoxifen or aromatase inhibitors is prescribed after surgery:
        • A systematic review evaluated the efficacy of primary endocrine therapy alone versus surgery in women over 70 years old with operable tumors:
          • The review reported similar survival between the two groups, but women treated with surgery had lower rates of local failure when compared to endocrine therapy alone
          • The authors concluded that primary endocrine therapy should be reserved for women who are unfit for surgery or decline surgery
    • Sentinel node biopsy:
      • Has become the standard method for staging the axilla in women with early stage breast cancer:
        • Who are clinically node negative
      • Axillary dissection is only performed in women with:
        • Documented nodal involvement
        • Inflammatory breast cancers
        • Those who fail lymphatic mapping
  • References:
    • National Comprehensive Cancer Network. Breast Cancer. 2014; https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed 8/28/2024, 2024
    • Fisher B, Anderson S, Bryant J, et al. Twenty-year followup of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New Engl J Med. 2002;347(16):1233-1241.
    • Litiere S, Werutsky G, Fentiman IS, et al. Breast-conserving therapy versus mastectomy for stage I-II breast cancer: 20 year followup of the EORTC 10801 phase 3 randomized trial. Lancet Oncol. 2012;13(4):412-419.
    • Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. New Engl J Med. 2002;347(16):1227-1232.
    • Morgan J, Wyld L, Collins KA, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev. 2014(5). https://www.cochrane.org/CD004272/BREASTCA_surgery-versus-primary-endocrine-therapy-for-elderly-women-with-operable-primary-breast-cancer Accessed August 25, 2019.

Pathologic Nipple Discharge

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Pathologic nipple discharge:
    • Is characteristically spontaneous, unilateral, or bloody
  • Physiologic discharge:
    • Is non-spontaneous, bilateral, and milk
  • The most common causes for pathologic nipple discharge:
    • Are benign:
      • Intraductal papillomas
      • Duct ectasia
  • The presence of abnormal clinical findings on imaging or physical exam:
    • Is associated with increased risk of malignancy:
      • 38% vs. 2%
  • Contemporary workup for nipple discharge includes:
    • Mammography
    • Evaluation of the retroareolar region with ultrasound
  • Patients with normal findings on mammography, ultrasound, and physical exam:
    • Can be further evaluated with breast MRI:
      • As it is highly sensitive and specific for cancer
  • Surgical management of nipple discharge includes:
    • Excision of a single duct or central duct apparatus:
      • Depending on the number of ducts involved
  • References:
    • Li GZ, Wong SM, Lester S, Nakhlis F. Evaluating the risk of underlying malignancy in patients with pathologic nipple discharge. Breast J. 2018;24(4):624-627.
    • de Paula IB, Campos AM. Breast imaging in patients with nipple discharge. Radiol. Bras. 2017;50(6):383-388.
    • Yilmaz R, Bender O, Celik Yabul F, Dursun M, Tunaci M, Acunas G. Diagnosis of nipple discharge: value of magnetic resonance imaging and ultrasonography in comparison with ductoscopy. Balkan Med J. 2017;34(2):119-126.

Radiation Fractionation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Three important areas form the foundation for the evolving use of altered fractionation:
    • Tissue response
    • Duration of treatment
    • Fraction size and number
  • Acutely responding tissues:
    • Are rather active in ongoing cellular proliferation
    • Most tumors (except perhaps prostate cancer, breast cancers, and melanoma) and some normal tissues such as skin, mucous membranes, and gastrointestinal epithelium:
      • Share this characteristic:
        • These tissues are most affected by the overall treatment duration rather than by the size or number of fractions used
  • Late-responding tissues:
    • Have a low proliferative rate and include the spinal cord, brain, bone, and cartilage
    • These tissues are most affected by the:
      • Size and number of fractions rather than by treatment duration:
        • Therefore are spared by decreasing the dose per fraction of radiation delivered
  • Because most tumors consist of rapidly dividing cells:
    • Local tumor control is strongly dependent on the overall treatment duration rather than on the size or number of fractions
  • When squamous cell carcinoma of the head and neck is exposed to radiation:
    • The less radiosensitive cells within the lesion:
      • Can undergo rapid proliferation:
        • Approximately 3 to 5 weeks after treatment commences
        • This accelerated repopulation can overwhelm the ongoing treatment effects of radiation:
          • Which ultimately can lead to local failure
        • The clinical significance of this phenomenon is that even with significant regression of the primary tumor mass:
          • Local failure still ultimately could result from proliferation of these resistant clones
        • Therefore it is essential to complete treatment in as short a time as possible so that accelerated repopulation is minimized:
          • Increasing the chance for local control
      • For this reason, split-course radiation:
        • Which incorporates a treatment break during the course of radiotherapy is not recommended
  • Based on the aforementioned principles:
    • The goal of altered fractionation schemes:
      • Is to improve the therapeutic ratio by maximizing the tumoricidal effect and minimizing acute and late toxicities while using readily available low-LET radiation
  • Two major categories of altered fractionation schemes exist:
    • Hyperfractionation
    • Accelerated fractionation
  • They share basic radiobiological principles yet have their own particular features (Table)
  • Accelerated fractionation:
    • Is the strategy of choice for rapidly proliferative tumors
    • Accelerated fractionation is based on the concept that the shortened overall treatment time:
      • Would reduce the opportunity for accelerated repopulation effectively
  • Hyperfractionation:
    • Is preferred for slowly proliferating tumors
    • Hyperfractionation improves the therapeutic ratio primarily through:
      • Redistribution of tumor cells into more radiosensitive phases as a result of multiple fractions
      • Differential sparing of late-responding normal tissues because of a decrease in the size of the dose per fraction

Contralateral Prophylactic Mastectomy (CPM) American Society of Breast Surgeon Guidelines

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Current consensus guidelines from the American Society of Breast Surgeons:
    • Do not recommend CPM for women with sporadic breast cancers
  • A Cochrane review of 8 studies evaluating patients who underwent CPM:
    • Concluded that while CPM reduces risk of contralateral breast cancer:
      • It is not associated with improved survival
  • Reasons for not recommending CPM include:
    • A low estimated risk of cancer in the contralateral breast (2% to 6% over 10 years)
    • Increased complication rates
    • Studies showing that CPM does not improve survival or recurrence from the index cancer
  • References:
    • Lostumbo L, Carbine N, Wallace J, Ko H. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev 2004(4):CD002748.
    • Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy consensus statement from the american society of breast surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016;23(10):3106-3111

Nerves that Could Potentially be Injured During Breast and Axillary Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Intercostobrachial nerve:
    • This nerve is a cutaneous branch of the intercostal nerves:
      • Most commonly the second intercostal nerve:
        • Which gives off a lateral cutaneous nerve:
          • Which continues as the intercostobrachial nerve
    • The intercostal nerves arise from:
      • The anterior rami of the thoracic spinal nerves
    • The intercostobrachial nerve pierces the serratus anterior:
      • Crosses the axilla to the medial side of the upper arm
    • The intercostobrachial nerve is commonly in the surgical field during axillary lymph node dissections and may be severed during surgery, or subject to traction or postsurgical inflammation:
      • Thus leading to intercostobrachial neuralgia
  • The larger intercostal nerves:
    • Can be preserved with meticulous dissection
  • Neuropathic symptoms:
    • May be limited to numbness or tingling:
      • But may also include a burning sensation
  • Techniques such as a regional nerve block:
    • Have been described to alleviate symptoms in severe cases
  • In a study of 200 patients who underwent axillary dissection:
    • 76% had symptoms of intercostobrachial neuralgia postoperatively
    • Of these patients, 82% reported improvement or resolution of these symptoms within 1 year:
      • Reflecting the richness of the sensory nerve supply to the axilla and upper arm
  • The thoracodorsal nerve:
    • Is a branch of the posterior cord of the brachial plexus:
      • It supplies motor function to the latissimus dorsi
    • If injured, patients experience weakness with arm abduction, lateral flexion, and difficulty with activities such as climbing, swimming, and using the arms to pull the body up
  • The medial cord of the brachial plexus:
  • Gives rise to the medial pectoral nerve:
    • Which innervates both the pectoralis minor muscle and the pectoralis major muscle
  • The medial pectoral nerve typically pierces the pectoralis minor muscle:
    • But may wrap around the lateral aspect of the pectoralis minor before traveling on to innervate the distal pectoralis major muscle
  • The lateral cord of the brachial plexus:
    • Gives rise to the lateral pectoral nerve:
      • Which innervates the pectoralis major muscle
    • This nerve travels along the medial border of the pectoralis minor muscle:
      • Then along the undersurface of the pectoralis major muscle along with the pectoral branch of the thoracoacromial artery to supply the proximal pectoralis major muscle
  • The medial pectoral nerve bundle:
    • Is often encountered during axillary dissection as it is located lateral to the lateral pectoral nerve
  • If either of these nerves is injured:
    • Pectoralis muscle atrophy can occur:
      • Which can present as a late complication of surgery, with weakness of shoulder adduction, interior rotation, and flexion
  • The long thoracic nerve:
    • Typically arises from anterior rami of the cervical spinal nerve roots C5 to C7
    • It courses along the chest wall and supplies the serratus anterior muscle
    • Injury to this nerve causes a winged scapula
  • References:
    • Sclafani LM, Baron RH. Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Cancer J. 2008;14(4):216-222.
    • Wisotzky EM, Saini V, Kao C. Ultrasound-guided intercostobrachial nerve block for intercostobrachial neuralgia in breast cancer patients: a case series. Prev Med Rep, 2016;8(3):273-277.
    • Roses DF, Brooks AD, Harris MN, Shapiro RL, Mitnick J. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Sur. 1999;230(2):194-201.
    • Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat. 2012;25(5):559-575.

Inflammatory Breast Cancer (IBC)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Inflammatory breast cancer (IBC):
    • Is a clinical syndrome in women with invasive breast cancer that is characterized by:
      • Erythema and edema (peau d’orange) of a third or more of the skin of the breast
    • The differential diagnosis includes:
      • Cellulitis of the breast or mastitis
    • Because most IBC cases are first seen by healthcare providers not necessarily familiar with IBC:
      • The absence of complete response to a trial of antibiotic therapy should heighten suspicion of IBC and prompt further investigation:
        • Further trial of antibiotics is not warranted in the absence of clinical signs of infection and previous adequate antibiotic therapy
    • Workup includes physical exam and imaging:
      • Imaging may not reveal a mass:
        • But thickening of the skin is frequently seen
      • The most common signs of IBC on mammography include:
        • Thickening of the skin (84%)
        • Trabecular thickening (81%)
        • Asymmetric focal density (61%)
        • Microcalcifications (56%)
      • Mammography is the least sensitive diagnostic tool available for IBC:
        • Whereas ultrasound and MRI are more sensitive:
          • In a series published by Yang, et al., sonography demonstrated a mass or architectural distortion in 95% of patients with associated global skin and subcutaneous thickening and dilated lymphatics
          • MRI can also show skin thickening and is more sensitive than mammography in detecting an underlying mass:
            • The same series by Yang and colleagues found that a primary breast lesion was present in every MRI obtained in patients with IBC as either nonmass or mass-like enhancement
    • IBC is a clinical diagnosis:
      • Dermal biopsy confirmation is not mandatory:
        • Dermal lymphatic invasion is seen only in approximately 60% of IBC cases:
          • It is neither required, nor sufficient by itself for a diagnosis of inflammatory breast cancer
    • Treatment is multidisciplinary trimodality therapy consisting of neoadjuvant chemotherapy, modified radical mastectomy, and local regional radiation:
      • Yet, the median survival at 5 years for patients presenting with primary IBC is still only approximately 55%
  • References
    • Yang WT, Le-Petross HT, Macapinlac H, et al: Inflammatory breast cancer: PET/CT, MRI, mammography, and sonography findings. Breast Cancer Res Treat. 2008;109(3):417-426.
    • Somio G, Jones V. Inflammatory breast cancer. In: Klimberg S, Bland K, eds. The Breast: Comprehensive Management of Benign and Malignant Disease. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:832-838.
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Hypofractionation Radiation Therapy

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Hypofractionation:
    • Larger fraction size (600 to 800 cGy) compared with conventional fractionation (180 to 200 cGy)
    • Fractions delivered several days apart
    • Lower total dosage (2100 to 3200 cGy) than
      conventional fractionation (7000 cGy)
    • Shortened overall treatment duration
      compared with conventional fractionation
  • Hypofractionation:
    • Is the administration of high-dose-per-fraction (HDPF) radiation:
      • In which only one or two fractions are given per week
    • This technique has evolved for the treatment of malignant melanoma:
      • Which generally is perceived as being radioresistant
  • Conventional fractions of 200 cGy delivered 5 days a week:
    • Allow normal tissues and tumor cells to recover during the intervals between fractions
  • Experimental in vitro data have shown that malignant melanoma cells are better at repairing radiation-induced sublethal damage compared with other cells:
    • This finding may explain the long-standing notion that melanoma is intrinsically “radioresistant”
  • HDPF regimens:
    • Deliver higher doses of radiation per fraction (600 cGy twice a week or 800 cGy once weekly):
      • With the aim of overcoming the reparative capacity of the tumor cells by increasing the damage per fraction
  • In retrospective analyses, response rates have been shown to correlate with dose per fraction but not with the total dose delivered:
    • However, a prospective randomized trial (RTOG 83–05) found no therapeutic advantage in a comparison of HDPF (800 cGy once a week up to a total dose of 3200 cGy) and conventional fractionation (250 cGy daily, 5 days a week, for a total of 5000 cGy):
      • Although no therapeutic advantage was seen, the shorter delivery time of HDPF radiation allows earlier initiation of systemic therapies if applicable
  • Moderately hypofractionated radiation (225 cGy per fraction):
    • Has demonstrated superior results for early-stage larynx cancers treated with radiotherapy alone:
      • This is currently considered the standard of care in this setting
  • Additionally, a regimen commonly referred to as quad shot:
    • Which was originally developed for advanced pelvic tumors:
      • Is sometimes applied for palliation of tumors in the head and neck
    • This involves cycles of a 1480 cGy course of radiotherapy delivered in four fractions over the course of 2 days:
      • Which can be repeated multiple times over a period of weeks or months depending on the treatment response
      • Aside from the demonstrated efficacy of this regimen, it also allows significant advantages in terms of patient convenience in the palliative setting

Breast Cancer-Related Lymphedema (BCRL):

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Breast cancer-related lymphedema (BCRL):
    • Has been a significant concern for breast cancer patients undergoing axillary surgery
  • The development of BCRL is associated with:
    • Significantly lower physical and psychosocial well-being and increased health care utilization
  • The risk of BCRL:
    • Is a function of the extent of axillary intervention:
      • Ranging from about 12% following a sentinel node biopsy to about 30% after an axillary lymph node dissection (ALND)
  • The highest risk of BCRL (51%) has been reported in patients with inflammatory breast cancer:
    • Who receive trimodality therapy (neoadjuvant taxane-containing chemotherapy, modified radical mastectomy, and adjuvant radiation):
      • Therefore, adjuvant radiotherapy is associated with an increased risk of BCRL
  • The value of routine screening for BCRL in patients at risk is controversial
  • There is growing evidence that subclinical lymphedema:
    • Defined as relative volume change of the affected arm of 5% to 10% compared to the baseline measurement:
      • Is strongly associated with the development of more symptomatic BCRL:
        • Which correlates with a relative volume change of greater than 10%
  • Consequently, identifying patients with subclinical lymphedema is a potential opportunity for early intervention and long-term improvement in quality of life
  • Furlan et al prospectively evaluated 85 breast cancer patients (n=40 had an ALND and n=45 had a sentinel node biopsy) by obtaining serial circumferential arm measurements preoperatively, then 1 month, 3, 6, 12, and 24 months after surgery:
    • Study results showed that the earliest signs of subclinical lymphedema were detected no sooner than the 6-month assessment, and those with subclinical lymphedema were promptly referred for decongestive therapy
  • An international randomized trial comparing bioimpedance spectroscopy (BIS) and tape measurement to detect subclinical lymphedema:
    • Showed that BIS had a higher sensitivity and was associated with an earlier referral for decongestive therapy
    • In the same study, earlier administration of decongestive therapy was associated with a lower risk of progression to symptomatic BCRL
    • The practical aspects of implementing BCRL screening with BIS versus tape measurements and other techniques warrant further study
  • References
    • Coriddi M, Kim LN, Haglich K, et al. The impact of lymphedema on patient-reported outcomes after breast reconstruction: a preliminary propensity score-matched analysis. Ann Surg Oncol. 2023;30(5):3061-3071. doi: 10.1245/s10434-022-12994-z
    • Cheville A, Lee M, Moynihan T, et al. The impact of arm lymphedema on healthcare utilization during long-term breast cancer survivorship: a population-based cohort study. J Cancer Surviv. 2020;14(3):347-355. doi: 10.1007/s11764-019-00851-0
    • Bucci LK, Brunelle CL, Bernstein MC, et al. Subclinical lymphedema after treatment for breast cancer: risk of progression and considerations for early intervention. Ann Surg Oncol. 2021;28(13):8624-8633. doi: 10.1245/s10434-021-10173-0
    • Farley CR, Irwin S, Adesoye T, et al. Lymphedema in inflammatory breast cancer patients following trimodal treatment. Ann Surg Oncol. 2022;29(10):6370-6378. doi: 10.1245/s10434-022-12142-7
    • Furlan C, Matheus CN, Jales RM, Derchain SFM, Bennini JR Jr, Sarian LO. Longitudinal, long-term comparison of single-versus multipoint upper limb circumference periodical measurements as a tool to predict persistent lymphedema in women treated surgically for breast cancer: an optimized strategy to early diagnose lymphedema and avoid permanent sequelae in breast cancer survivors. Ann Surg Oncol. 2021;28(13):8665-8676. doi: 10.1245/s10434-021-10290-w
    • Ridner SH, Dietrich MS, Boyages J, et al. A comparison of bioimpedance spectroscopy or tape measure triggered compression intervention in chronic breast cancer lymphedema prevention. Lymphat Res Biol. 2022;20(6):618-628. doi: 10.1089/lrb.2021.0084

Radiation Therapy in Head and Neck Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • A randomized study by the radiation therapy oncology group (RTOG) 90–03:
    • Evaluated the use of low-LET radiation alone
      with four fractionation schemes for the treatment of squamous cell carcinoma of the head and neck
    • Patients included in this trial underwent radiation therapy as a single modality, without the use of chemotherapy
    • The sites included the oral cavity, oropharynx, hypopharynx, and supraglottic larynx
    • The stages were limited to III and IV (with no distant metastases):
      • However, the base of the tongue and the hypopharynx subsites included stage II patients as well
    • The four arms were as follows:
      • Conventional fractionation:
        • The conventional fractionation schedule that entails use of 180 to 200 cGy per fraction
        • One fraction per day, 5 days per week for 6 to 7 weeks for a total dosage of 6500 to 7000 cGy has evolved empirically over many years
      • Hyperfractionation:
        • Hyperfractionation is preferred for slowly proliferating tumors
        • Hyperfractionation improves the therapeutic ratio primarily through:
          • Redistribution of tumor cells into more radiosensitive phases as a result of multiple fractions
          • Differential sparing of late-responding normal tissues because of a decrease in the size of the dose per fraction
        • Hyperfractionation:
          • Smaller fraction size (115 to 120 cGy) compared with conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Larger total dosage (7440 to 8460 cGy) than conventional fractionation (7000 cGy)
          • Similar overall treatment duration as
            conventional fractionation
      • Accelerated fractionation with split:
        • Accelerated fractionation is the strategy of choice for rapidly proliferative tumors
        • Accelerated fractionation is based on the concept that the shortened overall treatment time would reduce the opportunity for accelerated repopulation effectively
        • Accelerated fractionation:
          • Similar fraction size as conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Similar total dosage as conventional
            fractionation
          • Shortened overall treatment
            duration compared with conventional fractionation
      • Accelerated fractionation with a concomitant boost
  • The RTOG 90-03:
    • Had a significantly improved 2-year locoregional control and disease-free survival rate with:
      • Accelerated fractionation with a concomitant boost compared with conventional fractionation and accelerated fractionation with a split
    • Patients treated with hyperfractionation also had a trend toward improved results:
      • However, a phase III Groupe Oncologie Radiotherapie Tete et Cou cooperative trial did not show a benefit when altered fractionation was combined with chemotherapy
      • In fact, patients treated with accelerated fractionation with concurrent chemotherapy experienced more toxicities than did patients treated with conventional fractionation with concurrent chemotherapy
  • The RTOG 99-14 trial:
    • Asked the same question about whether chemotherapy given concurrently with concomitant boost radiation can further improve on locoregional control
    • Because of the encouraging preliminary results, RTOG 01-29 was conducted to answer the question of whether altered fractionation should be used in the setting of chemotherapy
    • The results of this two-arm prospective randomized trial of more than 700 patients was was reported:
      • Showing that when chemotherapy is given concurrently with radiation:
        • There is no added benefit of using altered fractionation compared with standard once-daily radiation
      • Furthermore, the long-term grade 3 to 4 late toxic effects of chemotherapy from RTOG 99-14 with concomitant boost radiation was extremely high at 42%
      • Gastrostomy tube dependence rates anytime during follow-up, at 1 year, and at 2 years were 83%, 41%, and 17%, respectively
      • However, it should be mentioned that these patients were treated with older, conventional nonconformal radiation techniques, such as Cobalt 60
      • Since the introduction of IMRT, which allows for significant reduction in radiation dose to normal tissues, treatment-associated toxicities have improved
  • Three randomized studies comparing conventional radiation technique versus IMRT for head and neck cancer:
    • Have indeed shown that there are lower late complications with IMRT
    • Furthermore, there is no evidence that IMRT causes compromise in locoregional control

Axillary Web Syndrome

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Axillary web syndrome:
    • Appears to be a common complication following axillary surgery
    • It consists of the appearance of a visible web of axillary skin overlying palpable cords of tissue:
      • That are made taut and painful by shoulder abduction
    • These cords can result in painful abduction of the shoulder and reduced range of motion
    • It typically results from axillary lymphadenectomies for treatment of breast cancer or melanoma
    • In general, axillary web syndrome is poorly defined and misunderstood:
      • In a large systematic review:
        • The incidence ranged from 0.6% to 85.4%
      • Extent of surgery (number of nodes removed), low body mass index, and age have been reported as possible risk factors for development of this syndrome
      • Although smoking, receipt of neoadjuvant chemotherapy, and radiation may play a role in its development:
        • These factors have not been described in the literature
      • In the majority of cases:
        • Axillary web syndrome:
          • Appears to develop within 2 to 8 weeks of axillary surgery
      • Although patients generally do well with resolution of their symptoms:
        • Current evidence for the treatment of axillary web syndrome is insufficient to provide clear guidance for clinical practice
      • Suggested interventions have included:
        • Early education
        • Physiotherapy
        • Thermal therapy
        • Medications
        • Surgery
  • References:
  • Koehler LA, Haddad TC, Hunter DW, Tuttle TM. Axillary web syndrome following breast cancer surgery: symptoms, complications and management strategies. Breast Cancer. 2018;11:13-19.
  • Yeung WM, McPhail SM, Kuys SS. A systematic review of axillary web syndrome (AWS). J Cancer Surviv. 2015;9(4):576-598