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Breast Imaging

E3180. Ultrasound of Axillary Web Syndrome: What the Radiology Should Know

Mullen L. Johns Hopkins Medical Institutions, Baltimore, MD

Address correspondence to L. Mullen (lmullen1@jhmi.edu)

Background Information: Axillary web syndrome, also known as axillary cording, is thought to be due to thrombosis of superficial lymphatic vessels in the axilla and arm, leading to palpable subcutaneous “cords”, accompanied by pain, a pulling sensation, and limitation of arm range of motion. It is often a complication of axillary surgery, including sentinel node biopsy and axillary node dissection. It affects breast cancer patients, melanoma patients, and also patients with infectious or inflammatory conditions of the axilla. Axillary cording is generally a clinical diagnosis, and therefore, the syndrome is relatively unknown among radiologists, and not described in the radiology literature. Patients may present for axillary ultrasound for evaluation of pain, pulling, or a palpable lump or cord. As the palpable cord may be mistaken for venous thrombosis, patients may also be referred for upper extremity venous ultrasound. The goals of this exhibit are to raise awareness of the condition in the radiology community and teach breast and body imagers the clinical presentation and ultrasound findings associated with axillary cording.

Educational Goals/Teaching Points: The purpose of this exhibit is to raise awareness of axillary web syndrome (AWS), also known as axillary cording, in the radiology community; to describe at-risk populations, including breast cancer and melanoma patients who have had sentinel node biopsy or axillary node dissection; to describe the clinical presentation of AWS, including a palpable cord in the axilla or arm, pain, a pulling sensation, and limitation of arm movement; to describe the ultrasound findings of AWS, and the difference between acute and chronic cases; and to discuss the possible etiology, treatment, and clinical course of axillary web syndrome.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: In axillary web syndrome, soft-tissue cords form in the subcutaneous fat of the axilla, and can extend down the arm to the hand. The cords are associated with pain and a pulling sensation in the arm, and limitation of motion of the arm, especially at full extension. On physical examination, the cords are visible and/or palpable as firm linear structures just under the skin, and can be mistaken for superficial venous thrombosis. With careful ultrasound using a high-frequency probe, the cords can be seen just under the skin. Ultrasound of the palpable cords should be performed in the transverse and sagittal plane. In the acute phase, the cords are isoechoic to subcutaneous fat, and difficult to image. In the chronic phase, they are visible as thin linear echogenic structures under the skin. The condition can be treated with physical therapy and stretching exercises. Although the cords often resolve over the course of a few months, they can persists for months or years in other patients.

Conclusion: Axillary web syndrome, or axillary cording, is a common clinical problem among patients treated with axillary sentinel node biopsy and axillary node dissection, as well as patients with inflammatory conditions of the axilla. Radiologists should be aware of this condition and should be able to use ultrasound to make the diagnosis.