Comment to: Ryans K et al. Incidence and predictors of axillary web syndrome and its association with lymphedema in wome
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LETTER TO THE EDITOR
Comment to: Ryans K et al. Incidence and predictors of axillary web syndrome and its association with lymphedema in women following breast cancer treatment: a retrospective study Anke Bergmann 1
&
Jaqueline Munaretto Timm Baiocchi 2
&
Luiz Claudio Santos Thuler 1
Received: 28 May 2020 / Accepted: 2 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, We have read with great interest and congratulate the recent published article by Ryans et al. [1]. The novel findings raise an important discussion on postsurgical complications after breast cancer treatment. However, some key points should be addressed. Axillary web syndrome (AWS), or cording, is a postoperative dysfunction that usually occurs between the first and fifth weeks following breast cancer surgery. It is characterized by the presence of a visible and palpable stretched band under the skin, which is taut and painful during shoulder flexion or abduction. The cords are always present in the axilla and may extend down into the medial ipsilateral arm or trunk. This condition is responsible for significant morbidity in the postoperative period [2, 3]. Lymphedema (LE) is a chronic and progressive disorder originated from impaired lymphatic system function that leads to an accumulation of protein-rich fluid in tissues. Breast cancer-related lymphedema (BCRL) is detected in 7–77% of patients who undergo axillary lymph node dissection (ALND) and 3–7% due to sentinel lymph node biopsy (SLNB). This incidence is based on multiple factors such as extent of disease, treatment modality (i.e., radiotherapy), obesity, and duration of follow-up (> 6 months) [4]. In the study of Ryans et al. [1], only 26.6% of the patients were addressed to physical therapy (PT) at the first month after surgery, and most cases (35.7%) were referred at PT from 2 to 6 months after surgery. Neoadjuvant chemotherapy was done in 38.7% and adjuvant radiotherapy in 59.3%. However, there
is no data regarding the clinical staging and type of breast and axillary surgical procedure. The prevalence of AWS was 31.9% and correlated to a 44% higher risk in developing lymphedema during the first postoperative year (RR1.44, CI 95% 1.12–1.84; p = 0.002). Despite reporting the lymphedema prevalence among AWS patients, the authors did not mention the prevalence in patients who did not developed AWS. Moreover, the study has important limitations that should be taken in consideration:
* Anke Bergmann [email protected]
We have published a prospective cohort study involving 964 breast cancer patients treated in a single cancer center. We founded AWS and lymphedema prevalence of 35.9% and 31.4%, respectively. There was no association between AWS and the development of lymphedema (OR = 0.87, 95% CI 0.65–1.15; p = 0.329) [6].
1
Clinical Epidemiology Program, National Cancer Institute, Rio de Janeiro, Brazil
2
Oncofisio Institute, São Paulo, Brazil
1. Patients referred to PT were included mostly after 2 months of surgery, and the majority attended on
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