Axillary web syndrome, the lost cord, and lingering questions.

Axillary Web Syndrome (AWS), sometimes also referred to as cording lymphedema, is an unfortunate and frustrating complication that can follow operation and specifically axillary lymphadenectomy for the treatment of breast cancer. Although most lymphologists are familiar with AWS, the mechanism(s) of its origin and development are largely unknown, there is disagreement about what the cords are composed of, and worldwide treatments vary widely. In this issue, the two lead articles focus on imaging the cords and offer insights into their composition. Olivier Leduc and his team follow up on their 2009 article (1) describing further the clinical features of the cord and reporting (2) images of the cord by both ultrasound (US) and magnetic resonance imaging (MRI). The second article by Linda Koehler and her colleagues looks specifically at US imaging of the cord and uses a blinded radiologist as a mechanism to avoid observer bias in image interpretation (3). Imaging of the cord is not easy with specific techniques described by Leduc et al and lack of identification of the cord using a blinded radiologist reported by Koehler et al. Two other groups worldwide have also found difficulty in imaging the cord using US (personal communication). What is the cord? Despite the obvious external appearance of the cords to the patient and management team, a clear understanding of what the cord is composed of remains elusive as well as whether all cords are the same (perhaps a complicating factor). Various opinions have been put forth ranging from a lymphatic or vein or a lympho-venous structure with other tissue possibilities such as nerves or fascia. Both Leduc and Koehler with their colleagues demonstrate with their imaging techniques that their findings are inconsistent with an origin from a vein, nerve, or the fascia, and both suggest that the cords are lymphatic in origin. Although they report that normal lymphatic vessels would be difficult to visualize using these techniques, it remains confusing as to why the cords can’t be seen despite being clearly visible. A possible answer to this question may be found in studies of cord biopsies. This procedure would raise ethical issues since there is no medical benefit (and possible risk to aggravate the process) to biopsy the cords, which are thought to be self-limiting to the patient. Nonetheless, there are a few reports from tissue biopsies in the literature. One of the earliest is the report by Moskovitz et al (4) who biopsied only 4 patients and found fibrin