AWS can develop during many conditions and is considered to be a type of Mondor’s disease, characterized by a thick-wall blood vessel or lymphatic vessel [4, 5]. It has been attributed to prior trauma or breast surgery, such as breast reduction, mammoplasty or lumpectomy . Moskovitzet al. coined the term AWS and proposed that the pathogenesis is lymphovenous damage, hypercoagulation, superficial venous and lymphatic stasis, and disorders and injuries of tissues as a result of the disruption of superficial lymphatic and blood vessels during axillary surgery. Our patient developed AWS after secondary breast surgery without lymph-node dissection to achieve negative margins, which suggests that it was the secondary breast surgery that promoted development of AWS rather than the original axillar lymph-node biopsy. This differed from previous studies, in which stress from the axillar lymph-node dissection or axillar lymph-node biopsy caused AWS [8, 9]. We propose that the tissue injury caused by the secondary surgery led to the release of inflammatory factors, which caused phlebitis via intravasation in the axilla, medial arm, breast and thoracoabdominal wall through multiple mechanisms. The hypothesis is consistent with the B-type ultrasonography findings, but was not definitive due to the lack of a histopathology report. Most of the investigators were inclined to define the cord-like structure as a lymph vessel [7, 8, 10, 11].
AWS is a self-limiting cause of morbidity in the early postoperative period following axillary surgery [7, 8].There are no standard therapeutic methods reported for AWS. Previous studies have indicated that physical therapy can shorten the natural course of AWS to 6 to 8 weeks [7, 8, 12]. In this case, we recommended that the patient perform physical therapy to alleviate the symptoms and treated her with Aescuven Forte, which is used to treat phlebitis in the clinic. After the interventions, the duration of AWS in this case was shortened to 3 weeks, which suggests that Aescuven Forte might be effective in improving AWS in combination with physical therapy. However, we cannot determine exactly which therapeutic method had the better effect on the alleviation of AWS. Therefore, more clinical data should be collected to study the therapy of AWS.
In summary, AWS is a self-limited disease that presents typical symptoms of pain, tightness, restriction of shoulder ROM and a subcutaneous cord-like structure. It is thought to be caused primarily by axillary lymph node dissection or sentinel lymph node biopsy. In addition to the physical symptoms, AWS also leads to patient anxiety and fear due to a poor understanding of the complication, which affects the patient’s quality of life. However, many surgeons learn little about and usually overlook this complication and seldom put the patient on appropriate treatment. Consequently, we need to learn more about the pathogenesis, histopathology and effective therapy for AWS. To further investigate AWS, more prospective clinical studies are warranted.