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Am Fam Physician. 2003;68(5):967

Sentinel node biopsy (SNB) is thought to provide accurate lymphatic staging of the axilla in breast cancer surgery with less morbidity than the traditional axillary clearance (AC) procedure. Nevertheless, stasis, lymphovenous damage, hypercoagulability, and tissue injury from either procedure could cause axillary web syndrome. Leidenius and colleagues compared the rates of shoulder restriction and axillary web syndrome in women undergoing SNB or AC in a Finnish teaching hospital.

The 85 study participants were assessed by a physical therapist before surgery to document their range of shoulder flexion and abduction. Any preoperative symptoms of axillary web syndrome, such as palpable or visible tissue cords, pain, or limitation of range of motion, were documented. More than one half of the women (49 patients) underwent SNB only. AC was performed in 36 patients because metastases were identified in frozen sections of the sentinel node, multifocal carcinoma was detected, or sentinel nodes could not be identified. Axillary metastases were identified in five women in the SNB group (10 percent) and 30 women in the AC group (83 percent). The median number of axillary nodes removed was three (range, one to nine) in the SNB group and 16 (range, nine to 29) in the AC group. A physical therapist reassessed all patients two weeks and three months after surgery, and a surgeon examined the women two weeks after surgery to document signs of axillary web syndrome.

Shoulder function was identical in the two groups before surgery. Two weeks later, 24 women in the SNB group (45 percent) and 31 of the women in the AC group (86 percent) had restricted shoulder abduction and flexion. Among women with normal measurements of function, an additional 15 patients in the SNB group and five in the AC group reported subjective symptoms of shoulder restriction. These patients attributed their symptoms to axillary web syndrome or pain in the wound, axilla, or pectoral muscles. A surgeon diagnosed axillary web syndrome in 10 women in the SNB group (20 percent) and 26 women in the AC group (72 percent). Postoperative shoulder restriction was not related to preoperative shoulder function or the presence of axillary metastases. Restricted shoulder function and axillary web syndrome were less common in obese patients. Three months after surgery, almost all patients had full range of shoulder abduction and flexion.

The authors conclude that women who underwent SNB experienced less restriction of shoulder function than women who underwent AC. Nevertheless, 75 percent of women who had SNB had significant symptoms two weeks after surgery. All patients who underwent AC had objective or subjective functional shoulder restriction two weeks after surgery. Three months after surgery, symptoms had resolved in almost all patients.

editor's note: With so much optimistic news about improved survival with early detection of breast cancer, many women approach breast-conserving surgery with high expectations. They anticipate a brief hospital stay and a rapid return to normal activities. For many women, postoperative symptoms come as a nasty and unexpected shock. This study shows that even with minimal axillary surgery, 75 percent of women had symptoms at the two-week follow-up. Family physicians should encourage an optimistic outlook but must prepare patients for some shoulder symptoms and arrange for suitable therapy.—a.d.w.

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