ThoraxPECTORALREGION2Supraclavicularnerves(C3andC4)Clavicle.DeltoidPlatysmaClavipectoral(deltopectoral)triangleCephalic veinSkinClavicular headPectoralisPectoral fascia coveringmajorpectoralis majorSternocostal headIntercostobrachial nerve (T2)Subcutaneous tissueLateral mammaryandposteriorbranchesof lateral pectoral cutaneousnerves (T3 to T6)(from intercostal nerves)> Lateral mammary branches oflateral pectoral cutaneous branchesof intercostal nervesMedial mammary branches ofanteriorpectoral cutaneousSerratus anteriorbranches of intercostal nervesCostal cartilage of6th ribExternal obliqueAnteriorView1.2SUPERFICIALDISSECTION,MALEPECTORALREGIONTheplatysmamuscle,whichdescendstothe2ndor3rd rib,is cutshortonbothsidesof thespecimen;together with the supraclavicular nerves, it is reflected superiorly on the right side.Thepectoralfasciacoversthepectoralismajor.TheclavicleliesdeeptothesubcutaneoustissueandtheplatysmamuscleThecephalic veinpassesdeeply intheclavipectoral (deltopectoral)triangleto jointheaxillaryvein.Supraclavicular(C3andC4)andupperthoracicnerves(T2toT6)supplycutaneousinnervationtothepectoral region.The clavipectoral (deltopectoral) triangle, bounded by the clavicle superiorly,the deltoid muscle laterally,andtheclavicularheadofthepectoralismajormusclemedially,underliesasurfacedepressioncalledtheinfraclavicularfossa
Skin Platysma Subcutaneous tissue Lateral mammary branches of lateral pectoral cutaneous branches of intercostal nerves Pectoral fascia covering pectoralis major Costal cartilage of 6th rib Medial mammary branches of anterior pectoral cutaneous branches of intercostal nerves Supraclavicular nerves (C3 and C4) Clavipectoral (deltopectoral) triangle Intercostobrachial nerve (T2) Lateral mammary and posterior branches of lateral pectoral cutaneous nerves (T3 to T6) (from intercostal nerves) Serratus anterior External oblique Clavicle Cephalic vein Clavicular head Sternocostal head Pectoralis major Anterior View Deltoid Agur_Chap01.indd 3 11/14/2011 2:43:12 PM
1BREASTClavicleSuprasternal (jugular) notchManubrium of sternumDeltoid Anterioraxillary foldIntermammary cleftoverlying body ofsternumNippleSupermumeraryAreola-nipple (polythelia)XiphoidprocessA. Anterior ViewSite of axillaryprocess (tail)AreolartubercleNippleAreola-B. Anterior View1.3SURFACEANATOMYOFFEMALEPECTORALREGIONA.Overview.B.Breast.Theroughly circularbase of the femalebreast extendsPolymastia(supernumerarybreasts)orpolythelia(accessorynipples)transverselyfromthelateral borderof thesternumtothemidaxillary lineandmayoccursuperiororinferiortothenormalpair,occasionallydevelopingverticallyfromthe2ndto6thribs.Asmall partofthebreastmayextendalongintheaxillaryfossaoranteriorabdominal wall.Supernumerarybreaststhe inferolateral edgeofthepectoralismajormuscle toward the axillaryfossa,usuallyconsistofonlya rudimentarynippleand areola,whichmaybeforminganaxillaryprocessortail (ofSpence).mistakenforamole(nevus)untiltheychangepigmentationwiththenor-mal nipplesduringpregnancy
Deltoid Anterior axillary fold Nipple Areola Clavicle Suprasternal (jugular) notch Manubrium of sternum Intermammary cleft overlying body of sternum Supernumerary nipple (polythelia) Xiphoid process A. Anterior View Site of axillary process (tail) Areolar tubercle Nipple Areola B. Anterior View Agur_Chap01.indd 4 11/14/2011 2:43:20 PM
ThoraxBREAST5Suprasternal jugular) notchClavicleClaviclePectoralfasciaDeltoidCephalic veinPectoralismajorPectoralis majorLatissimusdorsiRetromammary space(bursa)consisting ofloose connective tissueSuspensoryligaments of breastLactiferous ductLactiferoussinusAxillaryprocess (tail)ofbreastFatAreolaSerratus anteriorA. Anterior View1.4SUPERFICIALDISSECTION,FEMALEPECTORALREGIONA.DissectionOnthespecimen'srightside,theskinisremoved:ontheleftside,thebreastissagit120clocktally sectioned.Twothirdsofthebreastrestsonthepectoral fascia coveringthepectoralismajor:theAxillary tailSuperomedial/quadrantotherthirdrestsonthefascia covering theserratus anteriormuscle.15%=60%The regionof looseconnective tissue between thepectoral fascia and thedeep surface Areola (10%)Superolateral5quadrantofthebreasttheretromammaryspace(bursa).permitsthebreasttomoveonthedeepNipplefascia.93Cancercanspreadbycontiguity(invasionofadjacenttissue).WhenbreastcancerInferomedialInferolateralcellsinvadetheretromammaryspace,attachtoorinvadethepectoralfasciaoverlying10%=5%quadrantquadrantthepectoralismajor,ormetastasizetotheinterpectoral nodes(Fig.1.7),thebreastelevateswhenthe muscle contracts.This movement is a clinical sign of advanced6cancerofthebreastRight Breast, Anterior ViewB.BreastQuadrants.Fortheanatomical location anddescriptionoftumorsandB. Quadrants of Breast: Percentage of Malignant TumorsCysts,the surfaceofthebreast is divided intofourquadrants.Forexample:"Ahardirreqularmasswasfeltinthesuperiormedialquadrantofthebreastatthe2oclockposition,approximately2.5cmfromthemarginoftheareola
Agur_Chap01.indd 5 11/14/2011 2:43:25 PM
BREASTFat hasbeen removedLobule of mammary glandSuspensoryTerminal ductligamentof breastLobules of fatLactiferous ductsSuspensoryligamentofbreastNippleLactiferousductsLactiferous sinusAreolaNippleLobeofmammaryglandLactiferousB.SchematicSagittalSectionductsA. Anterior ViewPectoral fasciaSubcutaneous tissueRetromammaryspace(bursa)Suspensory ligamentsofbreast1.5FEMALEMAMMARYGLANDGlandular tissue(mammaryA.Dissection.Areas of subcutaneousfatwereremovedto showthelobule)suspensory ligaments of thebreast.The mammaryglandsare modi-Lactiferousductfiedsweatglandslocatedinthesubcutaneoustissue.Theyconsistofglandulartissue,theparenchyma,and supportingfibroustissue,theNipplestroma.Themammaryglandsareattachedtothedermisoftheskinbysuspensoryligaments,B.andC.Sagittal sections.Theglandulartissueconsistsof15to20lobes,eachcomposedoflobules.EachlobeLactiferous sinushasalactiferousductthatwidenstoformthelactiferoussinusbeforeopeningonthenipple.InterferencewiththelymphaticdrainagebyFatcancermaycauselymphedema(edema,excess fluid inthesubcuta-neoustissue),whichinturnmayresultindeviationofthenippleandaleathery,thickenedappearanceofthebreastskin.Prominent(puffyskinbetweendimpledporesmaydevelop,whichgivestheskinanorange-peelappearance(peaud'orangesign).Largerdimplesmayform if pulled bycancerous invasionofthe suspensory ligaments ofC. Sagittal Section of Breastthe breast
Agur_Chap01.indd 6 11/14/2011 2:43:30 PM
ThoraxBREASTA. Lateral ViewB. Lateral ViewC. Superior ViewOrientation forAand BOrientationforCandDD.Superior View1.6IMAGINGOFBREASTA.Mediolateraloblique (MLO)mammogramof leftbreast.Thepectoralismajormuscle isindicatedwithwhitearrowheadsand the inframammaryfoldwitha curved whitearrow.Thenipple is seen inprofile.Observetheconnective tissue network of the breast The stroma is radiopaque and changes with age and during lactationB.Digital mammogram.C.Craniocaudal (CC)mammogramof left breast.Pectoralis major (white arrows).D.Glactogram.Contrasthasbeeninjectedintoalactiferousduct,outliningthebranchingpattenofitstributaries
Orientation for A and B Orientation for C and D A. Lateral View B. Lateral View C. Superior View D. Superior View Agur_Chap01.indd 7 11/14/2011 2:43:37 PM