8BREASTSupraclavicular lymph nodesSubclavian lymphatictrunkInfraclavicular lymph nodesJugular lymphatic trunk*Apical lymph nodeLeft internal jugular veinLymphatic vesselRight lymphatic duct*Central lymph nodesBronchomediastinal lymphatic trunkInterpectoral lymphnodes*Humeral (lateral)lymph nodes*pectoral (anterior)lymph nodesParasternal lymphnode*Subscapular (posterior)lymph nodesSubareolar lymphatic plexus*Axillary lymph nodesA. Anterior View1.7LYMPHATICDRAINAGEOFBREASTA.Overview.Lymphdrained from the upper limb andbreast passes through nodes arranged irregularlyingroupsofaxillarylymphnodes:(1)pectoral,alongtheinferiorborderofthepectoralisminormuscle:(2)subscapular,alongthesubscapulararteryandveins;(3)humeral,alongthedistalpartoftheaxillaryvein;(4)central,atthebase of theaxilla,embedded inaxillaryfat;and (5)apical,along the axillaryveinbetweentheclavicleandthepectoralisminormuscle.Mostofthebreastdrainsviathepectoral,central.andapicalaxillarynodestothesubclavianbymphtrunk,whichjoinsthevenoussystematthe junctionofthesubclavianandinternal jugularveins.Themedialpartofthebreastdrainstotheparasternalnodes,whicharelocatedalongtheinternalthoracic-vessels
Interpectoral lymph nodes Parasternal lymph node *Subscapular (posterior) lymph nodes *Pectoral (anterior) lymph nodes *Central lymph nodes *Humeral (lateral) lymph nodes Lymphatic vessel *Apical lymph node Supraclavicular lymph nodes Subclavian lymphatic trunk Subareolar lymphatic plexus Infraclavicular lymph nodes Jugular lymphatic trunk Left internal jugular vein Right lymphatic duct Bronchomediastinal lymphatic trunk A. Anterior View *Axillary lymph nodes Agur_Chap01.indd 8 11/14/2011 2:43:40 PM
ThoraxBREASTSubclavianlymphatictrunkSupraclavicular lymph nodesBreastUpperLimbPectoralis minorInternal jugular vein-Right lymphatic ductAxillary lymph nodesRight subclavianLocation:Inferolatetal to pectoralis minorveinAxillary vein(Levell)and artery1.Pectoral nodesPectoralis major2.Subscapularnodes3.Humeral nodes4.Central nodesParasternallymph nodesInterpectoralnodes (5)Location:On pectoralisminor (Level I)To abdominalApical nodes (6)B. Anterior View(subdiaphragmatic) lymphaticsInfraclavicular(deltopectoral)nodes(7)Location:Superomedialtopectoralisminor(Level I)Subclavian lymph trunkThoracic duct or right lymphatic duct1.7LYMPHATICDRAINAGEOEBREAST(CONTINUEDB.Pattemof lymphaticdrainage.Breastcancertypicallyspreadsbymeans oflymphaticvessels(lymphogenicmetastasis),whichcarrycancercellsfromtheVenous angle (junction of internal jugularandsubclavianveins)breasttothelymphnodes,chieflythoseintheaxilla.Thecellslodgeinthenodes,producing nests oftumorcells(metastases).AbundantcommunicationsamongC. Flow of lymphfrom the breast and upperlymphaticpathwavsandamongaxillary.cervicalandparasternalnodesmayalsolimb to the venous angle.causemetastasesfromthebreasttodevelopinthesupraclavicularlymphnodes,the opposite breast,orthe abdomen.Theprognosis of breast cancerhasbeencorrelatedwiththelevelofmetastasis(l,ll.orlll)andtothenumberofinvolvedaxillarylymphnodes.C.Flowoflymphfromthebreastandupperlimbtothevenousangle
Agur_Chap01.indd 9 11/14/2011 2:43:44 PM
10BREASTClavicleEu-7110Anterior ViewAnteriorViewArteries:Veins:1.Lateralmammary branches of lateral cutaneousbranches of posterior intercostal arteries1.Lateral mammary branches of lateral cutaneous branches of posterior intercostal veins2. Lateral mammary branches of lateral thoracic artery2. Lateral mammary branches of lateral thoracic vein3. Lateral thoracic artery3. Lateral thoracic vein4. Pectoral branch of thoraco-acromial artery4. Pectoral branch of thoraco-acromial vein5. Axillary artery5. Axillary vein6. Mammary branch of anterior intercostal artery6.Mammarybranch of anterior intercostalvein7. Subclavian artery7.Subclavianvein8. Internal thoracic artery8. Internal thoracic vein9. Perforating branches9. Perforating branches10. Stemal branches10. Sternal branches11. Medial mammary branches11.Medialmammary veins1.8ARTERIALSUPPLYANDVENOUSDRAINAGEOFBREASTArteriesenterandveinsdrainthebreastfromitssuperomedialandsuperolateralaspects:vesselsalsopen-etratethedeepsurfaceofthebreast.Thevesselsbranchprofuselyandanastomosewitheachother.Breastincisionsareplaced inthe inferiorbreastquadrantswhenpossiblebecausethesequadrantsarelessvascularthanthesuperiorones
Lateral mammary branches of lateral cutaneous branches of posterior intercostal arteries Lateral mammary branches of lateral thoracic artery Lateral thoracic artery Pectoral branch of thoraco-acromial artery Axillary artery Mammary branch of anterior intercostal artery Subclavian artery Internal thoracic artery Perforating branches Sternal branches Medial mammary branches Arteries: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Lateral mammary branches of lateral cutaneous branches of posterior intercostal veins Lateral mammary branches of lateral thoracic vein Lateral thoracic vein Pectoral branch of thoraco-acromial vein Axillary vein Mammary branch of anterior intercostal vein Subclavian vein Internal thoracic vein Perforating branches Sternal branches Medial mammary veins Veins: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Anterior View 2 1 3 4 Clavicle 5 6 7 8 11 11 9 2 1 3 4 Clavicle 7 5 6 8 10 10 9 Anterior View S t e r n u m S t e r n u m Agur_Chap01.indd 10 11/14/2011 2:43:46 PM
ThoraxBREAST11Intercostobrachialnerves (T2 and T3)-Pectoralismajor Lateral mammary branch oflateral pectoral cutaneousbranch of intercostalnerveT4Long thoracic nerve -NippleSerratus anteriorLatissimus dorsiExternal obliquePosterior branches of lateralAnterior branches ofabdominalcutaneousnerveslateralabdominalcutaneousnerves (T7, T8)A. Anterolateral View (Male)C5T4C5C8T11.9MUSCLESANDNERVESOFBEDOFBREASTT2A.Muscles comprising bed and cutaneousT3nerves. B.Dermatomes.Local anesthesia of an intercostalT4space(intercostalnerveblock)isproducedby injecting a local anesthetic agentaroundthe intercostal nerves between the paraver-T5tebral line and the area of required anes-thesia.Because any particular area of skinT6usually receives innervation from two adja-cent nerves,considerable overlapping ofcontiguous dermatomes occurs.Therefore,1T9complete loss of sensation usuallydoes notoccurunlesstwoor moreintercostal nervesB.Anterolateral View (Female)are anesthetized
Agur_Chap01.indd 11 11/14/2011 2:43:53 PM
12BONYTHORAXANDJOINTS1st thoracic vertebraJugular notch Sternocostal synchondrosisof1stribRibs:Clavicle1st2ndScapula3rdManubrium4thManubriosternal joint(sternal angle)5thBodyofstemumXiphistermaljoint6thXiphoidprocess7thCostochondraljoint8thCostal cartilage9th8th rib8th intercostal space10thCostal10th ribBody ofmargin12th12ththoracicvertebra11thInfrasternal angleA. Anterior View1.10BONYTHORAXThe thoracic cage consists of 12 thoracic vertebrae, 12 pairs of ribs andat the sternal angle, located at the junction of the manubrium and body ofcostal cartilages,and the sternumthesternumAnteriorly.thesuperiorsevencostalcartilagesarticulatewiththesternumThe3rdto10thribscanbepalpatedinsequenceinferolateralyfromthethe8th,9th,and1othcartilagesarticulatewiththecartilageaboveform2ndrib:thefusedcostalcartilagesofthe7thto1othribsformthecostaling the costal margin;the 11th and 12thare"floating"ribs,that is, theirarch (margin),andthetipsof the11thand 12thribs canbepalpatedcartilages do not articulate anteriorly.posterolaterally.Theclavicle liesoverthe1strib,making it difficulttopalpate.The2nd ribAribdislocationisthedisplacementofacostalcartilagefromthester-num;aribseparationreferstodislocation ofthecostochondral joint.iseasilypalpablebecauseitscostalcartilagearticulateswiththesternum
1st thoracic vertebra Clavicle Scapula Manubrium Manubriosternal joint (sternal angle) Body Costal cartilage 8th rib 10th rib Costal Body of margin 12th thoracic vertebra Costochondral joint 12th 8th intercostal space Xiphoid process Xiphisternal joint Sternocostal synchondrosis of 1st rib Ribs: 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th Infrasternal angle of sternum 11th A. Anterior View Jugular notch Agur_Chap01.indd 12 11/14/2011 2:44:04 PM