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HISTORY
A history of breast surgery and anatomy is found in Table 3-1.
Table 3-1. Anatomic and Surgical History of the Breast
Egypt (Ebers
Papyrus)
1600
B.C.
Diagnosis and treatment of breast tumors. Suggestions included heat cauterization with "fire drill," and excision by knife
Democedes ca.
525
B.C.
According to Herodotus, he successfully treated a woman with a breast tumor
Hippocrates
(460-377 B.C.)
Made references to breast cancer, providing detailed descriptions of its effects
Celsus (ca. 14-
37 A.D.)
Recommended against surgery, due to further irritation of breast cancer. If surgery had to be performed, he advised against removal
of pectoralis muscles.
Galen (ca. 130-
ca. 200 A.D.)
Claimed an excess of black bile (melancholia) caused cancer. Treatment centered on nutrition and purgation. Surgical excision was
only recommended if tumor was removable.
Leonides of
Alexandria
1st
Cent.
According to Atius of Amida (6th Cent.), he used extensive cauterization, along with a knife, in amputating breast
Lanfrank 1296 Published Chirurgica Parva. Described surgery of breast using Leonides' method.
De Mondeville
(1260-ca.
1320)
Advocated deep incision, extirpation, and cauterization for small breast tumors. Used zinc chloride caustic pastes on large tumors.
DeChauliac 1363 In his Chirurgica Magna, advocated purgation and dietary regulation for conservative treatment of breast cancer. If tumor was
operable, then a wide excision and removal of all "rests" was recommended.
Arees 1493 Advocated dividing cancerous breast lengthwise and dissolving tumor with ligature
Fuchs (1501-
1566)
Compressed breast cancers with lead plate
Vesalius
(1514-1564)
Treated breast cancers with wide excision and hemostasis with ligatures
Par (1510-
1590)
Recognized relationship between breast cancer and axillary node extension. With a small cancer, removed tumor beyond these
extensions. With a large cancer, used sweet milk, vinegar, and ointments. He also attempted tumor compression with lead plates.
Fabricius ab
Aquapendente
(1537-1619)
Performed radical surgery only at patient's request. He felt partial excision was worthless.
Von Hilden
(1560-1624)
Designed an instrument that constricted and fixed base of breast for faster amputation
Cabrol 1570 Reported removal of pectoralis major muscle to successfully treat breast cancer
Severinus 1632 Removed large axillary nodes during breast excision
Tulp 1652 Thought breast cancer was contagious, arguing that a servant girl had contracted it from her mistress
Clowes (1560-
1634)
Used exorcism to treat breast cancer. Physician to Queen Elizabeth, he believed that laying on of royal hands would heal breast
tumors.
De Houppeville 1693 Reported removing breast while also removing part of pectoralis major muscle
Le Dran (1685-
1770)
Recognized that cancer spread through lymphatics to regional nodes; removed axillary nodes whenever possible. Recognized need
for early operation.
Sharp 18th
Cent.
Wrote of breast removal through an oval incision and excision of "knobs" in armpit
Bidloo 1715 Designed pronged fork used to transfix breast for amputation
Tabor 1721 Designed guillotine-type instrument used for breast amputation
Petit 1774 Published Traite des Operations, which explained that roots of cancer lie in enlarged lymphatic nodes. Advocated removing lymph
nodes, pectoral fascia, and some muscle fibers.
Bell 1784 Removed tumors early. Cleared the axillary nodes in armpit while preserving pectoral muscle and sparing much of the skin.
Cruikshank 1786 Described lymphatics of human breast
Young 1818 Tried a modern version of Par's compression treatment
Cooper 1845 Described suspensory ligaments bearing his name
Paget 1853 Wrote, "[W]e have to ask ourselves whether it is probable that the operation will add to the length or comfort of life enough to
justify incurring the risk for its own consequences."
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justify incurring the risk for its own consequences."
Velpeau 1856 His Treatise on the Diseases of the Breast advocated thorough excision of tumor and its overlying skin not total amputation of
breast preserving nipple if possible.
Moore 1867 Argued that recurrence of cancer was due to fragments left after operation. Advocated removal of breast and its surrounding tissue
(skin, lymph nodes, fat, and some pectoral muscle).
Sweeting 1869 Reported on removal of pectoralis major muscle during mastectomy. Wrote in his On a New Operation for Cancer of the Breast, "The
surgical anatomist can readily see that you do not by these incisions add to the dangers of the operation."
Lister 1870 Refined Moore's technique of axillary exposure and divided pectoral muscles
Volkmann 1875 Removed as much tissue as possible, including pectoralis major muscle and sometimes pectoralis minor muscle during breast tumor
excision
Gross 1880 In Tumors of the Mammary Gland, he extended Moore's procedure to include excision
Halsted 1882-
1907
Worked extensively on procedure known as radical mastectomy: "About eight years ago (1882) I began not only to typically clean
out the axilla in all cases of cancer of the breast but also to excise in almost every case the pectoralis major muscle, or at least a
generous piece of it, and to give the tumor on all sides an exceedingly wide berth."
Sappey 1885 Noted presence of subareolar plexus into which parenchymal lymphatics drained, claiming that most of drainage was to axilla
Heidenhain 1888 Investigated spread of breast cancer through lymphatics into retromammary tissue, pectoral fascia, and pectoralis major muscle.
Argued that lymphatics follow pectoral fascia down into muscle; cancer often found in this deep plane.
Welch 1891 Used frozen sections in diagnosis of breast cancer
Stiles 1892 While studying 100 surgical specimens of breast cancer, found cancer in connective tissue radiating from tumor into surrounding
circum-mammary fat, parenchyma, in septa separating lobulus of circum-mammary fat, and in Cooper's suspensory ligaments
Meyer 1894 Reported his experiences with radical mastectomy procedure similar to Halsted's (differing only in skin incision)
Czerny 1895 Replaced surgically removed breast with large lipoma (breast reconstruction)
Grossman 1896 Injected mercury in adult cadavers while studying their axillary lymph nodes. Noted lymphatic trunks with interspersed lymph nodes
lying between pectoralis muscles.
Tansini 1896 Performed immediate breast reconstruction using latissimus dorsi musculocutaneous flap after radical mastectomy
Gocht 1897 Irradiated case of inoperable breast cancer (Roentgen's x-rays were discovered in 1895)
Rotter 1899 Noted metastases while tracing lymphatics from breast to inter-pectoral nodes
Bloodgood 1914 Advocated biopsy followed by immediate mastectomy
Janeway 1917 Used interstitial irradiation instead of mastectomy
Stibbe 1918 Published detailed study on internal mammary lymphatics
Keynes 1922-
1931
Starting with 1922 work with Gask, argued against radical mastectomy. Used combination of radiation therapy (with radium needles)
and simple mastectomy.
W.S. Handley 1927 Suggested standard radical mastectomy be extended to include internal mammary lymphatics. Also implanted radium tubes
parasternally as prophylaxis.
Patey and
Dyson
1943 Developed modified radical mastectomy. Advocated wide skin excision and axilla clearing while sparing pectoralis major muscle.
McWhirter 1948 Promoted combination of simple mastectomy and high voltage x-ray therapy
Wangensteen 1949 Advocated using intrapleural extended radical mastectomy sometimes extending into mediastinum to treat breast cancer. This
supra-radical surgery included cervicothoracic approach and median sternotomy with supraclavicular dissection, upper mediastinal
dissection, and removal of internal mammary chain of lymph nodes.
Pack 1951 Called for prophylactic bilateral mastectomy even with cancer in one breast
Margottini and
Bucalossi
1952 Advocated extrapleural excision of parasternal nodes during radical mastectomy
Urban 1952 Performed intrapleural removal of parasternal nodes during radical mastectomy.
Extensive surgery included en-bloc resection of breast and axilla, removal of pectoralis, wide skin excision with thin flaps, and en-
bloc excision of internal mammary glands (splitting sternum as well as 2nd-5th ribs).
Gershon-
Cohen et al.
1953 Reported some success with roentgenography
Bauclesse,
Ennuyer, and
Cheguillaume
1960 Performed lobectomy (tumorectomy) followed by radiation therapy
Egan 1962 Correct interpretation of mammograms in 501 of 518 proven carcinomas (96.7%) and recognition of 351 of 383 benign lesions
(91.6%)
Gros 1963 Proposed "senology" as special discipline for study of breasts
Dodd et al. 1963 First needle-localization procedure. Published in 1965.
Witten 1964 Stated that 80-90% of breast cancer determined by surgical biopsy can also be discovered from mammography
Funderburk 1964 Located intraductal papillomas by injection of 50% solution of diatrizoate of sodium into bleeding duct, followed by mammography
Berger et al. 1966 Described non-invasive localization method for mammographically detected occult lesion
Olivari 1974 Used latissimus dorsi myocutaneous flap.
1976 Placed silicone prosthesis under flap.
Frank et al. 1976 Used self-retaining wire to guide needle
Dreaver 1977 Pioneered breast reconstruction with myocutaneous flaps. Published in major journals in 1981, 1986.
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Bostwick 1978 Systematized use of latissimus dorsi myocutaneous flap
Veronesi et al. 1981 First study report that survival rates for breast conserving procedure could equal those of Halstead radical mastectomy
Hartramp et al. 1982 Demonstrated transverse myocutaneous flap
Lagios et al. 1982,
1989
Developed criteria for excision of ductal carcinoma in situ
Laing 1984 First use of ultrasound to guide needle localization
Sarhadi et al. 1997 Studied innervation of nipple and areola
March et al.
Joint Task
Force
1997 National surveys of breast core biopsy use
Note: It is not within the scope of this survey to include hormonal therapy, chemotherapy, and immunotherapy.
History table compiled by David A. McClusky III and John E. Skandalakis.
References:
Allen JG. Breast. In: Moyer CA, Rhoads JE, Allen JG, Harkins HN (eds). Surgery: Principles and Practice (3rd ed). Philadelphia: JB Lippincott, 1965, pp. 621-661.
Ellis H. The treatment of breast cancer: a study in evolution. Ann R Coll Surg Eng 1987;69:212-215.
Baum M. Breast cancer 2000 B.C. to 2000 A.D.: time for a paradigm shift? Acta Oncol 1993;32:3-8.
Figueira-Fo ASS, Salvador-Silva HM, Novais-Dias E. Reconstruction of the breast: types and techniques. In: Figueira-Fo ASS, Salvador-Silva HM, Novais-Dias E,
Barros ACSD (eds). Mastology: Breast Diseases. New York: Elsevier, 1995, pp. 367-374.
Fisher BF. The revolution in breast cancer surgery: science or anecdotalism? World J Surg 1985;9:655-666.
Forest APM. Lister Oration: Breast cancer: 121 years on. J R Coll Surg Edinb 1989;24:239-248.
Goldwyn RM. Vincenz Czerny and the beginnings of breast reconstruction. Plast Reconstruct Surg 1978;61:673-681.
Lewison EF. The surgical treatment of breast cancer. Surgery 1953;34:904-953.
Robinson JO. Treatment of breast cancer through the ages. Am J Surg 1986;151:317-333.
Rubin E, Simpson JF. Breast Specimen Radiography. Philadelphia: Lippincott-Raven, 1998.
Silverstein MJ. Ductal Carcinoma in Situ of the Breast. Baltimore: Williams & Wilkins, 1997.
Vaeth JM. Historical aspects of tylectomy and radiation therapy in the treatment of cancer of the breast. Front Radiat Ther Oncol 1983;17:1-10.
EMBRYOGENESIS OF THE BREAST
Normal Development
The breast is a group of large glands derived from the epidermis. It lies in a network of fascia derived from the dermis and the superficial fascia of
the ventral surface of the thorax. The nipple itself is a local proliferation of the stratum spinosum of the epidermis.
During the second month of gestation, two bands of slightly thickened ectoderm appear on the ventral body wall extending from above the axilla to
below the groin. These bands are the milk lines and represent potential mammary gland tissue (Fig. 3-1). In humans, only the pectoral portion of
these bands will persist and ultimately develop into adult mammary glands. Occasionally, vestigial, or even functional, breast tissue may arise from
other portions of the milk line.
Fig 3-1.
A. The milk lines in a generalized mammalian embryo. Mammary glands form along these lines. B. Common sites of formation of supernumerary nipples or
mammary glands along the course of the milk lines in the human. (From Carlson BM. Human Embryology and Developmental Biology, 2nd ed. St. Louis:
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mammary glands along the course of the milk lines in the human. (From Carlson BM. Human Embryology and Developmental Biology, 2nd ed. St. Louis:
Mosby, 1999; with permission.)
The glandular portion of the breast develops from the ectoderm. It arises from the local thickening of the epidermis (Fig. 3-2A). From this thickening,
16 to 24 buds of ectodermal cells grow into the underlying mesoderm (dermis) during the twelfth week (Fig. 3-2B). These buds, at first solid, will
become canalized near term to form the lactiferous ducts (Fig. 3-2C). The tips of the buds will give rise to the secretory acini during lactation. The
epidermal surface of the future nipple is at first a shallow pit (Fig. 3-2D). Near term it becomes everted (Fig. 3-2E). The areola is said to be visible
from the fifth month onward. Note that an inverted nipple may be a developmental arrest rather than a true pathological condition.
Fig 3-2.
Development of the breast. A-D. Stages in the formation of the duct system and potential glandular tissue from the epidermis. Connective-tissue septa are
derived from the mesenchyme of the dermis. E. Eversion of the nipple near birth. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical
Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.)
The mammary glands form in the same manner as do sweat glands; they are often considered to be modified sweat glands. The areolar glands (of
Montgomery) around, but not on the nipple, appear to be transitional between sweat and lactiferous glands. They serve to lubricate the nipple
during lactation (milk production and nursing). The connective-tissue stroma of the breast forms from the mesoderm, which will form the dermis of
the skin and the superficial fascia (tela subcutanea) as well. Fibers forming the suspensory ligaments (of Cooper) will develop from both layers. This
development, as well as the appearance of fat in the superficial fascia, does not occur until puberty in the female (Fig. 3-3).
Fig 3-3.
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Development of the mammary ducts and hormonal control of mammary gland development and function. A. Newborn. B. Young adult. C. Adult. D. Lactating
adult. E. Postlactation. (From Carlson BM. Human Embryology and Developmental Biology, 2nd ed. St. Louis: Mosby, 1999; with permission.)
Although minor changes occur during each menstrual cycle, pregnancy and lactation bring about the ultimate development of the breasts.
Progesterone, prolactin, and placental lactogen are key hormones in stimulating the formation of secretory alveoli which develop at the ends of the
branched ducts. As development continues, the cells of the secretory alveoli acquire increased organelles related to protein synthesis and secretion.
During lactation, prolactin from the anterior pituitary gland causes mammary glands to secrete milk proteins and lipids. Milk ejection occurs in
response to the neural impulses elicited by sucking activity at the breast. This stimulus causes release of oxytocin by the paraventricular nuclei of
the hypothalamus via the posterior pituitary gland. These neural impulses also inhibit the release of luteinizing hormone.
When nursing ceases, prolactin secretion is reduced. Nonejected milk in the alveoli effects the cessation of milk production. The alveoli regress, and
the duct system regresses to the nonpregnant state.
Read an Editorial Comment
Congenital Anomalies
The multiple but rare congenital anomalies of the breast may be associated with various other syndromes. It is not within the scope of this chapter
to study these syndromes or their associated anomalies.
Velanovich
2
reviewed the embryology of ectopic breast tissue, supernumerary breasts, and supernumerary nipples in a brief article, and we
recommend it to the interested reader.
Amastia, Athelia, and Amazia
Absence or lack of development of the breast (amastia), or of the areola and nipple only (athelia) is rare. These conditions may be unilateral or
bilateral. The corresponding pectoral muscles are often absent as well. There is some indication that the condition is inherited.
3
Failure of breast
tissue to form when the nipple is present is called amazia.
Supernumerary Breasts or Nipples
Supernumerary breasts or nipples are called accessory if they are on the embryonic milk line, and ectopic if they lie elsewhere. The latter are very
rare.
4
Among accessory organs, one can distinguish (1) polymastia, in which there is glandular tissue with or without an areola and a nipple; and (2)
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Among accessory organs, one can distinguish (1) polymastia, in which there is glandular tissue with or without an areola and a nipple; and (2)
polythelia, in which there is a nipple, an areola, or both, but no glandular tissue, as in amazia. It is not always easy to confirm the presence of
glandular tissue. Swelling may be produced by subcutaneous fat only (pseudomammae).
Among Caucasians, supernumerary mammary structures are thoracic in 90 percent, axillary in 5 percent, and abdominal in 5 percent. The actual
incidence of these structures in the population is between 1 and 5 percent, depending partly on the zeal with which they are sought.
4
Discomfort, the risk of neoplasm, and cosmetic considerations are indications for surgical excision of supernumerary mammary structures. Primary
breast cancer in aberrant axillary breast tissue was reported by Yerra.
5
Bailey et al.
6
reported supernumerary breasts of the vulva and primary mammary carcinoma of the vulva.
Congenital Inversion of the Nipple
Congenital inversion is a failure of evagination of the nipple.
Anomalies of Breast Size
In megalomastia, the breast is extremely enlarged. According to Anastassiades and colleagues,
7
unilateral megalomastia is extremely rare. However,
Netscher et al.
8
reported massive asymmetric virginal breast hypertrophy in a 13-year-old girl. In micromastia, the breast is very small, failing to
develop beyond its prepubertal state.
Gynecomastia
Gynecomastia refers to enlargement of the male breast. Guvenc et al.
9
reported on the incidence of pubertal gynecomastia in 646 Turkish boys in
Ankara. The highest incidence was at age 14 years (61.1%). The incidence of gynecomastia at various pubertal stages and ages was 34.6%. The
incidence of unilateral gynecomastia was 19.6%. A study of healthy young men aged 18-26 found an incidence of 40.5%.
10
In a study of 115 men
attending a dermatologic clinic, Seibel et al.
11
found an incidence of 27.8% with a skinfold exceeding 2-3 cm and the diameter of the areola greater
than 3 cm.
Read an Editorial Comment
SURGICAL ANATOMY
Topographic Anatomy and Relations
Though the terms "mammary gland" and "breast" are not synonymous, the latter will be used here for simplicity to indicate both the gland and the
associated regional skin, fat, and connective tissues as described hereafter.
The adult female breast is located within the superficial fascia of the anterior chest wall. The base of the breast extends from the second rib above
to the sixth or seventh rib below, and from the sternal border medially to the midaxillary line laterally. Two-thirds of the base of the breast lies
anterior to the pectoralis major muscle; the remainder lies anterior to the serratus anterior muscle. A small part may lie over the aponeurosis of the
external oblique muscle.
12
In about 95 percent of women there is a prolongation of the upper lateral quadrant toward the axilla. This tail (of Spence) of breast tissue enters a
hiatus (of Langer) in the deep fascia of the medial axillary wall. This is the only breast tissue found normally beneath the deep fascia.
Skin
The epidermis of the areola and the nipple is distinguished from that of the surrounding skin by the pink color imparted by blood vessels carried close
to the surface in long dermal papillae. In females at puberty, and with each pregnancy, there is an increase in the melanin content of the basal cells,
further darkening the area. The dermis of the skin merges with the superficial fascia, which envelops the parenchyma of the breast.
Superficial Fascia
The superficial fascia (Fig. 3-4) enveloping the breast is continuous with the superficial abdominal fascia (of Camper) below, and the superficial
cervical fascia above. Anteriorly, it merges with the dermis of the skin.
Fig 3-4.
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Diagrammatic sagittal section through the nonlactating female breast and anterior thoracic wall.
Deep Fascia
The deep pectoral fascia envelops the pectoralis major muscle and is continuous with the deep abdominal fascia below. It attaches to the sternum
medially and to the clavicle and axillary fascia above and laterally. Along the lateral border of the pectoralis major muscle, the anterior lamina of the
deep pectoral fascia unites with the fascia of the pectoralis minor muscle and, more inferiorly, with the fascia of the serratus anterior. A posterior
extension of this fascia is continuous with the fascia of the latissimus dorsi and forms the so-called suspensory ligament of the axilla.
Deep to the pectoralis major muscle, the clavipectoral fascia envelops the pectoralis minor muscle and part of the subclavius muscle and attaches to
the inferior aspect of the clavicle, dividing into two laminae, anterior and posterior to the subclavius (Fig. 3-5). The posterior layer is fused with the
fascial anchor of the midportion of the omohyoid muscle and is connected deeply with the axillary sheath. It extends between the axillary fascia, the
clavicle, and the coracoid process. Laterally it unites with the anterior layer of the pectoralis major fascia.
Fig 3-5.
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Parasagittal section through the pectoral region. 1. Trapezius muscle. 2. Cervical investing fascia. 3. Clavicle. 4. Subclavius muscle. 5. Pectoral fascia. 6.
Pectoralis major. 7. Axillary sheath. 8. Lateral pectoral nerve. 9. Medial pectoral nerve, entering pectoralis minor muscle. 10. Suspensory ligament of axilla.
11. Latissimus dorsi muscle. 12. Blade of scapula. (Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy. Pearl River NY: Parthenon, 1993; with
permission.)
Laterally, this fascial layer is often thickened as a stout band between the first rib and the coracoid process, and is referred to as the costocoracoid
ligament. That part of the fascia between the subclavius and the superior border of the pectoralis minor muscle is sometimes referred to as the
costocoracoid membrane. Between the clavicle and the upper edge of the pectoralis minor muscle, this part of the clavipectoral fascia is pierced by
the cephalic vein, the thoracoacromial artery and vein, lymphatic vessels and a branch of the lateral pectoral nerve which innervates the clavicular
head of the pectoralis major muscle.
The axillary fascia lying across the base of the axillary pyramidal space is an extension of the pectoralis major fascia and continues as the fascia of
the latissimus dorsi. It forms the dome of the axilla (Fig. 3-6A). As noted earlier, the lamina of muscle fascia which interconnects the pectoral
musculature and the anterior border of the latissimus dorsi is referred to as the suspensory ligament of the axilla. Occasionally, there is a muscular
interconnection within this fascia, which is called the suspensory muscle of the axilla.
Fig 3-6.
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Diagram of the walls of the axilla. (Skandalakis JE, Skandalakis PN, Skandalakis LJ. Surgical Anatomy and Technique: A Pocket Manual, 2nd Ed. New York:
Springer-Verlag, 2000; modified by permission of Basmajian JV, Slonecker CE. Grant's Method of Anatomy, 11th Ed. Baltimore: Williams & Wilkins, 1989.)
The prevertebral fascia gives off a sheet that covers the floor of the posterior triangle of the neck. Where the axillary vessels and the nerves to the
arm pass through the fascia, they take with them a tubular fascial sleeve, the axillary sheath. The axillary vessels and the nerves to the arm pass
through the sheet and floor, and take with them a tubular fascial sleeve, the axillary sheath.
The clavipectoral fascia can be thought of as consisting of five parts (Fig. 3-6A):
The attachment to the clavicle and the envelope of the subclavius muscle
That part between the subclavius and pectoralis minor muscles, referred to by some as the "costocoracoid membrane"
The thickened lateral band between the first rib and the coracoid process, the costocoracoid ligament
The pectoralis minor envelope
The suspensory ligament of the axilla attaching to the axillary fascia.
Axilla
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Axilla
The axilla is defined as a pyramidal space having an apex, a base, and four walls. The apex is a triangular space bordered by the clavicle, the upper
border of the scapula, and the first rib, which is sometimes called the cervicoaxillary canal. The base consists of the axillary fascia beneath the skin
of the axillary fossa. The anterior wall is composed of three muscles (the pectoralis major, the pectoralis minor, and the subclavius) and the
clavipectoral fascia, which envelops the muscles and fills the spaces between them (Fig. 3-6A). The posterior wall is formed by the scapula and
three muscles: the subscapularis, the latissimus dorsi, and the teres major (Fig. 3-6B). The medial wall consists of the lateral chest wall, with the
second to sixth ribs, and the serratus anterior muscle (Fig. 3-6C). The lateral wall is the narrowest of the walls, being formed by the bicipital groove
of the humerus (Fig. 3-6D).
Read an Editorial Comment
The axilla contains lymph nodes (about which more will be said later in this chapter); the axillary sheath (which covers blood vessels and nerves);
and the tendons of the long and short heads of the biceps brachii muscle and the coracobrachialis muscle (Fig. 3-7).
Fig 3-7.
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Topography of the axilla. Anterior view. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission.)
Read an Editorial Comment
Muscles
The muscles and nerves with which the surgeon must be familiar are listed in Table 3-2. However, the surgeon should also be familiar with their
related fasciae and with the topography of the blood vessels.
Table 3-2. Muscles and Nerves Involved in Mastectomy
Muscle Origin Insertion Nerve supply Comments
Pectoralis
major
Medial half of clavicle, lateral half of
sternum, 2nd to 6th costal cartilages,
aponeurosis of external oblique
muscle

Lateral lip, bicipital
groove
Lateral and
medial
pectoral
nerves
Clavicular portion of pectoralis forms upper extent of radical
mastectomy; lateral border forms medial boundary of modified
radical mastectomy; both nerves should be preserved in modified
radical procedure
Pectoralis
minor
2nd to 5th ribs

Coracoid process of
scapula
Lateral and
medial
pectoral
nerves

Deltoid Lateral half of clavicle, lateral border
of acromion process, spine of
scapula
Deltoid tuberosity of
humerus
Axillary nerve
Serratus
anterior (3
parts)
1. 1st and 2nd ribs

Costal surface of
scapula at superior
angle
Long thoracic
nerve
Injury produces "winged scapula"
2. 2nd to 4th ribs

Vertebral border of
scapula

3. 4th to 8th ribs

Costal surface of
scapula at inferior
angle

Latissimus
dorsi
Back, to crest of ilium Crest of lesser
tubercle and
intertubercular
groove of humerus
Thoracodorsal
nerve
The anterior border forms the lateral extent of radical
mastectomy; injury results in weakness of rotation and abduction
of arm
Subclavius Junction of 1st rib and its cartilage

Groove of lower
surface of clavicle
Subclavian
nerve

Subscapularis Costal surface of scapula Lesser tubercle of
humerus
Upper and
lower
subscapular
nerves
Subscapular nerves should be spared
External
oblique
aponeurosis
External oblique muscle Rectus sheath and
linea alba, crest of
ilium
Remember the interdigitation with serratus anterior and pectoralis
muscles
Rectus
abdominis
Ventral surface of 5th to 7th costal
cartilages and xiphoid process

Crest and superior
ramus of pubis
Branches of
7th-12th
thoracic
nerves

The rectus sheath is the lower limit of radical mastectomy
Source: Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill, 1983; with permission.
Morphology
Each breast is composed of between 15 and 20 lobes, some larger than others, within the superficial fascia, which is loosely connected with the
deep fascia. These lobes, together with their ducts, are anatomic units, but not surgical units. A breast biopsy is not a lobectomy; in such a
procedure, parts of one or more lobes are removed.
Between the superficial and deep fasciae is the retromammary (submammary) space, which is rich in lymphatics (Fig. 3-8, Fig. 3-4). This space was
at one time used for submammary infusions when the venous route was not used.
Fig 3-8.
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The retromammary space. 1. Membranous layer of superficial fascia. 2. Retromammary space. 3. Muscle fascia. (Modified from Colborn GL, Skandalakis JE.
Clinical Gross Anatomy. Pearl River NY: Parthenon, 1993; with permission.)
The lobes of parenchyma and their ducts are arranged radially with respect to the position of the nipple, so that the ducts pass centrally toward the
nipple like spokes of a wheel and terminate separately upon the summit of the nipple. The segment of the duct within the nipple is the narrowest
portion of the duct. Therefore, secretions or sloughed cells tend to collect within the part of the duct just deep to the nipple, resulting in apparent
expansion of the ducts which, when dilated by their contents, are called lactiferous sinuses (Fig. 3-9).
Fig 3-9.
Breast topography. From a dissection photograph. 1. Retinacula cutis. 2. Membranous layer. 3. Serratus anterior fascia. 4. Serratus anterior muscle. 5.
Pectoral fascia. 6. Pectoralis major muscle. 7. Suspensory ligament of axilla. 8. Lobe of breast parenchyma. 9. Lactiferous duct. 10. Ampulla. (Modified from
Colborn GL, Skandalakis JE. Clinical Gross Anatomy. Pearl River NY: Parthenon, 1993; with permission.)
In the fat-free area under the areola, the dilated portions of the lactiferous ducts (the lactiferous sinuses) are the only sites of actual milk storage.
Intraductal papillomas may develop here. The ducts are surrounded by a sheath of soft, cellular, intralobular connective tissue derived from the
upper papillary layer of the dermis. Between the ducts is the denser, less cellular connective tissue from the reticular layer of the dermis. Because of
the radial arrangement of the lobes with respect to the nipple, the site of production of serous or sanguinous fluid emerging upon the surface of the
nipple can be determined by stroking the breast tissue with the tip of a finger, beginning peripherally and terminating at the nipple.
The suspensory ligaments of Cooper form a network of strong, irregularly-shaped connective-tissue strands or bands connecting the dermis of the
skin with the deep layer of superficial fascia, passing between the lobes of parenchyma and attaching to the parenchymal elements and ducts.
Occasionally, the superficial fascia is fixed to the skin in such a way that ideal subcutaneous total mastectomy is impossible.
Read an Editorial Comment
With malignant invasion, portions of the ligaments of Cooper may contract, producing a characteristic fixation and retraction or dimpling of the skin
(Fig. 3-10). This must not be confused with the irregular, roughened appearance of the skin called peau d'orange, which is secondary to obstruction
of the superficial subcuticular lymphatic vessels. In peau d'orange, the subdermal attachment of hair follicles and the edematous skin results in the
pitted appearance of the skin.
Fig 3-10.
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Dimpling of the breast, resulting from involvement of Cooper's ligaments by invasive disease. The dimpling is emphasized by the pressure of the hand of the
examiner. From a clinical photograph. (Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy. Pearl River NY: Parthenon, 1993; with permission.)
In the resting (nonlactating) breast, the main duct system is present, but there are few or no secretory acini. During pregnancy, the ducts
proliferate, and secretory acini develop at the ends of each of the smaller branches. The intralobular connective tissue becomes thinned to form
well-vascularized septa separating adjacent acini. Although there is a relative reduction in the quantity of adipose tissue present, there is an
increase in the size of the breast because of duct and acinus formation.
Blood Supply
Arterial Supply
With considerable variation, the breast is supplied with blood from three sources: the internal thoracic artery, branches of the axillary artery, and the
intercostal arteries (Fig. 3-7, Fig. 3-11).
Fig 3-11.
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A. The breast may be supplied with blood from the internal thoracic, the axillary, and the intercostal arteries in 18 percent of individuals. B. In 30 percent,
the contribution from the axillary artery is negligible. C. In 50 percent, the intercostal arteries contribute little or no blood to the breast. In the remaining 2
percent, other variations may be found. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission.)
INTERNAL THORACIC ARTERY
The internal thoracic branches supply most of the blood to the breast. The internal thoracic (or internal mammary) artery is a branch of the
subclavian artery; it courses parallel with the lateral border of the sternum behind the transversus thoracis muscles. From the internal thoracic
artery, perforating branches pass through the intercostal muscles of the first six interspaces and the pectoralis major muscle to supply the medial
half of the breast and surrounding skin. The mammary rami of the first two of these perforating branches are the largest, although in some cases,
the first and third or second and fourth are the largest. Typically these arteries descend laterally toward the nipple-areolar complex so that most of
the arterial supply arises above the level of the nipple (Fig. 3-12). Therefore, radial incisions in the upper half of the breast are less likely to injure
the major arterial supply than transverse incisions. We agree with Morehead
13
that the inferior parts of the breast below the level of the nipple are
almost free of major vessels.
Fig 3-12.
Blood supply of the breast; drawing from a dissection photograph. The arterial supply is here derived chiefly from (A) direct mammary branches of the
axillary artery; (B) branches of the lateral thoracic artery; (C) perforating branches of the internal thoracic artery. The venous drainage is comparable, and is
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axillary artery; (B) branches of the lateral thoracic artery; (C) perforating branches of the internal thoracic artery. The venous drainage is comparable, and is
illustrated on the right side of the drawing. The rib levels are indicated by numbers. (Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy. Pearl
River NY: Parthenon, 1993; with permission.)
BRANCHES OF THE AXILLARY ARTERY
Four branches of the axillary artery may supply the breast. They are, in order of appearance, (1) the supreme thoracic branch, (2) the pectoral
branches of the thoracoacromial artery, (3) the lateral thoracic arteries, and (4) unnamed mammary branches. The lateral thoracic artery is the most
important of these vessels. The axillary vasculature supplies the lateral portion of the breast.
INTERCOSTAL ARTERIES
The lateral half of the breast may also receive branches of the third, fourth, and fifth intercostal arteries. Only about 18 percent of breasts are
supplied by all three of these sources.
14
Only the branches from the internal thoracic artery are always present to some degree (Fig. 3-11). In most
breasts, there are free anastomoses between the arteries supplying the breast; occasionally all three arterial sources remain separate.
14
Venous Drainage
The axillary, internal thoracic, and the third to fifth intercostal veins drain the mammary gland. These veins follow the arteries (Fig. 3-12).
The perforating tributaries from the medial half of the breast carry the greater part of the venous drainage. They enter the internal thoracic vein,
which joins the brachiocephalic vein.
The axillary vein is formed by the junction of the basilic and brachial veins. It lies medial or superficial to the axillary artery and receives one or two
pectoral branches from the breast. As it crosses the lateral border of the first rib, the axillary vein becomes the subclavian vein.
The intercostal veins communicate posteriorly with the vertebral venous system, which enters the azygos, hemiazygos, and accessory hemiazygos
veins, which in turn drain to the superior vena cava. Anteriorly, they communicate with the brachiocephalic vein by way of the internal thoracic
veins.
By the first two pathways, metastases of the breast readily reach the lungs. By the third pathway, metastases may travel to the skeleton and the
central nervous system (Fig. 3-13).
Fig 3-13.
Diagram of a frontal section through the right breast showing pathways of venous drainage. A. Medial drainage through internal thoracic vein to the right
heart. B. Posterior drainage to vertebral veins. C. Lateral drainage to intercostal, superior epigastric veins, and liver. D. Lateral superior drainage through
axillary vein to the right heart. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York: McGraw-Hill,
1983; with permission.)
There are several places in the body where communication exists between the systemic and the portal venous systems. With obstruction of the
portal vein, these communications may permit portal blood to enter the systemic veins. Even in the absence of portal obstruction, there is no reason
why systemic blood might not enter the portal system. One such location is the lower esophagus. It is drained by anastomosing tributaries of the
azygos (systemic) vein and tributaries of the left gastric (portal) vein. Another such site is in the region of the navel, where there are anastomoses
between small veins of the portal system, which pass from the umbilicus to the liver through the falciform ligament, and the epigastric veins, which
also drain the umbilical region into the internal thoracic veins. Through one or more of these portocaval anastomoses, metastatic cells from the
breast may reach the liver.
Read an Editorial Comment
Lymphatic Drainage
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Lymphatic Drainage
Lymph nodes of the breast region occur in inconstant groups of varying numbers. This inconstancy is mirrored, if not magnified, by the terminology
presented by different authors. We find the terminology of Haagensen
15
most useful. Keep in mind that the lymph nodes are not neatly grouped, and
that many nodes are very small (Fig. 3-14). Only the most careful search of the pathologic specimen will reveal all the lymph nodes present.
Fig 3-14.
Lymph nodes of the breast and axilla. Classification of Haagensen. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General
Surgery. New York: McGraw-Hill, 1983; with permission.)
The major groups of Haagensen
15
are 1) axillary, and 2) internal thoracic (mammary). The average number of nodes in each group follows.
Axillary Drainage (35.3 Nodes)
Group 1. External mammary nodes (1.7 nodes), also called the anterior pectoral nodes. These lie along the lateral edge of the pectoralis minor, deep
to the pectoralis major muscle, along the medial side of the axilla following the course of the lateral thoracic artery on the chest wall from the
second to the sixth rib (Fig. 3-15). Deep to the areola there is an extensive network of lymphatic vessels, the so-called subareolar plexus of Sappey.
In the circumareolar region, large lateral and medial trunks receive much of the lymph from the breast parenchyma. The lateral trunk receives
collaterals from the upper half of the breast and the internal trunk drains the lower part of the breast. These vessels pass around the lateral border
of the pectoralis major muscle to reach the external mammary nodes.
Fig 3-15.
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Lymphatic drainage of the breast. Direction of lymph flow from skin indicated by arrows on right breast and medial side of left breast. 1. Areolar plexus of
vessels, draining areola, nipple and some parenchyma. 2. Anterior pectoral nodes. 3. Central axillary nodes. 4. Interpectoral nodes (a path which can
bypass central axillary nodes). 5. Apical, infraclavicular nodes. 6. Retrosternal nodes. (Modified from Colborn GL, Skandalakis JE. Clinical Gross Anatomy.
Pearl River NY: Parthenon, 1993; with permission.)
Group 2. Scapular nodes (5.8 nodes). These lie on the subscapular vessels and their thoracodorsal branches. Lymphatics from these
intercommunicate with intercostal lymphatic vessels.
Group 3. Central nodes (12.1 nodes). This is the largest group of lymph nodes; they are the nodes most easily palpated in the axilla, because they
are generally larger in size. They are embedded in fat in the center of the axilla. When these nodes enlarge, they can compress the
intercostobrachial nerve, the lateral cutaneous branch of the second or third thoracic nerve, causing accompanying pain.
Group 4. Interpectoral nodes (Rotter's nodes) (1.4 nodes). These lie between the pectoralis major and minor muscles. Often there is a single node.
They are the smallest group of axillary nodes and will not be found unless the pectoralis major is removed.
Group 5. Axillary vein nodes (10.7 nodes). This is the second largest group of lymph nodes in the axilla. They lie on the caudal and ventral surfaces
of the lateral part of the axillary vein.
Group 6. Subclavicular nodes (3.5 nodes). These lie on the caudal and ventral surfaces of the medial part of the axillary vein. Haagensen
15
considered them to be inaccessible unless the pectoralis minor muscle is sacrificed.
Internal Thoracic (Mammary) Drainage (8.5 Nodes)
Lymphatic vessels emerge from the medial edge of the breast on the pectoralis fascia. They accompany the perforating blood vessels, which, at the
end of the intercostal space, pierce the pectoralis major and intercostal muscles to reach the internal thoracic nodes. These nodes also receive
lymphatic trunks from the skin of the opposite breast, the liver, the diaphragm, the rectus sheath, and the upper part of the rectus abdominis.
15
The
nodes, about four to five on each side, are small and are usually in the fat and connective tissue of the intercostal spaces. The internal thoracic
trunks empty into the thoracic duct or the right lymphatic duct. This route to the venous system is shorter than the axillary route.
Since dissection of the internal mammary nodes is not done today, Scatarige et al.
16
advised lateral chest radiography, computed tomography, high-
resolution sonography, magnetic resonance imaging, and radionuclide lymphoscintigraphy.
Read an Editorial Comment
Winer et al.
17
expanded the regional lymph node terminology to include a transpectoral route in the axillary group. We present their classification
verbatim.
The breast lymphatics drain by way of three major routes: axillary, transpectoral, and internal mammary. Intramammary lymph nodes are
considered with, and coded as, axillary lymph nodes for staging purposes; metastasis to any other lymph node is considered distant (M1),
including supraclavicular, cervical, or contralateral internal mammary. The regional lymph nodes are presented here:
1. Axillary (ipsilateral): interpectoral (Rotter's) nodes and lymph nodes along the axillary vein and its tributaries that may be (but are not
required to be) divided into the following levels:
a. Level I (low axilla): lymph nodes lateral to the lateral border of the pectoralis minor muscle
b. Level II (midaxilla): lymph nodes between the medial and lateral borders of the pectoralis minor muscle and the interpectoral (Rotter's)
lymph nodes
c. Level III (apical axillary): lymph nodes medial to the medial margin of the pectoralis minor muscle including those designated as
subclavicular, infraclavicular, or apical
Note: Intramammary lymph nodes are coded as axillary lymph nodes.
2. Internal mammary (ipsilateral): lymph nodes in the intercostal spaces along the edge of the sternum in the endothoracic fascia
Any other lymph node metastasis is coded as a distant metastasis (M1), including supraclavicular, cervical, or contralateral internal mammary
lymph nodes.
Arrangement of Lymph Nodes and Metastasis
The spread of malignancy of the breast is via a hematogenous route, via the lymphatics, and through local infiltration.
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The spread of malignancy of the breast is via a hematogenous route, via the lymphatics, and through local infiltration.
From a purely surgical standpoint, the axillary lymph nodes can be divided into 3 levels:
Level I: lateral to the lateral border of the pectoralis minor muscle
Level II: under the pectoralis minor muscle
Level III: medial to the medial border of the pectoralis minor muscle
Some authors have stated that regional lymph nodes are primary indicators and not instigators of distal disease. They advise that lower axillary
dissection is more than adequate to fulfill the aims of the operation. These authors believe that with removal of a few lymph nodes, the qualitative
axillary node status (positive or negative) can be determined with accuracy.
We quote from Brand et al.
18
:
The nearly identical patterns of treatment failure in lymph node negative and positive breast cancer patients suggest that metastasis in node
negative patients occurs by a similar mechanism. The shorter time to recurrence and larger primary tumor may only reflect a lead time bias, in
that node-positive patients have a greater tumor burden in their lymph nodes that facilitates identification by pathologists.
The pathway of metastasis follows the direction of lymph flow to the lymph nodes (I, then to II and III).
However, Veronesi et al.
19
reported that with a tumor mass measuring up to 2 cm, metastasis to lymph nodes of level I was 69.9%, to levels I and II
was 13.2%, and to all levels was 11.3%. Robinson et al.
20
reported skip metastasis to levels II and III in 5.6% of cases.
In general, the lymphatic drainage of the breast accompanies the blood supply. Hultborn and colleagues
21
concluded that drainage from any
quadrant of the breast passes to axillary nodes (75 percent) and to the internal mammary chain (25 percent).
Haagensen
15
traced lymph flow upward and laterally through the tail of the breast to the central lymph nodes (Fig. 3-16). It is here that metastases
are most frequently found. Another drainage path is by way of lymphatics that pierce the pectoralis major muscle and pass upward between the
pectoralis major and minor muscles to reach the axillary vein group or the subclavicular group of nodes. Between the two muscles there may be a
few interpectoral nodes (of Rotter). Lymphatics from these nodes may bypass the central axillary group and drain directly to subclavicular nodes.
The subclavicular group of nodes is important, since Haagensen
15
believed that metastasis to these nodes renders a surgical cure impossible.
Fig 3-16.
Diagram of lymphatic drainage of the breast. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
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Diagram of lymphatic drainage of the breast. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in General Surgery. New York:
McGraw-Hill, 1983; with permission.)
Read an Editorial Comment
Innervation
(Fig. 3-17, Fig. 3-18) Sarhadi et al.
22
stated that their findings ". . .are uncannily like those of Cooper
23
who described the nerves supplying the
breast as arising from the 2nd-6th intercostal nerves, with mammary branches passing on the surface of the gland and intercommunicating. He
[Cooper] also described the two mammary branches from the 4th lateral cutaneous nerve and mentioned that the nipple receives its innervation
through a plexus under it."
Fig 3-17.
Diagrammatic representation of important peripheral nerves encountered during mastectomy. (Modified from Aitken DR, Minton JP. Complications associated
with mastectomy. Surg Clin North Am 1983;63:1331-1352; with permission.)
Fig 3-18.
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A plan of the brachial plexus. The posterior division of the trunks and their derivatives are shaded. The fibers from C7 which enter the ulnar nerve are shown
as a heavy black line. Letters and numbers C4-C8 and T1-T2 indicate the ventral rami of these cervical and thoracic spinal nerves. (Modified from Williams PL
(ed). Gray's Anatomy (38th ed). New York: Churchill Livingstone, 1995; with permission.)
Thoracodorsal Nerve
The thoracodorsal nerve (middle subscapular) arises deeply from the posterior cord of the brachial plexus, ventral to the subscapularis muscle (Fig.
3-19); it passes downward and medially to reach and innervate the latissimus dorsi muscle. Feller and Woodburne
24
stated that the nerve and its
associated vessels can best be found near the medial border of the latissimus dorsi about 5 cm above a plane passing through the third
sternochondral junction. Once located, the neurovascular bundle should be marked with umbilical tape for protection. If there is obvious involvement
of lymph nodes around the nerve, it must be sacrificed.
Fig 3-19.
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The triangular bed of an axillary dissection. (Modified from Skandalakis LJ, Vohman MD, Skandalakis JE, Gray SW. The axillary lymph nodes in radical and
modified radical mastectomy. Am Surg 1979;45:552; with permission.)
Long Thoracic Nerve
The long thoracic nerve innervates the serratus anterior muscle and lies on it (Fig. 3-19). When the superficial fascia is reflected, the nerve or
branches from it can be reflected also, making identification of the nerve difficult. Unless actually invaded by cancer, this nerve should be spared to
avoid "winging" of the inferior angle of the scapula. The landmark for locating the nerve is the point at which the axillary vein passes over the second
rib. Careful dissection of this area will reveal the nerve descending on the second rib posterior to the axillary vein.
24
Anterior Thoracic Nerves (Pectoral)
The importance of the medial and lateral pectoral (anterior thoracic) nerves was emphasized by Scanlon and Caprini,
25
Moosman,
26
and Scanlon.
27
The medial pectoral nerve is superficial to the axillary vein and lateral to the pectoralis minor muscle. The lateral pectoral nerve, which is larger than
the medial nerve, is the nerve supply of the clavicular part of the muscle as well as the sternal portions of the pectoralis major muscle. It is also
superficial to the axillary vein and lies at the medial edge of the pectoralis minor muscle. The branch of the lateral pectoral nerve to the clavicular
head of the pectoralis major muscle arises proximal to, or beneath, the clavicle.
The medial pectoral nerve arises from the medial cord of the brachial plexus near the origin of the thoracoacromial artery from the axillary artery. The
lower part of the lateral pectoral nerve crosses the axillary artery just distal to the origin of the thoracoacromial artery and joins the medial pectoral
nerve, forming a neural loop of varying size. From this loop, several branches arise which pass into the pectoralis minor muscle, some penetrating
that muscle to enter the overlying pectoralis major muscle. Such branches supply the sternal and costal parts of the pectoralis major muscle.
Intercostobrachial Nerve
The intercostobrachial nerve is the lateral cutaneous branch of the 2nd or 3rd intercostal nerve, or a combination of the two intercostal nerves.
After crossing the fatty and lymphatic tissues of the axilla posteromedially, it reaches the medial area of the skin of the arm. Usually, this nerve is
sacrificed.
Read an Editorial Comment
HISTOLOGY AND PHYSIOLOGY
The majority of the material presented here is based on Ham's Histology
28
and Gray's Anatomy.
29
Breasts (Mammary Glands)
There are approximately 20 individual compound alveolar glands in each breast. Independent ducts open onto the surface through the nipple. A
rudimentary duct system is present at birth, and remains in that state until the onset of puberty in females.
At puberty, the breasts enlarge and become more rounded. The nipples become more prominent. Growth is largely due to increased fat between the
lobes and the lobules. There is some development of the duct system, but secretory structures develop only in response to pregnancy.
A small amount of breast tissue develops in 50% of adolescent boys but usually regresses after approximately one year. An approximately similar
incidence of this phenomenon is seen in old men.
Estrogen affects breast development in both males and females, physiologically and pathologically. Pregnancy brings about the addition of
progesterone, which affects the development of secretory alveoli. Prolactin and chorionic somatomammotrophin complete the development of the
secretory alveoli. Glucocorticoids, growth hormone, thyroid hormone, and insulin are also present during pregnancy.
Nipples
(Fig. 3-20) The nipple, which is well innervated by the 4th intercostal nerve, is surrounded by the areola. The pigmentation of the areola increases
with pregnancy. Within the nipple and areola are some dermal papillae, and a very thin epithelium.
Fig 3-20.
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Photomicrograph of a section of a nipple, cut perpendicular to the skin surface (very low power). (Modified from Cormack DC. Ham's Histology (9th ed).
Philadelphia: JB Lippincott, 1987; with permission.)
Approximately 20 ducts open onto the surface of each nipple. The main ducts are called the lactiferous ducts. Stratified squamous keratinizing cells
make up the epithelium of the ducts near their surface. Deeper in the ducts, the epithelium becomes a double layer of columnar cells. Smooth muscle
is embedded within the dense connective tissue which supports the parenchymatous tissue. Some muscle is oriented circularly around the ducts;
other muscle is longitudinally parallel with the ducts. Lactiferous sinuses are the dilated terminal portions of the lactiferous ducts, capable of storing
milk during milk ejection.
Due to loss of the placenta at birth, nipples can suffer from estrogen deficiency for a transient period until the ovaries increase hormone production.
Resting Breast
(Fig. 3-21) The resting breast is defined as a postpubertal breast in an inactive state, not stimulated to become secretory by adequate hormone
levels. The lactiferous sinus constitutes a lobe, with numerous lobules per lobe. It develops as a downgrowth of surface epithelium. Growth continues
through the dermal papillary layer and into the reticular layer as the duct system is formed.
Fig 3-21.
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Schematic diagram of the organization of the resting breast, illustrating how its intralobular connective tissue corresponds to the papillary layer of the
dermis. Extensions of the reticular layer of dermis constitute interlobular suspensory ligaments and septa. (Modified from Cormack DC. Ham's Histology (9th
ed). Philadelphia: JB Lippincott, 1987; with permission.)
Dermis tissue surrounding the duct system is more cellular than in typical dermis and becomes the intralobular connective tissue. Less cellular dermis
forms a coarser tissue which separates the lobules; it is thus interlobular connective tissue, with regions of adipose tissue contained within it. Some
of the larger of these interlobular support structures form the suspensory ligaments (of Cooper).
Intralobular ducts are lined with cuboidal epithelium: narrower ones have a simple cuboidal epithelium, larger ones a double layer of cuboidal
epithelium.
Lactation
(Fig. 3-22) With pregnancy, the duct system completes its development. Many intralobular ducts form extensively during the proliferative phase.
Secretory alveoli form at the tip of the smallest intralobular ducts and complete the lobules. Each secretory alveolus forms a small cul de sac
(secretory lobule) lined with columnar epithelium. Myoepithelial cells are related to the basal side of each secretory alveolus.
Fig 3-22.
Photomicrograph of fully developing breast. This tissue was obtained during the fifth month of pregnancy, when the secretory changes associated with
lactation become manifest. Alveoli at upper right are distended with colostrum; many of those at bottom right have not yet begun to secrete. (Modified from
Cormack DC. Ham's Histology (9th ed). Philadelphia: JB Lippincott, 1987; with permission.)
The secretory phase is brought on by changed levels of progesterone, lactogenic hormones (maternal and placental), and estrogen. Colostrum is
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The secretory phase is brought on by changed levels of progesterone, lactogenic hormones (maternal and placental), and estrogen. Colostrum is
secreted during the third trimester, milk shortly after birth. Not all lobules secrete at the same level. Therefore, under the microscope some lobules
are distended, others are not.
Interlobular partitions of connective tissue become considerably thinned as the secretory portions of the breast become more active and enlarged.
Secretory cells produce numerous lipid droplets of widely varying sizes. While intracellular, lipid droplets are not surrounded by a membrane, but
during exocytosis, they become enwrapped by cell membrane. Electron-dense secretory granules containing milk proteins also are found in secretory
cells. These, too, undergo exocytosis. Columnar cells with sparse populations of microvilli are another component of secretory lobules.
Milk Ejection
Milk ejection occurs only during nursing. The sucking stimulation of the breast sends neural impulses to the hypothalamus. The hypothalamus
stimulates oxytocin secretion by paraventricular nuclei cells, and suppresses the release of prolactin-inhibiting hormone (PIH). Oxytocin stimulates
myoepithelial cells of secretory alveoli of the breast, effecting milk passage through the lactiferous ducts. Prolactin secretion is maintained when the
PIH is suppressed and lactation continues.
Regression of Breast Tissue
During regression of breast tissue, alveoli disappear and lobules greatly reduce in size. Partitions formed by connective tissue become thicker again.
At menopause the estrogen level falls, resulting in atrophy of stroma and parenchymal elements. Changes include irregular growth and some
secretory fluctuation; some ducts proliferate, while others may secrete and form cysts.
SURGICAL APPLICATIONS
There are several types of mastectomy, distinguished by the extent of axillary dissection. Radical mastectomy involves removal of the breast and
axillary lymph nodes, as well as the pectoralis major and minor muscles and the fascia. Modified radical mastectomy involves removal of the breast
and axillary lymph nodes, preserving the pectoralis muscles. Simple, or total, mastectomy involves removal of the breast only. Lumpectomy or
removal of a small malignant tumor can be performed in combination with axillary node dissection. Excisional biopsy involves removal of a small tumor,
perhaps not palpable, with a rim of healthy breast tissue around it.
Peralta et al.
30
found that contralateral prophylactic mastectomy prevented contralateral breast cancer, prolonging both disease-free survival and
overall survival.
Our late friend John Bostwick
31
stated:
Today, women diagnosed with breast cancer have more and better options for treatment, preservation, and reconstruction of the breast. The
breast management team epitomizes the optimal care now available to women with immediate breast reconstruction. Patient education and
added value placed on this important part of the care of the woman with breast cancer are needed so that more women can have breast
cancer treatment and still have a breast.
Another procedure, for very small multiple tumors detected by mammography, is subcutaneous mastectomy, in which the glandular tissue is excised,
but the skin of the breast is preserved. However, this is controversial. In many patients, some peripheral glandular tissue will be overlooked.
32
The
pectoral fascia must be removed in order to extirpate deep mammary tissue. Frequent follow-up examinations are mandatory.
33
Park et al.
34
support the use of stereotactic large-core needle breast biopsies as a diagnostic procedure for suspicious lesions. D'Angelo et al.
35
also
support stereotactic excisional breast biopsy for nonpalpable mammographic breast lesions. Lanstberg et al.,
36
who consider mammography the "gold
standard" for breast imaging and early detection of breast cancer, also found wire-guided surgical breast biopsy "accurate and successful. . . for
diagnosing pathology at the price of invasive technique. Early detection and treatment leads to improved survival and less disfiguring treatments."
Wellman et al.
37
advocated the use of the imaging modality, tactile imaging, to estimate the size of breast masses, enhancing cancer surveillance for
patients with benign masses due to fibrocystic changes or scarring.
Meyer et al.
38
advised that in suspicious nonpalpable breast abnormalities, image-guided large-core needle biopsy is a reliable diagnostic alternaltive
to surgical excision. Smith et al.
39
found ultrasound an effective technique for localizing and excising nonpalpable lesions.
However, Dent,
40
in a review of axillary lymphadenectomy for breast cancer, stated, "The criterion standard of assessing axillary lymph node
involvement is still full histological assessment." He concluded: "During the course of a mastectomy, if glands are palpable (or selected glands are
positive on frozen section or on contact cytology) axillary clearance could be undertaken."
Winchester et al.
41
reported the anatomic subsite (distribution) of lobular and ductal carcinoma of the breast in Table 3-3.
Table 3-3. Distribution of Tumor Location According to Histology, All Patients
Location Lobular (%) Ductal (%) Combination (%)
Nipple 2.2 1.7 1.9
Central 6.0 5.3 6.1
Upper inner 7.3 9.2 8.3
Lower inner 3.8 4.7 3.9
Upper outer 37.0 36.9 37.1
Lower outer 5.8 6.4 5.7
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Axillary tail 0.8 0.8 0.6
Overlapping* 18.6 18.2 19.9
NOS

18.6 16.8 16.5
*Lesions overlap between two quadrants within the breast.
NOS, not otherwise specified.
Source: Winchester DJ, Chang HR, Graves TA, Menck HR, Bland KI, Winchester DP. A comparative analysis of lobular and ductal carcinoma of the breast:
presentation, treatment, and outcomes. J Am Coll Surg 186: 416-422, 1998; with permission.
Foster and Wood
42
have attempted to forecast the future of treatment of breast cancer. They believe that the current treatment of breast cancer
will be changed by advances in molecular biology and other technological advances. We advise the interested student to read their excellent
presentation.
In a personal communication (2000) to the senior author of this chapter (JES), William C. Wood emphasized that successful treatment of breast
cancer depends on understanding the anatomy of the breast:
The local therapy of breast cancer has been anatomically based from the time of Halstead a century ago. As better understanding of the
biology of the disease, both cellular and genetic, developed there came a sense that knowledge of the anatomy and embryology of the breast
and its environs was less important, perhaps even anachronistic. The new techniques for diagnosis, prediction, and local therapy are rapidly
reversing such ideas. A knowledge of lymphatic drainage, reflected in sentinel lymph node mapping and biopsy, makes it possible to perform
surgical clearance of residual axillary metastases only for those patients whose disease warrants it. Understanding the non-segmental nature
of breast ductal anatomy is essential to properly evaluating and treating ductal carcinoma in situ (DCIS). The ability to identify genetic
predisposition to breast cancer relieves half of the women with familial mutations already identified that they are free of the mutation. For
those found to have BRCA 1 or BRCA 2 mutations, prophylactic ovarian surgery is a major consideration. Most do not require serious
consideration of prophylactic mastectomy, but for those who do, detailed anatomical knowledge required for prophylactic skin-sparing
mastectomy with immediate reconstruction is essential for surgeons who would provide the best care. It is as true today as it was in the days
of John Hunter that the best anatomist makes the best surgeon.
The dictionary defines sentinel as "one who or that which watches or stands as if watching." Therefore, in anatomy or surgery, perhaps the sentinel
node is the first site of metastatic disease, the watchdog in cancer. We agree with Borgstein and Meijer
43
that "the role of regional lymph node
dissection in the treatment of most solid tumors remains enigmatic and controversial."
To be more anatomically correct, the sentinel node is the first node receiving lymph from the primary tumor. The topographic and anatomic location
of this node is not certain, but injection of blue dye or radio-labelled technicium will locate the node in the ipsilateral axilla by careful dissection. As
Singletary
44
stated, "Because of the significant frequency of false-negative results in [sentinel lymph node biopsy], which will depend upon the
surgeon's experience, caution is urged in determining when [axillary lymph node biopsy] can be safely eliminated in patients with a negative [sentinel
lymph node biopsy].
In 1977, Cabanas
45
postulated the existence of a specific lymph node center relatively proximate to a primary tumor and differentially identifable by
lymphangiography, the first site of possible metastasis. The significance of his work on penile carcinoma was not fully appreciated at that time. In
1992, Morton et al.
46
independently hypothesized the existence of the sentinel node. We quote from their report on early stage melanoma:
A new procedure was developed using vital dyes that permits intraoperative identification of the sentinel lymph node, the lymph node nearest
the site of the primary melanoma, on the direct drainage pathway. The most likely site of early metastases, the sentinel node can be removed
for immediate intraoperative study to identify clinically occult melanoma cells. We successfully identified the sentinel node(s) in 194 of 237
lymphatic basins and detected metastases in 40 specimens (21%). . . Metastases were present in 47 (18%) of 259 sentinel nodes, while
nonsentinel nodes were the sole site of metastases in only two of 3079 nodes from 194 lymphadenectomy specimens that had an identifiable
sentinel node, a false-negative rate of less than 1%. Thus, this technique identifies, with a high degree of accuracy, patients with early stage
melanoma who have nodal metastases and are likely to benefit from radical lymphadenectomy.
For the senior author (JES), questions surrounding the intersection of anatomy, biology and surgery make the sentinel node concept perhaps difficult
to accept. Certainly, more work needs to be done on the topographic anatomy of the sentinel node of the given anatomic entity with a solid tumor.
The biology and overall philosophy of cancer is still an unsolved problem. Finally, the "radicality" of surgery and the type chosen for different cancers
are points on which surgeons agree to disagree.
The study of Albertini et al.
47
indicated that lymphatic mapping is possible in breast cancer patients and that the histologic status of the sentinel
lymph node (or nodes) probably reflects the histologic status of the axillary nodes at risk. They concluded that if their results are confirmed by other
investigators, the combination of lymphatic mapping and selective lymphadenectomy might lead to more conservative treatment.
O'Hea et al.
48
advised that lymphatic mapping in breast surgery is technically feasible by injecting 0.3 mCi of technetium-99m unfiltered sulfur colloid
in 4 ml of saline at 12, 3, 6, and 9 o'clock positions around the tumor in the breast tissues prior to surgery. This reliably identifies a sentinel node in
most cases, and appears more accurate for T1 tumors than for larger lesions.
Kern
49
published an illustrated study in the hope that "the illustrations...will enable surgeons to perform subareolar injections of radiocolloid and blue
dye in a safe and effective manner. Although dye-only SLN [sentinel lymph node] mapping can be successfully performed with high accuracy using
the SA [subareolar] route, the addition of SA radiocolloid serves as an important aid to increase the efficiency of SLN biopsy, while keeping morbidity
to a minimum."
We quote from Smith et al.
50
:
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We quote from Smith et al.
50
:
[S]ubareolar injection was as accurate, if not more accurate, than peritumoral injection for locating the [sentinel lymph node]. This technique
is simpler than peritumoral injection and does not require injection under image guidance for nonpalpable lesions.
Foster
51
stated the following: "Initial data
52
indicate that if there is no evidence of metastasis to the sentinel node, the likelihood of detection of
metastasis in other nodes in the regional basin is very low (<2%). If this concept is proved by confirmatory studies, complete axillary dissection may
then be avoided in one half to two thirds of patients with invasive breast cancer."
Snider et al.
53
reported that in the staging of breast cancer, sentinel node biopsy with serial sectioning and immunohistochemical staining precisely
predicts the status of the axillary lymph nodes and that most likely it will replace full axillary lymph node dissection.
Linehan et al.
54
advised blue-dye mapping and gamma-probe localization of sentinel lymph nodes using unfiltered Tc-99m sulfur colloid.
Velanovich and Szymanski
55
found that of 827 patients with carcinoma of the breast who had had axillary lymph node dissection, 8.3 percent
developed lymphedema, and that diminutions in quality of life accompanied lymphedema. They advised use of sentinel lymph node biopsy or selective
axillary lymph node dissection to reduce the incidence of lymphedema.
Nwariaku et al.
56
reported that sentinel lymph node biopsy accurately predicts total axillary status and is valuable in the surgical staging of
carcinoma of the breast. Rubio et al.
57
also stated that the sentinel lymph node biopsy for carcinoma of breast staging is highly accurate. Bass et
al.
58
reported that lymphatic mapping and sentinel lymph node biopsy are indispensable tools for treatment of breast cancer.
Tanis et al.
59
commented on lymphatic mapping.:
Choosing the most attractive approach requires determining the aim of lymphatic mapping. A superficial injection technique may be adequate
when the purpose is to spare patients without lymph node metastases in the axilla an unneccasry axillary node dissection. An
intraparenchymal injection technique should be used when the additional purpose is to determine the stage as accurately as possible and to
identify sentinel nodes elsewhere.
Feldman et al.
60
reported that the accuracy of sentinel node biopsy in correctly predicting the status of remaining axillary lymph nodes may be
limited in patients with large segmental breast excision before radiolocalization of the sentinel node. Their findings suggest that excisional biopsy
should be avoided prior to lymphatic mapping for sentinel node biopsy (Fig. 3-23, Fig. 3-24).
Fig 3-23.
Injections around the perimeter of the biopsy excision site with lymphatic drainage from the site are completely missing the sentinel node. Large excision
biopsy results in inaccurate lymphatic mapping (false negative). (Modified from Feldman SM, Krag DN, McNally RK, Moor BB, Weaver DL, Klein P. Limitation in
gamma probe localization of the sentinel node in breast cancer patients with large excisional biopsy. J Am Coll Surg 188:248-254, 1999; with permission.)
Fig. 3-24.
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This illustration shows injections around the perimeter of the biopsy site with lymphatic drainage to the sentinel node. Multiple injections around large
excision biopsy may improve accuracy of lymphatic mapping. (Modified from Feldman SM, Krag DN, McNally RK, Moor BB, Weaver DL, Klein P. Limitation in
gamma probe localization of the sentinel node in breast cancer patients with large excisional biopsy. J Am Coll Surg 188:248-254, 1999; with permission.)
Read an Editorial Comment
Giuliano
61
stated, "There is no doubt that SLND [sentinel lymph node dissection] can accurately stage patients with breast cancer."
Winer et al.
17
cautioned, "The initial results of lymphatic mapping and sentinel node biopsy are extremely promising. However, data on the long-term
outcome of sentinel node biopsy alone in unselected populations and information on the ability of surgeons outside of centers of expertise doing a
low volume of breast surgery are needed before it can be determined if sentinel node biopsy will replace axillary dissection as the standard of care
for the node-negative or node-positive breast cancer."
Lucci et al.
62
wrote:
SLND may indeed prove to be a major advance in the surgical treatment of breast cancer, but there remain a number of troubling issues,
including routine use of IHC [immunohistochemistry] outside the clinical trial setting, and surgeon training in the procedure. We propose that
surgeons with a high volume of breast cancer patients gain experience by performing confirmatory ALND [axillary lymph node dissection], and
once eligible, enroll patients in the ongoing SLND clinical trials. These trials should answer many of the questions surrounding SLND, while
protecting patient interests through the informed consent process.
Tafra et al.
63
proposed credentialing criteria for institutional acceptance of sentinel lymphadenectomy in lieu of axillary dissection, since badly
performed sentinel node biopsy may be linked to unacceptably high false-negative rates.
Bland
64
wrote that the status of the axillary lymphatics remains the single most important prognostic predictor for outcomes of carcinoma of the
breast. Bland et al.
65
reported that the 10-year survival is worse in women with stage I or II breast cancer and who did not have axillary node
dissection. Pack and Thomas
66
stated that positive axillary lymph nodes in early breast cancer are an indication for axillary node dissection.
Mustafa et al.
67
found that small breast cancer size does not affect survival and that nodal status remains the most powerful determinant in
survival.
From an anatomic standpoint, we agree with the following statement by Bale et al.
68
: "In upper quadrants or deep breast cancers the interpectoral
nodes may be the earliest sites of nodal metastasis. This may lead to false negative results in some sentinel node biopsies."
Winchester et al.
69
advised that if the sentinel node is free of metastatic disease, axillary node dissection "must be omitted" in patients with
mammary carcinoma. By definition, a sentinel lymph node is the first lower node that receives lymph from the primary tumor. Hsueh et al.
70
stated
that sentinel node biopsy (SNB) is less invasive and as accurate as axillary lymph node dissection (ALND) in determining whether or not there is
axillary node involvement. They cautioned, however, that because the accuracy of the procedure is dependent upon the surgeon's capacity to
identify the sentinel node, patients should not be offered SNB without ALND until the surgeon is confident in his skill with the technique.
Kern
71
demonstrated that "study of dye-only injections into the subareolar plexus demonstrates a high sentinel node identification rate, absent
false-negative rate, and rapid learning curve." Morrow et al.
72
stated that their study does not identify any advantage for the use of the more
expensive and complex method of sentinel node identification using blue dye plus radioactivity compared with blue dye alone, even for surgeons
learning the techniques. Morton and Ollila
73
present the following thoughts about the "sentinel node hypothesis."
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Intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) is of potential diagnostic value for breast cancer and other solid
tumors that metastasize to the regional lymph nodes, but unless we can demonstrate a survival benefit for early excision of tumor-involved
nodes, then LM/SL will not have direct therapeutic relevance. In other words, unless a tumor metastasizes to the regional nodes before
distant sites, then a tumor-positive SN is merely a marker for the metastatic phenotype. Hopefully, blood and tissue analyses using molecular
and immunologic markers will confirm the sequential passage of tumor cells to regional lymph nodes and then to distant sites, thereby creating
a therapeutic window of opportunity for lymphadenectomy while the tumor cells are confined to the SNs. However appealing the theory
underlying LM/SL is, until the long-term results of the MSLT (Multicenter Selective Lymphadenectomy Trial) indicate the efficacy of LM/SL as a
therapeutic procedure, the theory remains a hypothesis with little scientific support from randomized trials.
Vetto et al.
75
concluded that an accurate diagnosis of breast masses in males can be made by physical examination and fine needle aspiration. Vetto
et al.
76
reported that prognostic factors of carcinoma of the breast in males are similar to those of females.
Contrary to anatomic evidence, there is a marked difference in mortality from lesions in different locations in the breast. In a series of 142 patients
reported by Skandalakis et al.,
77
the inner lower quadrant was the least frequently affected, but it had the highest relative mortality (Fig. 3-25).
Fig. 3-25.
A. Localization of breast tumors in 328 patients. The upper lateral quadrant is the most frequently affected. B. Five-year mortality from breast tumors by
location. Tumors of the inner lower quadrant are the most frequently fatal. (Modified from Skandalakis JE, Gray SW, Rowe JS Jr. Anatomical Complications in
General Surgery. New York: McGraw-Hill, 1983; with permission.)
Read an Editorial Comment
Cady
78
posited breast cancer as largely a progressive disease, not a systemic one, and lists three basic principles of surgical oncology.
The extent or radicalness of local resection, while directly related to local recurrence risk, does not affect survival.
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Lymph node metastases are also indicators, but not governors, of outcome.
Lymph node metastatic cells, which have the capacity to lodge and grow in lymph nodes, may have no capacity to lodge or grow elsewhere.
Ever the philosopher, Cady concluded:
When I look back on the treatment of breast cancer patients during my career from training in the 1960s with the routine application of radical
mastectomy, to patients seen in 2000, I can only imagine how foolish our current therapy will look to our successors in 2015.
Morton
79
gives this same theme a wry twist:
A mammographic lesion that a skilled mammographer wished to re-evaluate in 3 months, an excisional biopsy specimen that was unimpressive
grossly and initially interpreted officially as benign disease, a mastectomy specimen with 2 involved axillary lymph nodes, a patient living and
well 15 years later after a course of chemotherapy - do these events represent a triumph of careful follow-up and appropriate therapy? Or do
they represent the natural history of this disease in this particular patient? I still wonder.
In agreement with Cady (quoted previously), Gervasoni et al.
80
observed that "lymph node metastasis functions as an indicator of prognosis, not the
controlling or determining factor of prognosis."
The senior author of this chapter feels that more investigative work is necessary regarding the anatomic, biologic, and surgical approach to the
lymphatics of cancer in general and to the sentinel lymph nodes in particular.
It is not our intention to become involved in the controversy surrounding the relative merits of the preceding procedures, or to discuss the virtues of
radiation or chemotherapy, or the combinations of the various courses of treatment. The biology of breast cancer is not yet completely known.
DeCosse
81
wondered if the demise of radical mastectomy was premature. The water is muddy; we must wait for it to clear.
Orr et al.
82
advised axillary lymph node dissection in all patients with carcinoma of the breast. Axillary dissection should be omitted only for women
who have had an accurate sentinel node biopsy.
Anatomy of the Triangular Bed of Mastectomy
The triangular bed of radical mastectomy is formed by the cut pectoralis major and minor muscles medially (Fig. 3-19), the medial border of the
latissimus dorsi muscle laterally, and the axillary vein superiorly. The serratus anterior and the subscapularis muscles form the floor of the triangle.
The long thoracic nerve (Bell's) lies on the external surface of the serratus anterior muscle slightly anterior to the midaxillary line; the thoracodorsal
and subscapular nerves lie on the subscapularis muscle.
The triangular bed of a modified radical mastectomy, as described by Pickren and associates,
83
is similar, but the medial side is the upward and
medially retracted axillary margin of the pectoralis major muscle (Fig. 3-26). This results in a smaller triangle, but one that is adequate for good
dissection.
Fig 3-26.
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The triangular bed of a modified radical mastectomy. The pectoralis muscles are retracted rather than removed. The triangle is only slightly smaller than that
in Figure 3-19. (Modified from Skandalakis LJ, Vohman MD, Skandalakis JE, Gray SW. The axillary lymph nodes in radical and modified radical mastectomy. Am
Surg 1979;45:552; with permission.)
After the breast and the underlying fascia are removed, a good dissection consists of (1) removing remnants of the pectoralis major fascia at its
axillary border; (2) entering the axilla by incising and stripping the axillary fascia; (3) further stripping the fascia of the pectoralis minor muscle (lower
clavipectoral fascia); (4) exposing the axillary vein; (5) downward dissection of axillary fat and lymph nodes after ligating tributaries of the axillary
vein from the thoracic wall; and (6) continuing the dissection downward, partially removing the fasciae of the serratus anterior muscle, the
subscapularis muscle, and the medial border of the latissimus dorsi muscle. When the preceding steps are complete, the triangle is clean. The
beautiful description of this procedure by Madden
84
is worth reading.
Read an Editorial Comment
ANATOMIC COMPLICATIONS OF MASTECTOMY
Skin
Skin flaps must be kept thin, and all fat and glandular tissue must be removed to avoid recurrence of malignant disease. The choice of cautery or
knife is up to the surgeon. Remember that the most frequent complication of mastectomy is skin necrosis.
A bad incision of the axilla can, after cicatrization, leave a vertical scar that limits movement of the arm. An inadequate incision will invite local
recurrence. The general rule is to remove healthy tissue three fingerbreadths (approximately 5 cm or 2 inches) from the edge of the tumor.
Vascular Injury
The sources of bleeding during mastectomy are:
the perforating arteries and veins, especially those of the first and second intercostal vessels
the axillary vein and its tributaries
the axillary artery and its branches
Read an Editorial Comment
The average blood loss during radical mastectomy has been estimated to be 732 ml.
85
The perforating vessels should be ligated; the first three are too large for cautery. The axillary vein, if torn, must be ligated. The axillary artery is
rarely injured;
86
but when repair is necessary, it must be done between bulldog clamps.
Postoperative edema of the arm is a common sequel to radical mastectomy and extensive lymphadenectomy. According to Horsley,
87
about 10% of
radical mastectomy patients experience disabling lymphedema. At one time, obstruction to the axillary vein was considered an important factor in
edema formation. Subsequent studies
88,89
have shown this is not so. Lymphatic obstruction or destruction appears to be the sole cause of edema,
which appears transiently in about half of the patients undergoing radical mastectomy.
Organ Injury
Pneumothorax is a possible danger during ligation of perforating vessels. The surgeon should use curved hemostats and not apply them at right
angles. The pneumothorax is easily repaired, but the possible contamination of the pleural cavity with malignant cells is a delayed catastrophe. Zintel
and Nay
86
had one pneumothorax among 249 consecutive radical mastectomies.
Nerve Injury
Thoracodorsal Nerve
If the thoracodorsal nerve (middle subscapular) is cut, internal rotation and abduction are weakened, although there is no deformity.
Long Thoracic Nerve
Section of the nerve results in the "winged scapula" deformity.
Anterior Thoracic Nerves (Pectoral)
Inadvertent division of the lateral pectoral nerve results in atrophy of the clavicular head, with resulting unsightly cosmetic deformity just inferior to
the clavicle.
If branches of one or both pectoral nerves are injured, the result will be atrophy of the pectoralis major and minor muscles.
Brachial Plexus
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Brachial Plexus
Direct injury to the brachial plexus is possible, but most injury is the result of stretching the nerves during operation. One patient in the series of 249
mastectomies of Zintel and Nay
86
suffered transient injury to the plexus.
Flap Complications
Stevenson
90
studied complications of flap surgery and individual flap complications. He stressed the importance of a thorough anatomic knowledge of
vascularization of the flap for successful surgery.
Inadequate Procedure
To some surgeons, no procedure less than a full radical mastectomy is considered adequate. This philosophy that adequacy of breast resection
depends on removal of all metastatic nodes in addition to the breast itself is, of course, questioned today by a great number of surgeons. We will not
enter into this discussion.
Another measure of the adequacy of a mastectomy is the number of nodes actually removed from the axilla of the patient and examined by the
pathologist.
Skandalakis et al.
92
reexamined surgical specimens taken from 24 radical mastectomies and from 20 modified radical mastectomies. In the first group,
19.5 percent of the lymph nodes removed at operation escaped examination by the pathologist. In the second group, 7.7 percent were not found at
first examination. In one patient, a node sectioned only at reexamination proved to be malignant.
Most of the nodes overlooked in the beginning were very small and not palpable in the freshly excised tissue. These small nodes became barely
visible after several weeks of formalin fixation. To recover more of these microscopic nodes, the pathologist should section at least five less-fatty
areas of axillary tissue taken at random.
What is the modern view of axillary node dissection? Twenty years ago, Fisher and colleagues
93
stated that regional lymph nodes are primary
indicators and not instigators of distal disease. They advised that lower axillary dissection is more than adequate to fulfill the aims of the operation.
These authors believe that with removal of a few lymph nodes, the qualitative axillary nodal status (positive or negative) can be determined with
accuracy.
Read an Editorial Comment
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