PECTORAL REGION

(CLINICAL ANATOMY)
PRESENT BY
DR.SIDDHARTH ROY Guided by –
PG 1ST YEAR Dr. Ajitkumar wahane
DEPT. OF RACHANA-SHARIR Dr.Prasanna S.

PARUL INSTITUTE OF AYURVEDA

LIMDA-VADODARA
 LYMPHATICS IN BREAST
1. Superficial Lymphatics which drains the
skin over breast except areola and
nipple
2. Deep Lymphatics which drains of
parenchyma of the breast.
 LYMPH FROM THE BREAST DRAINS
INTO :
• 1) Axillary Lymph nodes
• 2)The internal Mammary lymph nodes
• 3)Some lymph nodes also reaches
• i) supraclavicular
• Ii)cephalic
• Iii)posterior
• Iv)intercostal
• V)sub diaphragmatic
• Vi) sub peritoneal
 AXILLARY LYMPH NODE
• The axillary lymph nodes (20-30 in number)
• Drains
• Lymphatics of breast
• Pectoral region
• Upper abdominal wall
• Upper limb
5 groups arrangement –
(1)Anteriorly : lying deep to pectoralis major along the lower border of
pectoralis minor
(2)Posterior – along the subscapular vessels
(3)Lateral – along the axillary vein
(4)Central – in the axillary fat
(5)Apical – through which all the other axillary nodes drain ; at the apex
of the axilla above pectoralis minor and along the medial
side of the axillary vein.
 SPECIAL POINTS:
• Lymph of the breast drains :
About 75% into axillary nodes (anterior group)
20% - internal mammary nodes
5% - posterior intercostal nodes
• Internal mammary nodes drain the lymph not only from
the inner half of the breast , but from the outer half as
well
• There is a tendency for the lateral part of the breast to
drain towards the axilla and the medial part to the
internal mammary node
 CONTINUED……..
• Subareolar plexus of sappey -- plexus of lymph vessel present deep to the
areola
• Lymphatics from deep surface of the breast pass through the pectoralis
major muscle and the clavipectoral fascia to reach the apical node, and
also to the internal mammary nodes.
• Lymphatics from lower and inner quadrants of the breast may communicate
with the subdiaphragmatic and subperitoneal lymph.
 CLINICAL ANATOMY
• Breast is frequent site of carcinoma .
• Abscesses are also formed in breasts.

• Cancerous cells may infiltrate the suspensory ligaments,

then breast become fixed.

These contractions of ligaments can cause retraction or

puckering of breast skin.
 BREAST CARCINOMA
CLINICAL ANATOMY
• Often it is a “Ductul carcinoma in situ (DCIS)” . During the
progression of the disease , cells grow uncontrollably from
epithelial lining of lactiferous ducts in breast.
• This carcinoma can metastasise to other regions of the body :
part of the original tumours breaks off and enters the lymphatic
circulation.
• The lymph fluid passes through the axillary nodes in the armpit
and trace of tumour is often left here, so a biopsy may be taken
of axillary lymph node.
• Surgical – removal of glandular and fibrous tissue, as well as
pectoralis major, axillary group of lymph nodes , to ensure the
complete removal of the carcinoma.
• Cancer can spread
through lymphatic system
to abdomen , liver and
cancer cells may drop into
the pelvis producing
secondaries in that region .
• Apart from lymphatics ,
cancer also can spread by
segmental veins
• Veins draining breast
communicate with
vertebral plexus of veins
and through this cancer
spread to vertebrae and
brain .
Tumours may grow through retromammary space
• Subsequently invade deep fascia & pectoralis
major muscle.
• Leads to fixation of malignant breast lesion to
chest wall .
• Shortens suspensory (Cooper’s) ligaments.
• Leads to irregular dimpling of skin or retraction
of nipple
 ABNORMALITIES OF BREAST
• Polymastia – Extra breast or breasts
• Polythelia – Extra nipple or nipples
• Amastia – Absence of breast or breasts
• Athelia- Absence of Nipple Or nipples
• Gynaecomastia – Hypertrophy of male breast after
puberty , imbalance of oestrogenic and androgenic
hormones .
• Another cause is excessive steroid abuse.

Case of polymastia
 NIPPLE RETRACTION
• Infiltration of lactiferous
ducts and their
consequents fibrosis
results in nipple
retraction or subareolar
breast cancer result in
nipple retraction.
 RETRACTION IN RELATION OF BREAST
CANCER
1) Congenital – Downgrowth of epithelium from future site of nipple
(Forming pocket or invagination of skin)

2) Inflammatory – Ducts may fill with secretion later infection occurs

• Other 3 varieties :>

1. Retraction of skin – Invasion of ligaments of cooper

2. Retraction of nipple – Due to extension of growth of along the main milk
ducts & subsequent retraction as fibrosis occurs
3. PEAU D’ORANGE
 PEAU D’ORANGE
• Interference with the
lymphatic drainage by cancer
may cause lymphedema.
Which in turn may result in
deviation of the nipple and a
thickened , leather like
appearance of the skin .
Prominent or “PUFFY” skin
between dimpled pores give it
an orange peel like
appearance.
 SKIN TETHERING

• Larger dimples Result

from cancerous invasion
of the glandular tissue
and fibrosis which
causes shortening or
place traction of the
suspensory ligaments.
 MAMMOGRAPHY
• Radiographic examination of
breasts – Mammography is one of
the techniques used to detect
breast masses.
• A carcinoma appears as a large
jugged density in the
mammogram.
• Generally, the skin is thickened
over the tumour and the nipple is
depressed.
MAMMOGRAPHY
RADIOLOGICAL
FINDINGS
 ADENOFIBROLIPOMA
RADIOLOGICAL FINDING
FNAC (FINE NEEDLE ASPIRATION
CYTOLOGY)
 IMPORTANT NOTE:

• Cancer cells can not be usually controlled by

surgery alone because of the concept of lymph
drains into venous system and this lymphovenous
anastomoses abound .
 SURGERY FOR BREAST CANCER
Radical Mastectomy-
 excise the whole organ with lymphatic field
which includes skin
 overlying the tumour
 the cutting of thin skin flaps
 total removal breast with its axillary contents
 Pectoralis major muscle
 Most of the pectoralis minor muscle
 MASTECTOMY BOUNDARIES

• 4 Boundaries for a Mastectomy

• Clavicle – superior boundary
• Inframammary fold (above
rectus sheath) – inferior boundary
• Sternum (midline) – medial
boundary
• Latissimus dorsi (ant. border) –
lateral boundary
BREAST LUMPECTOMY
 SURGICAL INCISIONS OF BREAST

• Given in the inferior breast quadrants when possible

because of less vascular supply.

• Incisions near areola or on the breast are usually

directed radially to either side of the nipple (Larger
tension lines) or circumferentially.
 SELF EXAMINATION OF BREAST
• Inspect the symmetry of breast and nipples
• Change In color of skin
• Retraction of nipple is a sign of cancer
• Discharge from nipple on sqeezing
• Palpate all four quadrant with palm , note any palpable lump.
• Raise arm to feel lymph nodes in axilla .
THANK YOU