Download anatomy of the axilla - Cairo University Scholars

ANATOMY OF THE AXILLA Omar Z. Youssef M.D A.  Professor of surgical oncology NCI-­‐ Cairo University Contents of the axilla •  Axillary Fat •  Axillary Lymph Nodes •  Axillary Vein •  Axillary Artery •  Brachial Plexus Boundaries of Axillary Fossa: 1. Clavicle: Anteriorly 2. Scapula: posteriorly 3. 1st rib: medially Walls of Axillary Fossa 1.  Anterior wall: •  1st layer: pectoralis major muscle & pectoral fascia •  2nd layer: subclavius muscle •  clavipectoral fascia (costocoracoid membrane). •  pectoralis minor muscle •  suspensory ligament of axilla Walls of Axillary Fossa 2. Posterior wall: •  subscapularis muscle -­‐ forms majority, esp. medially •  teres major muscle -­‐ form inf. & lat. porPon of posterior wall •  laPssimus dorsi muscle 3. Medial wall: •  upper 4 or 5 ribs. intercostal spaces (intercostal muscles & membranes). • above covered by serratus anterior muscle 4. Lateral wall: •  bicipital groove of humerus, containing (musculotendinous) porPon •  coracobrachialis muscle •  biceps brachii muscle Axillary artery • 
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1st part: superior thoracic artery 2nd part: thoracoacromial artery (trunk) long thoracic artery 3rd part: subscapular artery anterior circumflex humeral a. posterior circumflex humeral a Axillary Nodes 1.  Anterior (pectoral) set -­‐ (along the lat. thoracic v.) 2.  Posterior (subscapular) set -­‐ (subscap. V.) 3.  Lateral (humeral) set -­‐ (brachial v.) 4.  Central set -­‐ (axillary v.) 5.  Apical (suprascap. or subclavian) set -­‐ (upper axillary/subclavian v.) Axillary vein Brachial plexus Adequacy of ALND •  NCCN : Level I and II and a minimum of 10 nodes removed •  Controversy whether it is more important number of LN or the % between posiPve/total •  Usually median number excised is higher •  < 10 LN removed: –  neoadjuvant treatment –  increasing age –  Surgeon experience/pathologist experience ComplicaPons • 
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Lymphedema Axillary Web Syndrome Sensory Morbidity Shoulder FuncPon InfecPon Seroma Brachial Plexus Injury Lymphedema •  Level I-­‐III axillary nodes ~15-­‐50% rates of lymphedema •  Even with level I-­‐II ~5-­‐30% Lymphedema prevenPon •  Mapping the Drainage of the Arm with Blue Dye: Axillary Reverse Mapping (ARM) Would ↓ the Likelihood of DisrupPon of the Arm LymphaPc and Subsequent Lymphedema. ComplicaPons •  INFECTION Teijeirian et al. 2006-­‐ meta-­‐analysis Use of intraoperaPve anPbioPcs will lead to reducPon in infecPon (RR = 0.60) •  HEMATOMA 2%-­‐10%, although prospecPve trials 0%-­‐2% •  SEROMA Some degree in 100% -­‐ not a complicaPon Delay in range of moPon balance against shoulder morbidity Axillary Web Syndrome (AWS) /Cording Incidence: •  6-­‐72% following ALND •  Reported afer SLNB Clinical picture: •  thick, ropelike structures under the skin of axilla •  pain and Pghtness •  occurs anywhere from several days to several weeks afer surgery EPology ?? Management of Axillary Web Syndrome •  Stretching and flexibility exercises •  Manual therapy •  Moist heat •  Pain treatment Conclusion •  Knowing the anatomy is crucial for performing an ALND •  Several techniques are being developed in order to decrease morbidity from ALND Conclusion •  Axillary dissecPon remains the standard approach to the paPent who presents with clinically evident nodal metastases. •  Histologic confirmaPon of disease should be obtained by needle biopsy. •  If metastases cannot be documented, SLND, including the removal of clinically abnormal nodes, should be carried out prior to proceeding with axillary dissecPon