Download 1. A woman with breast cancer subsequently develops metastases

1. A woman with breast cancer subsequently develops metastases in
her vertebral column. The most direct route for spread of the tumor
to the vertebral column was via:
branches of the cephalic vein
branches of the lateral thoracic vein
branches of the thoracoacromial veins
lymphatic vessels draining into the axilla
branches of the intercostal veins
2. The clavipectoral fascia is penetrated by which artery?
Anterior circumflex humeral
Axillary
Subscapular
Thoracoacromial
Thoracodorsal
3. Mastitis is a condition which involves:
A type of leukemia
Inflammation of the breast
Infection of lymph nodes
Mast cells
Tumors of glandular tissue
4. In the process of doing an axillary lymph node dissection in a 50
year-old patient, the surgery resident cleans the space between
the pectoralis major and minor muscles, in an attempt to remove
all of the lateral pectoral lymph nodes. Upon recovery it is noted
that the patient's lower pectoralis major is paralyzed. The nerve
most likely injured is the:
axillary
lateral pectoral
medial pectoral
suprascapular
thoracodorsal
5. In lymphatic drainage of the breast, the major portion (about 75%)
enters eventually into which group of nodes?
Central axillary
Deltopectoral
Lateral axilllary
Parasternal
Subscapular
6. The prognosis in breast cancer is poorer as more proximal lymph
nodes are found to have cancerous cells in them. Spread of
cancer to which of the following axillary nodes would indicate the
worst prognosis?
apical
central
lateral
pectoral
subscapular
7. You are in the emergency room when a patient is brought in, the
loser in a street fight. He has received a stab wound about 1.5 cm
long in the right side of the chest about 1.5 cm below and 1 cm
medial to the coracoid process of the scapula. He has lost a lot of
bright red blood from a large (~1.2 cm in diameter) severed artery
found deep at this location. Intravenous fluids are immediately
administered and a surgeon is called in to repair the artery. He
begins by making an incision through the skin and subcutaneous
tissue just below the clavicle, then cuts the clavicular head of the
pectoralis major muscle and retracts it downward to obtain
sufficient exposure of the area. He next encounters a partially
severed muscle running downward and medially from the coracoid
process. He divides the remaining fibers of the muscle and has
you retract it downward. This exposes a bloody fat-filled space full
of vessels and nerves.
The muscle running downward and medially from the coracoid
process which was partially severed was the:
Coracobrachialis
Pectoralis minor
Long head of the biceps
Subclavius
Subscapularis
8. Postoperative examination revealed that the medial border and
inferior angle of the left scapula became unusually prominent
(projected posteriorly) when the arm was carried forward in the
sagittal plane, especially if the patient pushed with outstretched
arm against heavy resistance (e.g., a wall). What muscle must
have been denervated during the axillary dissection?
Levator scapulae
Pectoralis major
Rhomboideus major
Serratus anterior
Subscapularis
9. During a motorcycle accident, an 18-year-old male landed on the
right lateral side of his rib cage with his right upper limb abducted.
In the hospital he was found to have "winging" of the right scapula.
Which nerve was likely damaged in the accident?
Accessory
Lateral pectoral
Long thoracic
Phrenic
Vagus
10.
During the planning of therapeutic intervention for a 54-yearold female patient with cancer of the right breast, a 3rd year
medical student would need to first consider where most of the
cancer cells would metastasize, which would be:
Abdominal wall
Anterior mediastinum
Axillary lymph nodes
Opposite breast
Parasternal lymph nodes
11.
After a jarring blow to the left anterior shoulder region, a
young field hockey player was told by an examining physician that
she had a muscle tear that resulted directly from the superolateral
distraction of a fractured coracoid process. Which muscle was
torn?
Deltoid
Pectoralis major
Pectoralis minor
Serratus anterior
Subclavius
12.
Breast cancer cells can spread directly to the cranial cavity
and brain via the vertebral venous plexus. Through which route
can they reach this plexus?
Axillary lymph nodes
Internal thoracic vein
Intercostal veins
Parasternal lymph nodes
Thoracoacromial artery
13.
Upon finding a malignant tumor in the medial portion of the
breast of a 40-year-old female, the surgeon began to search for
the lymph nodes that would be the first ones reached by metastatic
spread of cancer cells from this site. Which group(s) would have to
be examined to determine whether metastasis had occurred?
Central only
Parasternal only
Parasternal and apical
Parasternal and lateral
Parasternal and pectoral
14.
After being thrown from a motorcycle moving at high speed,
a 16-year-old female was found to have a paralyzed right
pectoralis major muscle. Which set of movements at the shoulder
joint would be found greatly weakened?
Abduction and extension
Abduction and lateral rotation
Adduction and flexion
Lateral rotation and extension
15.
While observing a mastectomy on a 60-year-old female
patient, a medical student was asked by the surgeon to help tie off
the arteries that supply the medial side of the breast. The artery
that gives origin to these small branches is the:
Internal thoracic
Musculophrenic
Posterior intercostal
Superior epigastric
Thoracoacromial
16.
In the axilla the pectoralis minor is a landmark, being closely
related to all of the following structures except:
cephalic vein
cords of the brachial plexus
lateral thoracic artery
medial pectoral nerve
second part of the axillary artery
1. The correct answer is:
branches of the intercostal veins
The most likely route for the cancer to reach the vertebral column is
through the intercostal veins, i.e. hematogenous spread. The cephalic
vein and thoracoacromial vein would not be draining the breast, and the
lateral thoracic vein would not be directing blood toward the vertebral
column. Lymphatic vessels may carry some tumor cells to the axillary
lymph nodes and may participate in the spread of the cancer, but this
isn't the best answer for this question. The most direct way for the
cancer to spread to the vertebral column is through the venous system.
2. The correct answer is:
thoracoacromial artery
The thoracoacromial artery pierces the clavipectoral fascia before giving
off its four branches: pectoral, clavicular, deltoid, and acromial. It
supplies pectoralis major, pectoralis minor, the deltoid muscle, and the
acromioclavicular joint. It is a branch off of the axillary artery. The axillary
artery and all its other branches, including the anterior circumflex
humoral and subscapular arteries, run deep to the clavipectoral fascia.
The thoracodorsal artery is a branch of the subscapular artery which
also runs deep to the fascia.
3. The correct answer is:
inflammation of the breast
Mastitis is an inflammation of the breast. It usually occurs during
lactation and breast feeding and is usually caused by the organism
Staphylococcus aureus. Treating a patient with mastitis that involves
infection would include antibiotics, draining an abcess, and excising the
diseased mammary duct.
4. The correct answer is:
medial pectoral
Since the medial pectoral nerve pierces pectoralis minor to reach
pectoralis major, it seems likely for this nerve to be injured from trauma
to the space between pectoralis minor and major. Also, remember that
the medial pectoral nerve innervates the inferior part of pectoralis major,
while the lateral pectoral nerve innervates the superior part of pectoralis
major.
The medial pectoral nerve innervates both pectoralis major and
pectoralis minor, while the lateral pectoral nerve innervates pectoralis
major only. These two nerves are named after their origin from two
different cords of the brachial plexus. (This explains why their names
and relative locations are reversed from what you might expect.) The
thoracodorsal nerve (which is also derived from the brachial plexus)
innervates latissimus dorsi, and is not involved with the pectoral
muscles. The other two nerves, axillary and suprascapular, are also
derived from the brachial plexus and will be studied along with the upper
limb.
5. The correct answer is:
central axillary
About 75% of the lymph draining the breast goes to the axillary lymph
nodes, via the pectoral lymph nodes. All of this lymph from the pectoral
lymph nodes must drain to the central lymph nodes as well. This is why
it is so important to examine all these groups of axillary lymph nodes
when performing a breast exam. Most of the rest of the lymph drainage
from the breast goes to the parasternal nodes, although a small amount
goes to the opposite breast and a small amount drains to the abdominal
wall.
6. The correct answer is:
apical
As lymph drains from the breast into the axillary system, it moves from
pectoral, lateral, and subscapular nodes to the central nodes, and then
to the apical nodes. If cancer is found in the apical axillary nodes, this is
a sign that the cancer has spread through the regional lymphatic system
and may have metastasized to the rest of the body.
7. The correct answer is:
pectoralis minor
Pectoralis minor inserts on the coracoid process of the scapula. Its origin
is ribs 3-5, so it runs downward and medially from the coracoid process.
Coracobrachialis is a muscle of the upper limb which takes origin from
the coracoid process. However, it attaches to the shaft of the humerus
and runs laterally. The long head of the biceps, subclavius, and
subscapularis are not attached to the coracoid process.
8. The correct answer is:
serratus anterior
Serratus anterior, innervated by the long thoracic nerve, draws the
scapula forward. If it is denervated, there is no muscle to oppose the
motion of the trapezius which is elevating and retracting the scapula.
The medial border of the scapula falls away from the posterior chest wall
and begins to look like an angel's wing. This is termed a "winged
scapula." A winged scapula commonly occurs after an injury to the long
thoracic nerve, which runs on the superficial surface of serratus anterior
and is particularly vulnerable to trauma. The long thoracic nerve contains
contributions from C5, 6, and 7, so remember the saying "C5, 6, and 7
keep the wings from heaven."
This is a classic scenario to remember!
9. The correct answer is:
Long thoracic nerve
An injury to the long thoracic nerve denervates serratus anterior,
meaning that there will be no muscle protracting the scapula and
counteracting trapezius and the rhomboids, powerful retractors of the
scapula. This means that the scapula will be winged backwards, which is
this patient's main symptom. The long thoracic nerve is derived from the
nerve roots of C5-7. This nerve is particularly vulnerable to iatrogenic
injury during surgical procedures, such as mastectomies, because it is
located on the superficial side of serratus anterior.
The accessory nerve innervates trapezius--an injury to this nerve might
lead to an inability to raise the acromion of the shoulder. The lateral
pectoral nerve is a small nerve that provides innervation to pectoralis
major. The phrenic nerve innervates the diaphragm. The vagus nerve
provides parasympathetic innervation to the thorax and much of the
abdominal viscera. The patient's symptoms do not fit with an injury to
any of these nerves.
.
10. The correct answer is:
Axillary lymph nodes
About 75% of the lymph from the breast goes to the axillary lymph nodes
via the pectoral lymph nodes. This is the most important place to check
for metastasis of the cancer cells! The lymph from the axillary nodes
eventually drains into the subclavian lymph trunk.
Most of the rest of the lymph drains into the parasternal lymph nodes,
while a small amount drains to the abdominal wall and the opposite
breast. The anterior mediastinum is not an important place for lymphatic
drainage from the breast.
.
11. The correct answer is:
pectoralis minor
Of the muscles listed, pectoralis minor is the only one which is attached
to the coracoid process. The deltoid originates from the clavicle,
acromion and scapular spine and inserts on the deltoid process of the
humerus. Pectoralis major originates from the clavicle, sternum, and ribs
and inserts on the crest of the greater tubercle of the humerus. Serratus
anterior originates on the ribs and inserts on the medial border of the
costal surface of the scapula. Subclavius originates on the first rib and
inserts on the clavicle. So, none of these other muscles would be
detached by a fracture of the coracoid process.
What other muscles are attached to the coracoid process?
Coracobrachialis and the short head of the biceps.
12. The correct answer is:
Intercostal veins.
Hematogenous spread through the intercostal veins is the easiest way
for breast cancer to reach the internal vertebral venous plexus. It is true
that the axillary lymph nodes drain 75% of the lymph from the breast,
and the parasternal lymph nodes drain most of the remaining lymph.
However, these lymphatic channels are not the major way that cancer
would be transmitted to the internal vertebral venous plexus. This plexus
of veins would be most likely to receive cancer cells transmitted through
the blood. The internal thoracic vein drains some blood from the breast,
but it would not direct the blood toward the vertebral column. The
thoracromial artery and other arteries do not drain the breast; hence,
they would not provide a route for spreading cancer.
13. The correct answer is:
parasternal and pectoral
As lymph drains from the breast, the majority of fluid travels to two
groups of lymph nodes: the axillary and the parasternal. 75% of the
lymph goes to the axillary lymph nodes, with the pectoral nodes being
the first axillary nodes to receive the drainage. So, the pectoral nodes
would need to be inspected to determine whether cancer had spread to
the axillary system. Central and apical nodes are also part of the axillary
system. These nodes might receive cancerous cells, but they are more
distal sites of drainage. Cancer would be most likely to metastasize to
the pectoral nodes first.
The parasternal nodes receive most of the lymph that does not drain into
the axillary nodes. They are an especially important route of drainage
from the medial side of the breast. So, it is also important to survey
these nodes to determine whether cancer has spread into the
lymphatics.
14. The correct answer is:
Adduction and flexion
Pectoralis major flexes, adducts, and medially rotates the arm. It is
innervated by the lateral and medial pectoral nerves, from the lateral and
medial cords of the brachial plexus.
.
15. The correct answer is:
Internal thoracic
Small branches from the internal thoracic artery, known as medial
mammary branches, supply the medial side of the mammary gland. The
lateral side of the mammary gland is supplied by the lateral thoracic
artery. The musculophrenic artery is a branch of the internal thoracic
artery--it travels laterally and supplies blood to the 7th through 9th
intercostal spaces. The posterior intercostal arteries are branches from
the descending aorta--they supply the lateral and posterior portions of
the intercostal space. The superior epigastric artery is a branch of the
internal thoracic artery--it supplies the upper rectus abdominis muscle
and the upper abdominal wall. The thoracoacromial artery supplies
blood to the pectoral muscles, deltoid, subclavius, and the shoulder joint.
16. The correct answer is:
cephalic vein
The cephalic vein is the only structure listed that does not have a special
relationship to pectoralis minor. The cords of the brachial plexus are
found deep to pectoralis minor. The second part of the axillary artery is
defined as the segment of the axillary artery which is covered by the
pectoralis minor muscle. So, branches of the second part of the axillary
artery, including the lateral thoracic artery, lie deep to pectoralis minor.
The medial pectoral nerve pierces pectoralis minor to reach pectoralis
major.