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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.