All of the deaths occurred up to 12 h before the dissections. The ages of the deaths varied between 22 and 81 years median Prior to commencing the study, the research protocol obtained approval from our Institutional Ethical Committee. Median longitudinal incision in the overlying sternum skin Fig. Pectoralis major muscle desinsertion from the lateral sternal border at both sides of the thorax followed by its lateral traction.
Section of the intercostal muscles Fig. Cautious scissor dissection to expose and repair the ITA just over the posterior layer of the parietal pleura.
Excision of any LNs found, which are recognized as hard small corpuscular structures, measuring 1. Cut the costal cartilages in their sternal junctions using a small costotome this procedure was performed, as shown in Fig. Ribs traction toward the lateral side of the chest to allow RCS dissections Fig. Excision of an internal thoracic lymph node medially located in relation to the repaired artery and vein. This was a descriptive study with an analysis of the frequency of the findings.
Table 2 lists the mean number of retrieved LNs in each ICS, calculated by the relationship between the total number of LNs found in a specific space and the number of the corresponding spaces dissected.
In the third, at both sides, the mean number was the highest 1. The relationship between the ITNs and the ITA was not uniform, but at both sides, there was a tendency of the LNs to be laterally located in relation to the artery in the second spaces and medially in the downward direction. It was possible to observe that in the third and fourth spaces, the LNs were mainly located at the medial side of the artery Tables 3 and 4. Most of the RCs did not present any LN.
There were few internal thoracic lymph nodes ITLNs found in the second and third retrocostal regions, and they were rare behind the fourth costal cartilage Tables 5 and 6. Suami et al. According to their findings, lymphatic capillaries were found to be evenly spaced at the periphery of the anterior upper torso draining radially into the axillary LNs. As they reached the breast, some passed over and some passed through the parenchyma.
They also observed perforating lymph vessels that coursed beside the branches of the internal thoracic vessels that drained into the ITC. Turner-Warwick described that there are basically three intercommunicating lymphatic plexuses involved in the drainage: superficial, perforating, and deep [ 1 ]. The superficial and perforating plexuses drain almost exclusively to the axillary nodes through the subareolar Sappey lymphatic network.
The deep system drains to the axilla and to ITC [ 1 , 2 ]. Deeply located malignant lesions have a greater chance to be drained by the deep plexus and consequently to spread via ITNs. However, as the intermediate perforating plexus is connected to the deep plexus, BC diagnosed in every part of the gland, in theory, has the potential to metastasize via ITNs.
The prevalence of ITN drainage reflects the method of lymphoscintigraphy, where the peritumoral injections of radioisotopes deep lymphatic plexus have a much higher likelihood of ITN drainage than subdermal or subareolar injections superficial lymphatic plexus.
We published elsewhere that a single injection of a colloidal solution labeled with 99m Technetium directly into the center of small non-palpable lesions under imaginologic guidance with the goal of simultaneous occult lesion localization and SLN mapping comprises a precise model to verify breast lymphatic pathways [ 18 ]. The first draining node was mapped only in the axilla in For Shimazu et al. Estourgie et al. ITN biopsy is safe when a skillful surgeon knows the local anatomy and operates with gentle sharp and blunt dissection.
The ICSs are narrow and contain fine vessels, and the ITNs are confined between the two leaflets of the parietal pleura, 1. The ITA runs alongside the sternal border and is flanked by two parallel veins one medial and another lateral , just next to the sternum in the first ICS, progressively increasing the distance from its margin to 1. Two anterior and one posterior intercostal branches originate from the artery in each ICS.
In the sixth space, the artery divides into two terminal branches, the abdominal and the musclefrenic. The internal thoracic veins join at the level of the first rib and discharge into the brachiocephalic trunk. Under the same conditions, the mean number of LNs was 1. The surgeon must bear in mind that the first node observed is not always the true SLN, justifying the radioguided biopsy under a gamma ray-detecting probe guidance.
The detector is inserted into the spaces at different points to check the hottest spot. Nevertheless, we observed that in more than half of the cases, the ITNs are lateral to the artery in the second ICSs, and, more commonly, medially situated in the third or fourth.
One of the main complications of the SLN in the ITC biopsy is bleeding caused by inadvertent injury to the internal thoracic vessels. The control of bleeding is performed by vessel ligation or clipping.
When the vessel withdraws, the resection of a costal cartilage may be required to improve access. To prevent this complication, we recommend exposing and repairing the artery before starting the SLN harvest.
Simple opening of the pleural cavity without pneumothorax is another relatively common accident. There are two procedures for closing the defect, both of which are performed after lung hyperinsufflation: direct suture or application of a plug of absorbable hemostatic cellulose polymers.
In more severe lesions, when a pneumothorax is formed, drainage becomes necessary. The routine of full ITC clearance has thus been abandoned. Even so, the introduction of the procedure of SLN biopsy in the ITC has renewed interest in the status of ITLNs, because it can modify adjuvant therapy for BC patients without causing significant rise in morbidity [ 26 ].
For example, according to Caudle et al. Although the ITC is, along with the axilla, a site of first and direct lymphatic drainage for BC, at this point in time, the optimal management of SLN in this lymphatic pathway is still debated [ 7 , 27 , 28 ]. Precise knowledge of the topographic anatomy of the region containing the ITNs is paramount for performing successful SLN retrievals. In conclusion, we found that the topographic anatomy of the ITNs varies according to each woman.
Still, it was observed that most of the second and third ICSs presented at least one LN and that the mean number of LNs in the third space was greater. Turner-Warwick RT. The lymphatics of the breast. Br J Surg. Anatomy and physiology of lymphatic drainage of the breast from the perspective of sentinel node biopsy. J Am Coll Surg. Google Scholar.
American Joint Committee on Cancer. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Updating… Please wait. Unable to process the form. Check for errors and try again. Thank you for updating your details. Log In. Sign Up. Become a Gold Supporter and see no ads.
Log in Sign up. Articles Cases Courses Quiz. About Recent Edits Go ad-free. Edit article. The final drainage route flowed into the lateral lymph vessel through the thoracic duct located on the vertebra. These results show that India ink is absorbed from the peritoneal cavity, and that the lymph drainage first flows mainly towards the cranial mediastinal lymph nodes through the ventral lymphatic channels. Our serial observations suggest that, over time, the lymph drainage routes changed from the ventral abdominal to the dorsal thoracic lymphatic channels in the thorax.
0コメント