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Variant anatomy in the axillary region is of great clinical significance. It is one of the most frequently accessed regions for radical dissection surgery. During routine dissection of embalmed cadavers, we found a rare case of two accessory muscular slips emerging from the lateral border of latissimus dorsi (LD) and the inferolateral border of pectoralis major (PM), crossing the neurovascular structures in the axilla and merging distally together to the brachial fascia at the upper end of humerus below the bicipital groove. The accessory slip from LD is commonly referred to as the "axillary arch" in literature. We identified the accessory slip from the PM crossing over the axilla as pectoralis quartus. These aberrant slips can cause neurovascular compression in the axilla and can have clinical implications. Prior knowledge of the variant anatomy is the key to successful surgery in the axilla, thereby avoiding inadvertent injuries and post-operative complications.

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We read with great interest the article by Weninger et al. (2023) on the presence of the axillary arch (AA) (of Langer) found during anatomical dissections-"Axillary arch (of Langer): A large-scale dissection and simulation study based on unembalmed cadavers of body donors." The authors performed their study using 400 axillae from 200 unembalmed cadavers; they identified this variant muscle in 27 axillae of 18 cadavers. Weninger et al. (2023) described the muscular AA in 15 cases; AA was composed of connective tissue in six cases, and AA comprised muscular and connective tissue in six cadavers. Moreover, these authors indicated that after passive abduction and lateral rotation of the arm, 17 arches (63%) came into contact with the neurovascular axillary bundle, which is of clinical importance. In our opinion, this is the most precise and detailed AA muscle study in the literature, illustrated with excellent photographs and schemes. Such studies expand the existing data in the literature and are of real help to clinicians. However, we want to present our modest comments about the title of the article and would like to pose the question, "What is the axillary arch (of Langer)?" Weninger et al. (2023) stated that connective or muscular tissue crossing the axilla is termed the AA (of Langer). This structure splits from the latissimus dorsi muscle, crosses the axilla, and joins the anterior part of the upper limb. The first detailed description of this variation was published in 1846 by Karl Langer Ritter von Edenberg (Langer, 1846). Nowadays, a significant number of articles term all muscular and fibromuscular connections between the latissimus dorsi muscle and the anterior part of the upper limb as "Langers AA" (Markou et al., 2023; Sang et al., 2019; Scrimgeour et al., 2020; Taterra et al., 2019). What Langer described in his work "Zur anatomie des musculus latissimus dorsi" was a fibrous thickening of the medial edge of the axillary fascia between the borders of the pectoralis major and the latissimus dorsi muscles, a structure he termed "Achselbogen." In a sequel of this article, Langer investigated muscular fibers inserting at or encircling the connective tissue "Achselbogen" (Langer, 1846). Therefore, in our opinion, in the study of Weninger et al. (2023), the term AA (of Langer) should only be used to describe the cases presenting solely with a connective tissue "arch" or these comprised of both, muscular and connective tissue. Weninger et al. (2023) noted that muscle fibers could not be excluded in these cases. Of course, to answer this question accurately, a histological study of these cases would be necessary.

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OBJECTIVE: Secretory carcinoma of the breast (SCB) is a rare low-grade often triple-negative breast carcinoma. We aim to analyze the pathological and molecular features of 21 SCBs, especially the SCBs with axillary lymph node metastasis. METHODS: The clinicopathological characteristics of 21 SCBs were reviewed. Breast biomarkers, Pan-TRK and ETV6 break, and ETV6-NTRK3 fusion were performed on all cases. Next-Generation Sequencing (NGS) was performed on two cases with lymph node metastasis. RESULTS: 21 SCBs consisted of 2 men and 19 women aged 5～73 years (median 43 years), with a mean 2.1 cm (range 0.5～3.5 cm) tumor size. 90.1% (19/21) cases had mixed microcystic, solid, tubular, and papillary patterns. Pan-TRK and S100 are positive in 95% (20/21) and 90% (19/21) of cases, respectively. Tumor markers ER, PR, and HER2 expressions were 62% (13/21), 33% (7/21), and 0% (0/21). All cases showed ETV6 (21/21) rearrangement and ETV6-NTRK3 (11/11) fusion. 57% (12/21) of the cases had a balanced translocation and 38% (8/21) with unbalanced signals of ETV6. There was no clinical difference between balanced and unbalanced translocations in histological morphology and other prognosis factors. Furthermore, one case (#4) had a duplication of the ETV6 gene and presented axillary lymph node metastasis. NGS analysis revealed simple genomes, low tumor mutation burden, stable microsatellite sites, and single nucleotide polymorphism (SNP) heterozygous mutation in both SCBs with nodal metastasis. CONCLUSION: SCB is an indolent invasive carcinoma, even the cases with axillary lymph node metastasis, presenting simple genomes. Duplication of ETV6 cases may indicate lymph node metastasis.

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The location of these lesions and the odorous fluid that drained from them pointed to the diagnosis. The acne on the patient's back was another clue.

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BACKGROUND: Anterior axillary arch (AAA) is a slip of latissimus dorsi muscle, of variable thickness, which crosses anterior to the axillary vessels and brachial plexus. It is the most common anatomic variant in the axilla and surgeons operating in this area should be familiar with this finding to prevent confusion and complications. The aim of this study is to enhance surgeon's awareness of AAA, report the prevalence, and to describe our experience with this anomaly. METHODS: An institutionally maintained database was used to identify patients with AAA in a single surgeon's experience, from 2008 to 2019. Patient characteristics, including tumor type, laterality, and pathologic node counts were determined and compared with patients undergoing axillary lymph node dissection (ALND) without this anatomic anomaly. RESULTS: Nineteen patients with AAA were identified (13 on ALND and 6 during sentinel lymph node biopsy). Indications for ALND included breast cancer (12), melanoma (5), and Merkel cell carcinoma (2). In patients with AAA undergoing an ALND, the median number of lymph nodes pathologically identified was 23 and similar to those without AAA (27, P = 0.14). The prevalence of AAA in patients who underwent ALND was 3.1% (13/422). CONCLUSIONS: Surgeons who operate in the axilla are likely to encounter an AAA. Knowledge of this variant should improve operative efficiency and may prevent technical errors during an ALND or sentinel lymph node biopsy.

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RATIONALE: We hypothesize that with the determination of lymph fistula location 3-dimensionally, application of appropriate pressure would promote fistula healing, and a secondary surgery may be avoided. Ga-labeled 1,4,7-triazacyclononane-N, N', N"-triacetic acid (NOTA) conjugated with truncated Evan blue (NEB) forms a complex with serum albumin in the interstitial fluid after it is locally injected and allows rapid visualization of the lymphatic system. PATIENT CONCERNS: A 44-year-old woman had a chief complaint of left nipple discharge. A 38-year-old woman came to the hospital after sensing a right breast mass. DIAGNOSES: The 2 patients were diagnosed with chylous fistula after breast cancer surgery based on the findings of a novel method, Ga-NOTA-Evans Blue (NEB) positron emission tomography/computed tomography. INTERVENTIONS: We successfully obtained clear images to locate the fistula using Ga-NEB positron emission tomography/computed tomography (PET/CT) for both patients. The lymphatic vessels and lymph nodes could be clearly visualized owing to the Ga-NEB activity during PET/CT. OUTCOMES: Three-dimensional positioning to locate the fistula could direct the application of the pressure dressing and reduce drainage markedly. LESSONS: Ga-NEB PET/CT may be a new method for diagnosing chylous fistula and providing guidance for treatment.

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The axillary arch is a variant slip extending between the latissimus dorsi muscle and the pectoralis major. During educational dissection, a variant muscle was found in left arm of 70-year-old female cadaver. A slip muscle originated from the lateral margin of the latissimus dorsi and crossed the axilla obliquely. Therefore, we defined this muscular variation as axillary arch. It ran anterior (superficial) to the medial and lateral cords of the brachial plexus, and then it inserted to coracoid process. We reported this variant muscle and discussed its clinical significances.

El arco axilar es una variante que se extiende entre el músculo dorsal ancho y el pectoral mayor. Durante la disección educativa, se encontró una variante muscular en el brazo izquierdo de un cadáver de una mujer de 70 años. El músculo deslizante se originó en el borde lateral del dorsal ancho y cruzó la axila oblicuamente. Por lo tanto, definimos esta variación muscular como el arco axilar. Se extendió anterior (superficial) a los cordones medial y lateral del plexo braquial, y luego se insertó en el proceso coracoideo. Reportamos esta variante muscular y discutimos sus significados clínicas.

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BACKGROUND: Axillary hyperhidrosis is a common complaint affecting 5% of the general population. It can significantly impact quality of life (QOL) and may be extremely debilitating. Administration of intra-dermal botulinum toxin type-A (Botox) has been proven to be effective in managing axillary hyperhidrosis; however, to date, no long-term data has assessed its efficacy. AIM: We aim to assess long-term (> 5 years) QOL outcomes in this patient cohort. METHODS: In this single-centre series, all patients attending for axillary botox, with five or more years of follow-up, were prospectively included. QOL was assessed in all patients using the validated assessment tool, the modified Dermatology Life Quality Index (DLQI). Standard statistical methods were utilised with data reported as mean (± standard deviation). Subgroup analysis utilising previously published departmental data allowed for further assessment of change in QOL over time. RESULTS: A total of 75 patients (83% female) met the inclusion criteria with 67% completing the DLQI assessment. Follow-up ranged from 5 to 10 years with a mean age of 37.6 years (± 8.82). The mean number of treatments over the study period was 12 (± 3.1). Mean overall post-treatment DLQI score was 1.6 (± 2.01). This represented a significant improvement in patient QOL (p = < 0.0001) associated with long-term botox application. This statistical significance was identified consistently across all components of the DLQI tool. CONCLUSION: These data suggest that the established early QOL benefits associated with intra-dermal botox administration for AH are sustained in the long term. This benefit was seen across all subsets of the DLQI tool.

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The axillopectoral muscle is a rarely discussed variant of muscular anatomy of the axilla, with various clinical implications. We report a case of a 7-year-old girl with multiple genetic and developmental abnormalities who presented with asymmetrical right axillary bulging of unknown etiology. MRI demonstrated a small accessory axillary muscle, known as Langer's axillary arch and/or the axillopectoral muscle. Other than soft-tissue asymmetry, the patient experienced no additional related symptoms. However, this is an important variant to be aware of, as it can easily be discovered on imaging and may be a causative agent for various upper extremity symptoms that may resolve with appropriate recognition and surgical intervention.

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El tejido mamario ectópico se desarrolla debido a la involución incompleta de la cresta mamaria, de localización más frecuente en la axila y más común en mujeres. Este tejido sufre cambios fisiopatológicos similares a los de la mama normal, entre los cuales se encuentra la malignización. El carcinoma primario de este tejido es infrecuente, y su manifestación más común es la masa palpable. Al igual que en la mama normal, la histología más frecuente del cáncer de mama ectópica es el Carcinoma Ductal Infiltrante y, por su localización atípica, suele diagnosticarse tardíamente, y tendría un curso más agresivo y de peor pronóstico, dado por la mayor cercanía a ganglios, piel y pared torácica. Debido a los pocos datos publicados, el diagnóstico y tratamiento no están bien establecidos, pero los esquemas disponibles son similares a los utilizados en el cáncer de mama normal. Se presenta el caso de una paciente de 41 años, con diagnóstico de cáncer de mama ectópica en la región axilar derecha, sin invasión a distancia, tratada con cirugía, quimioterapia y radioterapia, que evoluciona favorablemente, sin metástasis ni recidivas durante seguimiento.

Ectopic mammary tissue develops due to the incomplete involution of the mammary crest, which is more frequently located in the axilla and more common in women. This tissue undergoes pathophysiological changes similar to those of the normal breast, among which malignancy is found. The primary carcinoma of this tissue is infrequent and its most common manifestation is the palpable mass. As in the normal breast, the most frequent histology of ectopic breast cancer is the Infiltrating Ductal Carcinoma and, because of its atypical location, it is usually diagnosed late and it would have a more aggressive course and a worse prognosis, due to the greater proximity to lymph nodes, skin and chest wall. Because of the few published data, the diagnosis and treatment are not well established, but the available schemes are similar to those used in normal breast cancer. We present the case of a 41yearsold female patient with a diagnosis of ectopic breast cancer in the right axillary region, without distant invasion, treated with surgery, chemotherapy and radiotherapy, whoevolves favorably, without metastasis or relapses during follow-up.

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Accessory breast tissue results from failed regression of primitive mammary tissue and is most often located in the axilla. Accessory breast tissue itself is normal and should not be misdiagnosed as an abnormality. Both benign and malignant diseases that occur in the normal breast can also develop in accessory breast tissue in the axilla. In this pictorial essay, we show sonographic findings of normal accessory breast tissue in the axilla and various lesions that occur in accessory axillary breast tissue, along with other imaging findings and pathologic features.

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During the dissection of a 79-year-old Caucasian female cadaver, a variant of Langer's axillary arch was found unilaterally in the left axilla. While Langer's axillary arches are not uncommon, this particular variant, attaching to the biceps brachii, is much rarer with a reported prevalence of only 0.25%. The case reported here, however, is only the third example of a Langer's axillary arch that has been found in the last 14 years in the Dissecting Room at St. George's, University of London, giving it an overall prevalence of approximately 1.0% amongst a population of around 280 Caucasian cadavers, much lower than the reported frequency of 7%. Langer's axillary arches can be completely asymptomatic in life, but may also cause a variety of issues both clinically and surgically.

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We illustrate a rare case of a 28 year-old woman with bilateral axillary masses, which were uncovered during her first pregnancy only and grew progresively in size ever since. On local examination, there were two 5/3/5 cm masses with benign clinical characteristics, developed apparently on the axillary extension of the mammary gland. During lactation, a milk-like liquid was evacuated through a brownish, rudimentary, nipple located in the center of each axillary masses. One year after parturition, the MRI showed bilateral axillary breast tissue appearance, separated from the eutopic mammary gland, but having similar signal intensity. Due to aesthetic reasons and the additional risk for subsequent malignant or benign breast disease, the ectopic breast tissues were completely surgically removed. The histology report showed normal glandular breast tissue.

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