Virchow Node

Blessing Aghedo; Anup Kasi

Virchow Node

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Definition/Introduction

Virchow's node, a left supraclavicular lymph node, was first described by German pathologist Rudolf Ludwig Karl Virchow (1821-1901) in 1848 as a sign of metastatic malignancy mainly from gastric cancer.[1] The term "Troisier sign"describes an enlarged palpable hard left supraclavicular node following Charles-Emile Troisier's work, which is now sometimes used interchangeably with Virchow's node.[2]

Several studies have established its clinical significance by demonstrating its association with various malignancies, including gastrointestinal, pulmonary adenocarcinoma, prostate cancer, lymphoma, among others.[3][4][5][1][6]

Considering its role in lymphatic drainage, researchers have theorized that its involvement in malignancies could be due to tumor embolization along the thoracic duct.[1][2]

Although there have been just a few studies on its anatomic description, they have helped understand the possible complications that the mass effect of Virchow's node can cause, which includes thoracic outlet syndrome, horner's syndrome, and unilateral phrenic neuropathy.[1][7][8]

Issues of Concern

Virchow's node, a left supraclavicular lymph node, was first described by German pathologist Rudolf Ludwig Karl Virchow (1821-1901) in 1848 as a sign of metastatic malignancy mainly from gastric cancer.[1] Subsequently, French pathologist Charles-Emile Troisier (1844-1919) in 1889 reported findings of enlarged palpable hard left supraclavicular lymph node linked to not just metastatic spread of gastric cancer but also other malignancies including GI, kidneys, testes, ovaries, and certain infections- tuberculosis, syphilis.[2] The term "Troisier sign" was coined, which is now sometimes used interchangeably with Virchow's node.

Following Virchow's and Troisier's work, researchers have conducted few studies on the anatomic description of Virchow's node. One of those studies by MitZutani et al. [9] described the Virchow's node and its anatomic variations on five subjects with thoracic end nodes with two adhered to the carotid sheath and the other three anterior to the anterior scalene muscle. Another was by Matthew J Zdilla et al. [5] using a cadaver with pulmonary adenocarcinoma with metastasis to the Virchow's node. In this study, they found Virchow's node to be located in the lesser supraclavicular fossa deep to the platysma and clavicular head of the sternocleidomastoid muscle, superolateral to the venous angle, and anterior to the anterior scalene muscle (forms the anterior border of the scalene triangle through which the brachial plexus and subclavian vessels run), phrenic nerve, and transverse cervical artery.

Virchow's node is a lymph node and is a part of the lymphatic system. It is the thoracic duct end node. It receives afferent lymphatic drainage from the left head, neck, chest, abdomen, pelvis, and bilateral lower extremities, which eventually drains into the jugulo-subclavian venous junction via the thoracic duct.[10]

Clinical Significance

Numerous studies have shown Virchow's node to be of clinical significance, especially concerning malignancies. Due to its lymphatic function, the Virchow's node is a potential seeding site for not only gastrointestinal malignancies, but also pulmonary adenocarcinoma, prostate cancer, lymphoma, and ovarian cancer, among others.[3][11][12][5][1][13][6][14][15] Some think that the mechanism of this lymphadenopathy in the setting of malignancy is due to tumor embolization from the primary sites through the thoracic duct, which eventually involves the Virchow's node where some of the cancer cells become trapped with resultant enlargement. Virchow's node enlargement or Troisier sign also has links to infections like tuberculosis, a theory earlier postulated in Troisier's studies.[16]

Considering its anatomy, researchers have theorized that Virchow's node results in certain complications secondary to mass effect.[5] One of these is a neurogenic and/or vascular thoracic outlet syndrome, as it lies on the anterior scalene muscle underneath, which contacts the brachial plexus and subclavian vessel and becomes compressed secondary to its enlargement.[17] Virchow's node can also result in unilateral phrenic neuropathy-ipsilateral diaphragmatic weakness but mostly asymptomatic, as the left phrenic nerve runs posterior to it. Horner syndrome would be another possible complication due to the proximity of Virchow's node to the cervical sympathetic chain.[8]

Virchow's node is an important clinical finding in association with metastatic malignancy, certain infections, and even a potential cause of neurovascular pathologies and hence should merit consideration in clinical practice.

Nursing, Allied Health, and Interprofessional Team Interventions

Due to the clinical significance of Virchow's node, all members of the healthcare team with clinical responsibilities should familiarize themselves with identifying it in patients so they can report it to the appropriate clinicians for further evaluation. [Level 5]

Details

References

[1]

Werner RA, Andree C, Javadi MS, Lapa C, Buck AK, Higuchi T, Pomper MG, Gorin MA, Rowe SP, Pienta KJ. A Voice From the Past: Rediscovering the Virchow Node With Prostate-specific Membrane Antigen-targeted (18)F-DCFPyL Positron Emission Tomography Imaging. Urology. 2018 Jul:117():18-21. doi: 10.1016/j.urology.2018.03.030. Epub 2018 Apr 4 [PubMed PMID: 29626569]

[2]

Karamanou M, Laios K, Tsoucalas G, Machairas N, Androutsos G. Charles-Emile Troisier (1844-1919) and the clinical description of signal node. Journal of B.U.ON. : official journal of the Balkan Union of Oncology. 2014 Oct-Dec:19(4):1133-5 [PubMed PMID: 25536635]

[3]

Kurayama E, Sasaki K, Satomura H, Yokoyama H, Kikuchi M, Kubo T, Ueno N, Otsuka K, Onodera S, Ito J, Nakajima M, Yamaguchi S, Miyachi K, Tsuchioka T, Kato H. [A Case of Advanced Gastric Cancer with Multiple Bone Metastases, Virchow Lymph Node and Para-Aortic Lymph Node Metastases That Responded to Combined Modality Therapy and Underwent Conversion Surgery]. Gan to kagaku ryoho. Cancer & chemotherapy. 2018 Oct:45(10):1453-1456 [PubMed PMID: 30382044]

Level 3 (low-level) evidence

[4]

Hirai K,Takeyoshi I,Kawate S,Sunose Y,Yoshinari D,Totsuka O,Ogawa H,Kato Y, [A case of gastric cancer with Virchow and para-aortic node metastases treated successfully using S-1]. Gan to kagaku ryoho. Cancer [PubMed PMID: 20332695]

Level 3 (low-level) evidence

[5]

Zdilla MJ, Aldawood AM, Plata A, Vos JA, Lambert HW. Troisier sign and Virchow node: the anatomy and pathology of pulmonary adenocarcinoma metastasis to a supraclavicular lymph node. Autopsy & case reports. 2019 Jan-Mar:9(1):e2018053. doi: 10.4322/acr.2018.053. Epub 2019 Feb 25 [PubMed PMID: 30863728]

[6]

Cervin JR, Silverman JF, Loggie BW, Geisinger KR. Virchow's node revisited. Analysis with clinicopathologic correlation of 152 fine-needle aspiration biopsies of supraclavicular lymph nodes. Archives of pathology & laboratory medicine. 1995 Aug:119(8):727-30 [PubMed PMID: 7646330]

[7]

Iyer VR, Sanghvi DA, Merchant N. Malignant brachial plexopathy: A pictorial essay of MRI findings. The Indian journal of radiology & imaging. 2010 Nov:20(4):274-8. doi: 10.4103/0971-3026.73543. Epub [PubMed PMID: 21423902]

[8]

Maslovsky I, Gefel D. Virchow's node and Horner's syndrome. The American journal of medicine. 2006 Feb:119(2):180-1 [PubMed PMID: 16443433]

[9]

Mizutani M, Nawata S, Hirai I, Murakami G, Kimura W. Anatomy and histology of Virchow's node. Anatomical science international. 2005 Dec:80(4):193-8 [PubMed PMID: 16333915]

[10]

Banjar FK,Wilson AM, Anatomy, Head and Neck, Supraclavicular Lymph Node 2020 Jan; [PubMed PMID: 31335020]

[11]

Kurebayashi H, Goi T, Morikawa M, Fujimoto D, Koneri K, Murakami M, Hirono Y, Katayama K. Long-term survival in a patient with Virchow's lymph node metastasis of cecal cancer. International cancer conference journal. 2018 Jan:7(1):1-5. doi: 10.1007/s13691-017-0307-9. Epub 2017 Aug 20 [PubMed PMID: 31149503]

[12]

Yamamoto K, Fujitani K, Tsujinaka T, Hirao M, Nishikawa K, Fukuda Y, Haraguchi N, Miyake M, Asaoka T, Miyamoto A, Omiya H, Ikeda M, Takami K, Nakamori S, Sekimoto M. [A case of HER2-positive advanced gastric cancer with extensive lymph node metastasis treated via chemotherapy with a trastuzumab-containing regimen followed by conversion surgery]. Gan to kagaku ryoho. Cancer & chemotherapy. 2014 Nov:41(12):2296-8 [PubMed PMID: 25731501]

Level 3 (low-level) evidence

[13]

Koerber SA, Stach G, Kratochwil C, Haefner MF, Rathke H, Herfarth K, Kopka K, Holland-Letz T, Choyke PL, Haberkorn U, Debus J, Giesel FL. Lymph Node Involvement in Treatment-Naïve Prostate Cancer Patients: Correlation of PSMA PET/CT Imaging and Roach Formula in 280 Men in Radiotherapeutic Management. Journal of nuclear medicine : official publication, Society of Nuclear Medicine. 2020 Jan:61(1):46-50. doi: 10.2967/jnumed.119.227637. Epub 2019 Jul 13 [PubMed PMID: 31302638]

[14]

Kemal Y, Kokcu A, Kefeli M, Tosun FC, Demirag G, Kurtoglu E, Yucel I. Virchow's node metastasis: an unusual presentation of ovarian cancer. European journal of gynaecological oncology. 2016:37(3):398-400 [PubMed PMID: 27352573]

Level 2 (mid-level) evidence

[15]

Rahman M, Nakayama K, Rahman MT, Katagiri H, Ishibashi T, Miyazaki K. Enlarged Virchow's node as an initial complaint of serous ovarian adenocarcinoma. European journal of gynaecological oncology. 2012:33(5):546-8 [PubMed PMID: 23185810]

Level 2 (mid-level) evidence

[16]

Galloy AC, Christophe JL, Cambier E, Petein M, Verhelst D. Virchow-Troisier's node in a haemodialysed patient: it is not always cancer. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2005 Mar:20(3):647-9 [PubMed PMID: 15735249]

[17]

Klaassen Z, Sorenson E, Tubbs RS, Arya R, Meloy P, Shah R, Shirk S, Loukas M. Thoracic outlet syndrome: a neurological and vascular disorder. Clinical anatomy (New York, N.Y.). 2014 Jul:27(5):724-32. doi: 10.1002/ca.22271. Epub 2013 May 29 [PubMed PMID: 23716186]