Virchow Node

Issues of Concern

Virchow node, a left supraclavicular lymph node, was first described in 1848 by German pathologist Rudolf Ludwig Karl Virchow as an indicator of metastatic malignancy, most notably from gastric cancer.[1] In 1889, French pathologist Charles-Emile Troisier expanded upon this observation, reporting that enlarged, palpable, hard left supraclavicular lymph nodes were associated not only with gastric cancer but also with other malignancies, including those of the gastrointestinal tract, kidneys, testes, ovaries, and certain infections, such as tuberculosis and syphilis.[2] This finding became known as Troisier sign, a term sometimes used interchangeably with Virchow node.  

The lymphatic system plays a crucial role in maintaining fluid homeostasis and supporting immune function. The system comprises a complex network of lymphatic vessels and lymph nodes responsible for transporting and filtering extracellular fluid containing toxins, cellular debris, macromolecules, and excess interstitial fluid. 

Lymph transport begins in the lymphatic capillaries, progresses through collecting lymphatic vessels, and is filtered by the lymph nodes before ultimately draining into the circulatory system via the right lymphatic and thoracic ducts. The right lymphatic duct drains the right head, neck, upper thorax, and right upper extremity into the right lymphatic vein.

In contrast, the thoracic duct—the largest lymphatic vessel—drains lymph from the left head, neck, thorax, abdomen, pelvis, and lower extremities. Virchow node, located at the terminal portion of the thoracic duct, receives afferent lymphatic drainage from these regions and empties into the venous system at the left jugulo-subclavian junction.[9][10]

Following the foundational work of Virchow and Troisier, a limited number of studies have explored the anatomical characteristics of Virchow node. One such study by MitZutani et al examined thoracic end nodes in 5 subjects, identifying anatomical variations in the location of Virchow node. In 2 cases, the node was attached to the carotid sheath, whereas in the remaining 3 cases, it was situated anterior to the anterior scalene muscle.[11]

Another study, conducted by Matthew J Zdilla et al, investigated a cadaver with pulmonary adenocarcinoma with metastasis to Virchow node.[4] The node was identified within the lesser supraclavicular fossa, deep to the platysma and clavicular head of the sternocleidomastoid muscle. The node was located superolateral to the venous angle, and anterior to several key structures—the anterior scalene muscle, which forms the anterior border of the scalene triangle through which the brachial plexus and subclavian vessels pass; the phrenic nerve; and the transverse cervical artery. The vagus nerve, which travels through the neck and thorax, runs posterior to the carotid sheath in this region, placing it in relative proximity to Virchow node.[10]

In his original description, Troisier noted that One or several ganglions are present over the middle third of the clavicle in the supraclavicular triangle or behind the clavicular fascicle of the sternocleidomastoid muscle. The adenopathy could be located in both supraclavicular sides, but it has a predominance for the left supraclavicular fossa. These ganglions are isolated or could be fused. At the beginning, they could be felt only by careful palpation, but at an advanced stage, they could form a projection deforming the supraclavicular fossa. The lymph nodes are mobile, enlarged, hard without adherence in the skin, and painless. Rarely, phenomena of compression could appear.[2]

Clinical Significance

Numerous studies have demonstrated the clinical significance of Virchow node, particularly in malignancy. Due to its role in lymphatic drainage, Virchow node serves as a potential site for metastatic spread from various primary cancers. Although it is classically associated with gastrointestinal malignancies, involvement has also been reported in pulmonary adenocarcinoma, prostate cancer, lymphoma, ovarian cancer, and other malignancies.[1][3][4][5][6] 

The proposed mechanism underlying this lymphadenopathy involves tumor embolization through the thoracic duct. As malignant cells disseminate from primary tumor sites, they may travel via the lymphatic system and become trapped in Virchow node, resulting in its enlargement. This phenomenon gives rise to the clinical findings known as Troisier sign.[2][12] 

There have been documented cases in which the presence of a Virchow node served as the initial indication of an underlying malignancy. In a case series by Mochizuki et al, 3 cases presented with left supraclavicular lymphadenopathy—commonly referred to as Virchow node—which was the first clinical sign that led to the diagnosis of primary infradiaphragmatic tumors.

The cases detailed 3 Japanese patients—a 78-year-old female diagnosed with cholangiocarcinoma, a 64-year-old male with bladder carcinoma, and a 61-year-old male diagnosed with prostate carcinoma. In all 3 cases, detecting a Virchow node preceded the eventual identification of the primary malignancy.[13] 

Similarly, a case report by Yang et al described a 56-year-old male who presented with a single symptom of a left cervical mass. Further investigation revealed advanced-stage sigmoid colon cancer with distant lymph node metastasis, with Virchow node being the first and only initial clinical sign. [14]

Although metastatic gastric cancer commonly involves the Virchow node, there are reported cases in which it is bypassed. In a case report by Di Stadio et al, a 78-year-old White female was diagnosed with metastatic gastric cancer that did not involve Virchow node.[15] This finding highlights the importance of maintaining vigilance for metastasis even in the absence of left supraclavicular lymphadenopathy. The absence of a palpable Virchow node does not exclude the possibility of advanced disease. 

Virchow node can present bilaterally. In an autopsy case reported by Zdilla et al, an unusual finding of bilateral Virchow nodes was documented, indicating metastasis from a small cell neuroendocrine carcinoma. The authors noted that, although rare, right-sided and bilateral involvement of Virchow node can occur in addition to the classic left-sided presentation. Based on these findings, they proposed that the term Virchow node should be used with reference to laterality, distinguishing between left-sided, right-sided, and bilateral involvement.[16] However, further research and additional case studies are needed to better understand the prevalence and clinical significance of these atypical presentations.

Virchow node does not exclusively indicate malignancy; it can also result from infection [17] or inflammation. A distinguishing feature of infectious involvement is that the node is often painful or tender, unlike the typically painless presentation associated with malignancy.

The difference in tenderness is believed to stem from the rapid stretching of the lymph node capsule that occurs in infections, compared to the gradual, progressive stretching observed with malignant involvement. However, tenderness is nonspecific and can occasionally occur in malignant cases, often attributed to hemorrhage into the necrotic center of a neoplastic node.[18]

There have been documented cases of left supraclavicular masses mimicking Virchow node unrelated to malignancy. In a case report by Duman et al, a 36-year-old female presented with a painless enlarging mass in the left supraclavicular region. Laboratory workup was unremarkable. However, imaging revealed a lesion suspicious for malignancy, prompting total excision and histopathological examination. Surprisingly, the mass was identified as a hydatic cyst.[19]  

Another case report by Borges-Canha et al involved a 47-year-old female with a known history of thyroid nodules who was discovered to have a nodule in the left supraclavicular fossa during routine cervical ultrasonography. Cytology analysis revealed features consistent with a benign follicular nodule in ectopic thyroid tissue.[20] 

Vaccinations have also been associated with reactive lymphadenopathy that mimics Virchow node. In a report by Mitchell et al, several cases of supraclavicular lymphadenopathy were observed following COVID-19 vaccination. A notable case involved a patient with a prior history of rectal carcinoma treated surgically, who presented with left supraclavicular lymphadenopathy that was ultimately determined to be vaccine-related rather than malignant.[21]

Considering its anatomical location, researchers have theorized that Virchow node may cause certain complications secondary to mass effect.[4] One such complication is neurogenic and vascular thoracic outlet syndrome. Virchow node lies over the anterior scalene muscle, which houses the brachial plexus and subclavian vessels. When the node enlarges, it can compress these structures, leading to neurovascular symptoms.[22] 

Virchow node has also been associated with unilateral phrenic neuropathy, which may result in ipsilateral diaphragmatic weakness. This condition is typically asymptomatic due to the posterior course of the left phrenic nerve related to the node. Although rare, vagus nerve compression can occur as well. Because the vagus nerve passes near the supraclavicular region (before giving off the recurrent laryngeal nerve), compression at this level may produce hoarseness and other autonomic symptoms, rather than isolated recurrent laryngeal nerve involvement.[16] 

Horner syndrome is another possible, though uncommon, complication, potentially resulting from compression of the cervical sympathetic chain near Virchow node.[8]

Diagnostic Workup

The presence of Virchow node often warrants thorough evaluation, as it may indicate advanced disease.[13] Detecting Virchow node should prompt clinicians to consider a broad differential diagnosis and pursue a timely diagnostic workup to determine the underlying cause.

The diagnostic approach should begin with a detailed history and physical examination. Clinicians should assess for risk factors and symptoms suggestive of malignancy, such as unintentional weight loss, fatigue, abdominal pain, or other systemic signs. Infectious or inflammatory causes should also be considered in the appropriate clinical context. The suspected underlying etiology should guide initial laboratory testing. Imaging studies are valuable for further evaluation. Ultrasound can assess the node's size, shape, and internal characteristics, whereas chest x-ray, computed tomography, or positron emission tomography scans may be warranted depending on the clinical suspicion.

Tissue diagnosis is often required. Fine-needle aspiration is typically the first-line procedure due to its minimally invasive nature and diagnostic yield.[5] If fine-needle aspiration results are inconclusive, a core needle biopsy or complete excisional biopsy may be necessary for definitive diagnosis.

Subsequent workup should be tailored based on the etiological findings. For instance, if gastric cancer is suspected, upper endoscopy is indicated to confirm the diagnosis and determine the extent of the disease. 

Treatment

Management of Virchow node is guided by the underlying etiology. When malignancy is the cause, treatment strategies are dictated by the type and stage of the primary cancer. Therapeutic options may include surgical resection, systemic chemotherapy, radiation therapy, and hormonal therapy, depending on the specific diagnosis. For example, Yang et al reported a case in which both the primary malignancy and the involved Virchow node were surgically excised, with the patient receiving both neoadjuvant and adjuvant chemotherapy.[14] In contrast, when the underlying cause is infectious, such as tuberculosis, targeted antimicrobial therapy is typically sufficient to resolve the lymphadenopathy.[18]

Prognosis

Similar to treatment, the prognosis associated with Virchow node largely depends on the underlying etiology. In malignant cases, its presence often indicates metastatic spread and advanced-stage disease, which may correlate with a poorer prognosis. For instance, in stage IV colorectal carcinoma with distant lymphatic involvement, including Virchow node, the median overall survival is typically reported to range between 9 and 10.3 months.[23]

Conversely, outcomes can be significantly more favorable when the underlying cause is benign or curative treatment is initiated promptly. In tuberculosis cases, for example, appropriate antimicrobial therapy can result in node regression within 2 to 4 months of starting treatment.[18]

Nursing, Allied Health, and Interprofessional Team Interventions

Due to the clinical significance of Virchow node, its management requires a comprehensive, interdisciplinary approach that prioritizes clinical expertise, ethical practice, effective communication, and coordinated care. By using the distinct knowledge of each healthcare professional, a multidisciplinary team can deliver patient-centered care, enhance treatment outcomes, and maintain high standards of safety and healthcare quality. Early recognition of Virchow node by any healthcare provider is essential, as timely referral to the appropriate specialists is critical for accurate diagnosis and effective management.