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]