The VN gross and histological appearance spurred further investigation in order to identify a primary tumor. The cut surfaces are almost entirely replaced by a grossly evident metastatic tumor. Intra- and extra-cellular mucin was also identified. Histological studies revealed evidence of neoplastic cells, with a high nuclear-to-cytoplasmic ratio and aberrant nuclei and nucleoli, embedded within residual lymphoid tissue. The VN was resected and macroscopically assessed, revealing that the node was enlarged by tumor ( Figure 4). The long axis of the VN was oriented parallel to the internal jugular vein and the distal thoracic duct. The platysma and sternocleidomastoid muscles are reflected posteriorly and proximal half of the clavicle was resected to reveal the Virchow node and its surrounding vascular anatomy. The node joined the thoracic duct ( TD) which joined together with the internal jugular vein ( Int Jug v) to contribute to the subclavian vein ( Subclav v).
The node was partially obscured at its superior pole by the superior belly of the omohyoid muscle ( Sup Omo m) which has been retracted in this image. Gross dissection of the left-sided lower anterior cervical region revealing a Virchow node ( VN). The report includes anatomical studies as well as relevant gross pathology and histopathology. Our report describes a case of a VN discovered during cadaveric dissection and found to arise from an antecedent pulmonary adenocarcinoma. 31 Therefore, its regional anatomy holds particular clinical significance.ĭespite the clinical significance of the VN, only a few studies have been performed regarding its regional anatomical relationships. Outside of its role as a signal node, the VN may, itself, cause signs and symptoms from its mass effect the VN may lead to Horner syndrome. 30 Because of its diverse etiology, the Virchow node holds clinical significance for many medical specialties. 29 Even a hydatid cyst has been reported to masquerade as a classic VN. 16, 27, 28 Furthermore active tuberculosis has manifested as a VN. 26 The VN has also been reported with squamous cell carcinoma and lymphoma. 4 - 9 In addition, the VN has been identified as a seeding location for cancers arising from myriad locations apart from the stomach, including the intestines, 7 urogenital system, 10 - 18 esophagus, 19 common bile duct, 20 liver, 21 - 23 as well as the pancreas, 24, 25 and lungs. The VN has been well-established as a signal node for the spread of gastric cancer. 1 The eponyms “Troisier” and “Virchow” acknowledge the individuals who identified the enlargement of supraclavicular nodes as a clinical sign of gastric cancer metastasis in the mid-to-late 19 th century. The enlarged supraclavicular lymph node is known as a Virchow node (VN), Troisier node, or Virchow-Troisier node. The Troisier sign represents an enlargement of a left-sided supraclavicular lymph node. Conversely, when a VN is identified, the possibility of concomitant or subsequent thoracic outlet syndrome and phrenic neuropathy should be considered. The presence of a Troisier sign/VN should be assessed when thoracic outlet syndrome and phrenic neuropathy are suspected.
Similarly, an appreciation of the anatomy surrounding the VN, and the potential for the enlarged node to encroach on neurovascular structures, is also important in the study of a patient. Recognition of the Troisier sign/VN is of great clinical importance. Further, the VN has the potential to cause compression of the phrenic nerve, contributing to unilateral phrenic neuropathy and subsequent dyspnea. Our anatomical findings suggest that the VN may contribute to vascular thoracic outlet syndrome as well as the brachial plexopathy of neurogenic thoracic outlet syndrome. Our report includes a regional study of the anatomy as well as relevant gross pathology and histopathology. The VN was found to arise from an antecedent pulmonary adenocarcinoma. Our report presents a case of a Troisier sign/VN discovered during cadaveric dissection in an individual whose cause of death was, reportedly, chronic obstructive pulmonary disease. The VN is of profound clinical importance however, there have been few studies of its regional anatomical relationships. Metastatic spread of cancer via the thoracic duct may lead to an enlargement of the left supraclavicular node, known as the Virchow node (VN), leading to an appreciable mass that can be recognized clinically - a Troisier sign.
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