Virchow node

DEFINITION: Virchow node = enlarged left supraclavicular lymph node (between the clavicle and sternocleidomastoid, lateral to the sternoclavicular junction). Troisier sign = the presence of a palpable Virchow node.

PATHOPHYSIOLOGY: The thoracic duct drains lymph from the entire body below the diaphragm plus the left upper body (left arm, left head and neck, left thorax). It ascends through the thorax and empties into the junction of the left internal jugular and left subclavian veins (left venous angle). Abdominal malignancies spread via lymphatics, retrograde or via the thoracic duct, to the left supraclavicular nodes. The right lymphatic duct drains only the right upper quadrant of the body, so right supraclavicular nodes are more associated with thoracic (lung, esophageal) disease.

CLINICAL FEATURES: Firm, hard, fixed, nontender nodes. Indicates advanced (usually stage IV, metastatic) disease.

KEY ASSOCIATIONS: - Gastric adenocarcinoma (classic; most common association for boards) - Other intra-abdominal/pelvic malignancies: pancreatic, hepatobiliary, colorectal, ovarian, renal, testicular, prostate - Also thoracic malignancies (lung, esophageal), breast cancer, and lymphoma

RELATED EPONYMS (high-yield "Gastric cancer metastasis" signs): - Sister Mary Joseph nodule: periumbilical metastasis - Krukenberg tumor: bilateral ovarian metastases with mucin-secreting signet-ring cells - Blumer shelf: palpable mass in the rectouterine/rectovesical pouch on rectal exam (drop metastasis) - Irish node: left axillary node

WORKUP/MANAGEMENT: Evaluate with CT chest/abdomen/pelvis, endoscopy (EGD/colonoscopy) guided by symptoms, and tissue diagnosis via fine-needle aspiration or excisional biopsy of the node. Management depends on primary tumor; a Virchow node generally indicates metastatic, often palliative-stage disease.

BOARD PEARL: Hard left supraclavicular node + early satiety, weight loss, epigastric pain, or iron deficiency anemia in an older patient → think gastric adenocarcinoma. Gastric cancer risk factors: H. pylori, intestinal-type (nitrosamines, smoked foods, achlorhydria/pernicious anemia, blood type A), diffuse-type (E-cadherin/CDH1 mutation, linitis plastica, signet-ring cells).