Virchow's node: left supraclavicular lymph node and abdominal cancer
Virchow's node is an enlarged left supraclavicular lymph node (a node in the hollow just above the left collarbone), classically a sign of cancer in the abdomen or pelvis.
Remember
An enlarged left supraclavicular node should make you look for an abdominal or pelvic cancer, and it is a warning sign rather than a diagnosis.
Memory aid
A left collarbone node, look down into the abdomen.
Use it to remember that a node at the left collarbone should send you to look in the abdomen.
Virchow's node is the left supraclavicular lymph node. It lies deep in the supraclavicular fossa, the hollow just above the left collarbone. Lymph is the clear fluid that drains from the tissues, and lymph nodes are small bean-shaped filters for it.
Of the two main lymphatic ducts, the thoracic duct is the larger, and lymph from the abdomen and pelvis flows up it. At the root of the neck it empties into the left subclavian vein, the large vein under the collarbone, close to this node. Tumour cells travelling in that lymph can lodge in the node and make it swell.
The best-known source is gastric (stomach) cancer. Abdominal and pelvic cancers, for example those of the stomach, ovary, testis and kidney, show a tendency to spread to this left-sided node.
Cancers of the chest can involve the right or left supraclavicular nodes equally, so a node on the right is less specific.
Abdominal cancers can stay silent while they spread. A patient with weight loss or vague symptoms should have the left supraclavicular fossa checked.
A hard, enlarged left supraclavicular node is also called Troisier's sign. It is a warning sign rather than a diagnosis: the node needs sampling, for example by fine-needle aspiration (taking cells through a thin needle).
Key facts
- Meaning
- Virchow's node suggests metastatic cancer (cancer that has spread from its original site) from the abdominal cavity, most often gastric cancer.
- Why left
- The thoracic duct delivers abdominal lymph to the left side of the neck.
- Distance
- The node can be far from the tumour where the cancer began, so a neck finding may reveal an abdominal problem.
- Versus infection
- Reactive nodes (nodes that enlarge as they respond to infection) are usually tender and tend to settle within 1 to 2 weeks, whereas Virchow's node is firm and non-tender.
- Painless is not harmless
- Cancers can spread without symptoms, so a well patient with a firm, non-tender node needs investigation.
- Next step
- Examination alone cannot establish the cause, and a needle biopsy of the node is a common first step.
Exam traps
- A right supraclavicular node does not point specifically to the abdomen, because it is the side that cancers of the chest reach as readily as the left.
- Reactive nodes after a viral infection fit poorly with a firm, non-tender left supraclavicular node, because they are usually tender and tend to settle within 1 to 2 weeks.
- Cancer of the thyroid gland is a local neck source, so it does not give the classic meaning of Virchow's node, which is cancer that has travelled from the abdomen.
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