A 54-year-old woman presents to her physician with a complaint of a “firm knot" above her left collarbone that she noticed while showering. She has also experienced unintentional weight loss of 12 lbs over the last three months and occasional epigastric discomfort. Past medical history is negative, and she has never smoked cigarettes. Vital signs are within normal limits. On physical examination, there is a 2-cm, hard, non-tender, fixed lymph node in the left supraclavicular fossa. The remainder of the head and neck exam is unremarkable, and there is no axillary or inguinal lymphadenopathy.
Which of the following is the most likely source of this patient's lymphadenopathy?
The correct answer is:
B) Gastric adenocarcinoma
An enlarged left supraclavicular lymph node is famously known as a Virchow node. This node (part of the Trosier sign) is highly suggestive of metastatic malignancy from an abdominal or pelvic primary, most classically gastric adenocarcinoma. The pathophysiology relates to the anatomy of the lymphatic system: the thoracic duct carries lymph from most of the body, including the abdomen, and empties into the left venous angle (the junction of the left subclavian and internal jugular veins). Because a Virchow node is located near this junction, it serves as a sentinel site for the deposition of metastatic cells traveling via the thoracic duct.
Answer choice A: Breast adenocarcinoma, is incorrect. While breast cancer can metastasize to the supraclavicular nodes, it more commonly spreads to the axillary lymph nodes first. In this patient, the epigastric pain and weight loss strongly point toward a gastrointestinal primary.
Answer choice C: Nasopharyngeal carcinoma, is incorrect. Nasopharyngeal cancer typically drains to Level II or Level V (posterior triangle) cervical nodes. While it can involve the lower neck in advanced stages, it is not the classic cause of a solitary left supraclavicular node.
Answer choice D: Oral squamous cell carcinoma, is incorrect. Oral cancers typically drain to Levels I, II, and III in the upper neck.
Answer choice E: Renal cell carcinoma, is incorrect. While renal cell carcinoma can metastasize to distant sites, a right supraclavicular node is more commonly associated with thoracic malignancies like lung or esophageal cancer due to the drainage of the right lymphatic duct.
Key Learning Point
A Virchow node in the left supraclavicular area is highly suggestive of abdominal or pelvic malignancy such as gastric, pancreatic, ovarian, or testicular cancer. A right supraclavicular node is often associated with intrathoracic malignancy such as lung or esophageal cancer or mediastinal disease. The next diagnostic step for a supraclavicular node is typically CT of the chest, abdomen, and pelvis or an upper endoscopy if gastrointestinal symptoms are present.
