Virchow’s Nodes and Troisier Sign | Radiology Capsule

Answer:

The Virchow node is the left supraclavicular lymph node, and its enlargement is the classical imaging and clinical marker of metastatic disease from an infradiaphragmatic primary, most famously gastric carcinoma. The Troisier sign is the clinical counterpart, that node being palpable on examination. Both are pathological and clinical eponyms rather than radiological signs in the strict sense, but both are routinely identified and characterised on ultrasound, CT and PET/CT, and an abnormal node here often precedes detection of the primary tumour. The left side predominates because the thoracic duct, which drains roughly three-quarters of the body’s lymph including the whole abdomen and pelvis, terminates at the junction of the left subclavian and left internal jugular veins, so tumour emboli ascending from an abdominal primary are delivered to the left supraclavicular fossa; a right supraclavicular node instead suggests a thoracic, oesophageal, pulmonary or head and neck source. Although the eponym is bound to gastric cancer, the same node is involved by pancreatic, oesophageal, hepatobiliary, renal, ovarian, testicular, prostatic and pulmonary malignancy and by lymphoma, and it may also enlarge in benign disease, particularly tuberculosis and sarcoidosis. On ultrasound a malignant node is rounded rather than reniform, with a short axis over about 5 mm, loss of the echogenic fatty hilum, hypoechoic or heterogeneous cortex, and peripheral or chaotic rather than hilar vascularity; necrotic, markedly hypoattenuating nodes are characteristic of metastatic testicular germ cell tumour and of tuberculosis. Because any palpable or imaging-detected supraclavicular node in an adult is abnormal until proven otherwise, the finding should trigger a search of the abdomen and chest for a primary, and tissue sampling of the node itself, which is superficial and readily accessible to ultrasound-guided biopsy, is often the quickest route to a diagnosis.

Why is it called so?

The node is named after Rudolf Virchow, the German pathologist who in 1848 linked enlargement of the left supraclavicular node to gastric carcinoma. The Troisier sign, the same node found to be hard and palpable at the bedside, is named after the French pathologist Charles-Emile Troisier, who described it later in the nineteenth century.

Pathophysiology

Lymph from the entire abdomen and pelvis, the lower limbs and the left half of the thorax, head and neck converges on the thoracic duct, which ascends from the cisterna chyli and empties into the venous system at the left jugulo-subclavian junction, immediately deep to the left supraclavicular fossa. A group of nodes sits at this terminal segment. Tumour cells shed from an abdominal primary travel in the duct and are trapped in those nodes before they reach the systemic venous circulation, so the left supraclavicular node behaves as the last filter on that pathway and can be the first clinically apparent site of distant spread. Retrograde lymphatic flow, caused by obstruction of the duct by bulky tumour or by increased intra-abdominal pressure, contributes in some patients. Metastatic deposits replace the nodal cortex and obliterate the fatty hilum, which is what produces the rounded, hypoechoic, hilum-less node on ultrasound; central necrosis produces the hypoattenuating node on CT. The right lymphatic duct drains only the right upper quadrant of the body, which is why a right-sided supraclavicular node points to a thoracic or head and neck primary instead.

Alternative names: Signal node, sentinel node, Troisier node, Virchow-Troisier node

Other associated named signs: The Sister Mary Joseph nodule at the umbilicus, the Irish node in the left axilla, the Blumer shelf in the rectouterine pouch, and the Krukenberg tumour of the ovary, all of which indicate spread from a gastric or other abdominal primary

References

1. Adler C, Lubner MG, Menias CO, Lubner SJ, Dahiya N. What’s in a node? The clinical and radiologic significance of Virchow’s node. Abdom Radiol (NY). 2022;47(6):2244-2253. PMID: 35316379.
2. Franzen A, Günzel T, Buchali A, Coordes A. Etiologic and differential diagnostic significance of tumor location in the supraclavicular fossa. Laryngoscope. 2018;128(3):646-650. PMID: 28727141.