Adenopathy or a mass in the supraclavicular fossa should heighten suspicion for metastatic or locally invasive disease. A Virchow node, also called a sentinel node (Troisier sign), is a left supraclavicular node in the area where the thoracic duct enters the superior vena cava (SVC). This node, located behind the sternocleidomastoid muscles, suggests metastatic abdominal cancer, particularly gastric cancer spread via lymphatics. Carcinoma affecting right supraclavicular nodes often arises from cancer of the breast or lung and is typically lateral to a Virchow node.
Apical Lung Mass. This 68-year-old male cigarette smoker complained of cough and weight loss. A chest radiograph shows a left apical tumor. There is erosion of the tumor into the chest wall, with an indurated supraclavicular and infraclavicular mass. Moderate JVD is apparent, suggesting venous outflow obstruction. (Photo contributor: Stephen W. Corbett, MD.)
Virchow Node. This middle-aged woman presents with multiple complaints including lateral neck swelling. She was diagnosed with abdominal lymphoma. (Photo contributor: David Effron, MD.)
A Pancoast tumor involves the apical lung and may affect contiguous structures such as the brachial plexus, sympathetic ganglion, vertebrae, ribs, SVC, and recurrent laryngeal nerve (more common for left-sided tumors). Horner syndrome, extremity edema, nerve deficits, hoarseness, and SVCS may result. Erosion of tumor through the chest wall can cause compression of venous outflow, with resultant JVD.
Management and Disposition
ED management focuses on identification of the cause of the mass or adenopathy. Contrast-enhanced CT of the neck, chest, abdomen, and pelvis should provide a clue to the cause. Unstable patients and those who lack support and resources should be admitted for continued workup.
Left Supraclavicular Node. This 16-year-old patient developed left supraclavicular swelling and intermittent fever. She was diagnosed with lymphoma. (Photo contributor: Lawrence B. Stack, MD.)
Right Supraclavicular Node. This 25-year-old patient developed right supraclavicular swelling and intermittent fever. She was diagnosed with lymphoma. (Photo contributor: Alan B. Storrow, MD.)
Malignancies originating the in the abdomen and pelvis are significantly more likely to metastasize to the left supraclavicular lymph nodes.
The primary site and types of malignancies that involve the left supraclavicular lymph nodes are different from those involved the right supraclavicular lymph nodes.
A Virchow node is made more evident if the patient performs a Valsalva.