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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.
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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.
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Management and Disposition
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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.
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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.