What does a positive Troisier's sign indicate in a patient?

Troisier Sign: Clinical Significance and Diagnostic Implications

A positive Troisier sign—palpable enlargement of the left supraclavicular lymph node (Virchow's node)—indicates metastatic malignancy, most commonly from gastrointestinal or pelvic primary tumors, and represents advanced, typically inoperable disease with poor prognosis. 1, 2, 3

Anatomical Basis and Pathophysiology

• The left supraclavicular node (Virchow's node) receives lymphatic drainage from the thoracic duct, which collects lymph from the abdomen, pelvis, left thorax, and left upper extremity 2, 3
• Metastatic spread occurs via retrograde lymphatic flow through the thoracic duct, allowing abdominal and pelvic malignancies to preferentially metastasize to this specific nodal station 2, 3
• The anatomical predilection for left-sided involvement distinguishes abdominopelvic primaries from thoracic malignancies, which can involve either right or left supraclavicular nodes without laterality preference 3

Primary Malignancies Associated with Troisier Sign

Gastric adenocarcinoma is the classic primary malignancy associated with Virchow's node, though multiple abdominopelvic cancers can present this way 1, 2, 3:

• Gastric cancer (most historically recognized association) 1, 4
• Pancreatic cancer 1
• Gastroesophageal junction cancers 5
• Colorectal malignancies 3
• Pelvic malignancies (ovarian, uterine, prostate) 3
• Pulmonary adenocarcinoma (can present with left supraclavicular metastasis via thoracic duct) 2

Clinical Significance and Prognostic Implications

The presence of a palpable Virchow's node indicates inoperable, advanced-stage disease with significantly reduced survival 1:

• Supraclavicular lymphadenopathy is classified as a sign of inoperability in gastric and pancreatic cancers 1
• Physical findings indicating inoperability include: palpable fixed epigastric mass, ascites, and enlarged supraclavicular lymph node 1
• In gastric cancer specifically, a palpable abdominal mass and supraclavicular adenopathy are major independent prognostic factors associated with poor survival 4

Diagnostic Approach

When Troisier sign is identified on physical examination, the following systematic evaluation should be performed 1, 3:

Immediate Assessment

• Confirm the finding is left supraclavicular (not right, which suggests different pathophysiology) 3
• Assess for other signs of inoperability: ascites, hepatomegaly, fixed abdominal mass, jaundice 1
• Evaluate for primary symptoms: dysphagia, weight loss, abdominal pain, gastrointestinal bleeding 1, 4

Diagnostic Workup

• The enlarged left supraclavicular node provides a safe and accessible target for tissue diagnosis via fine-needle aspiration or core biopsy 3
• Abdominal ultrasonography should be the initial imaging modality to identify pancreatic tumors, dilated bile ducts, and liver metastases 1
• CT imaging provides superior staging information and should follow ultrasound for comprehensive evaluation 1
• Upper endoscopy with biopsy is essential when gastric or gastroesophageal junction cancer is suspected 1

Critical Clinical Pitfalls

Several important caveats must be recognized when evaluating supraclavicular lymphadenopathy 2, 3:

• Do not assume benign etiology in the absence of other symptoms—the Virchow's node may be the first and only clinical manifestation of occult malignancy 3
• Right supraclavicular adenopathy has different implications and suggests thoracic rather than abdominopelvic primary malignancy 3
• The enlarged node can cause secondary complications including brachial plexopathy (neurogenic thoracic outlet syndrome), vascular compression (vascular thoracic outlet syndrome), and phrenic nerve compression leading to dyspnea 2
• When thoracic outlet syndrome or unilateral phrenic neuropathy is present, assess for concomitant Virchow's node as a potential compressive etiology 2

Therapeutic Implications

The presence of Troisier sign fundamentally alters treatment strategy from curative to palliative intent 1, 5:

• Surgical resection is contraindicated when supraclavicular metastasis is confirmed 1
• Systemic chemotherapy becomes the primary treatment modality, though outcomes remain poor with median overall survival of 10.7 months for first-line therapy in metastatic gastric/gastroesophageal junction cancer 5
• Only 32% of patients with advanced gastric cancer receive second-line therapy, reflecting the aggressive nature and rapid decline associated with metastatic disease 5