Virchow's Node (Left Supraclavicular Lymph Node)
The left supraclavicular lymph node, known as Virchow's node, is the specific gland on the left side of the neck that can indicate gastric cancer when enlarged. 1, 2
Anatomic Basis and Clinical Significance
The left supraclavicular lymph node has a unique anatomic relationship with abdominal malignancies due to the drainage pattern of the thoracic duct. 1, 2 This lymph node serves as a sentinel site for metastatic disease from the abdomen and pelvis, with gastric cancer being one of the classic primary malignancies that spreads to this location. 1, 3
When an enlarged left supraclavicular node is palpated on physical examination, this finding is specifically termed Troisier's sign, which should immediately raise suspicion for an underlying abdominopelvic malignancy. 2
Metastatic Pattern Specificity
Research demonstrates that abdominal and pelvic malignancies show a strong predilection for the left supraclavicular node rather than the right:
- All primary abdominal malignancies (including gastric cancer) metastasize to the left supraclavicular node 1
- 16 of 19 pelvic tumors (84%) metastasized to the left rather than right supraclavicular node 1
- This lateralization is critical for diagnosis—the absence of right supraclavicular lymphadenopathy in the presence of left-sided enlargement significantly increases suspicion for abdominopelvic primary malignancy 2
Diagnostic Approach
Fine-needle aspiration biopsy is the excellent initial diagnostic procedure for an enlarged supraclavicular lymph node, providing a safe and accessible target for tissue diagnosis. 1, 2 This approach is particularly valuable because the supraclavicular location allows easy access without requiring invasive surgical procedures.
When evaluating a patient with left supraclavicular lymphadenopathy, the differential diagnosis should prioritize:
- Gastric adenocarcinoma (historically the classic association) 2, 3
- Other gastrointestinal malignancies 1
- Genitourinary carcinomas 2
- Lymphoproliferative disorders (10.4% of positive nodes) 1
Important Clinical Caveats
The epidemiology of Virchow's node is changing in regions with declining gastric cancer incidence. Recent data from areas with lower gastric cancer prevalence show that lung (22.5%), oral cavity (19.2%), and breast (12.5%) primaries now exceed gastric cancer as sources of left supraclavicular metastases, with primary gut carcinomas constituting only 9% of cases. 4 This shift means clinicians should not assume gastric cancer is the most likely primary in all geographic regions.
Thoracic malignancies (including lung cancer) can metastasize to either right or left supraclavicular nodes without lateralization preference, so bilateral or right-sided supraclavicular lymphadenopathy should prompt consideration of thoracic rather than abdominal primary malignancies. 1, 5
In rare cases, collision tumors can occur where two separate malignancies simultaneously involve Virchow's node, such as concurrent Hodgkin's lymphoma and metastatic gastric adenocarcinoma. 3 This underscores the importance of complete histopathologic evaluation rather than assuming a single diagnosis.
Integration with Gastric Cancer Staging
When gastric cancer is diagnosed or suspected, comprehensive staging should include physical examination with specific attention to the left supraclavicular fossa. 6, 7 The presence of Virchow's node indicates M1 (distant metastatic) disease, fundamentally altering treatment from curative surgical resection to palliative systemic therapy. 6, 7