supra-clavicular Lymph nodes

 

Anatomical boundaries

The supraclavicular lymph node chains have an investing fat pad, which is bounded by the following structures:

  • Posteriorly: by the scalene muscles; hence, which leads to their reference as scalene nodes in some texts
  • Anteriorly: by the sternocleidomastoid muscle
  • Medially: by the common carotid artery and internal jugular vein
  • Laterally by lateral edge of the sternocleidomastoid

Rudolf Ludwig Karl Virchow—“Pope of Medicine” in the 19th Century and Social Reformer

Remembered as the most influential pathologist in the 19th century, Virchow was also famous as a liberal politician and as one of the leaders of the “Deutsche Fortschrittspartei” (German Progressive Party), the liberal political movement in Germany. In a time of competing political ideologies including nationalism, socialism and conservatism, the “Progressive Party” led the opposition to the constitutional forces of the Prime Minister of Prussia, Otto von Bismarck. However, because of his role in the 1848 “Märzrevolution” (March Revolution), Virchow was finally forced to leave Berlin and was subsequently appointed as the first Chair of Pathological Anatomy at the University of Würzburg in 1849. Five years later, the Charité Berlin reassigned him as the first Chair of Pathological Anatomy and Physiology due to his increasing international popularity and reputation. Known as the father of cellular pathology, Virchow established the journal “Archiv für pathologische Anatomie und Physiologie und für klinische Medizin” in a close collaboration with his friend Benno Reinhardt (1819-1852). Pursuing the goal of transforming the esoteric medicine in Germany to a scientific discipline, this journal is still with us today and is now known as “Virchows Archiv”, the official journal of the European Society of Pathology.

As a broadly influential thinker of his day, Virchow's career in social science remains equally as remarkable as his work in medicine. More specifically, he is credited with founding the newspaper “Die medicinische Reform” (Medical Reform), popularizing the term “social medicine,” and promoting the concept of physicians serving as “attorney(s) of the poor.” One of his most famous contributions in medical literature is the “Report on Typhus Epidemic in Upper Silesia.” Asked by the Education Minister of Prussia, Virchow investigated the 1848 typhus epidemic in Upper Silesia (now within the borders of Poland) and stated that Prussian authorities had failed in preventing the outbreak of this devastating disease.

Virchow and His Aftermath

With close to 2000 publications, Virchow has made major contributions to the field of cellular pathology and should be remembered for the introduction of certain medical terms that are still used today; Virchow defined the term “embolus” along with its thrombosis mechanism, the word “amyloid” and its reaction with iodine and sulphuric acid in the brain, and the term “granuloma.”

The Virchow Node

Indisputably, the first description of an enlarged supraclavicular lymph node involved in metastatic malignancies dates back to Virchow. In 1848, he outlined in his article “Zur Diagnose der Krebse im Unterleibe“

History of the Name - Rudolf Virchow

Dr Rudolf Virchow is the namesake of Virchow’s node. He was born in 1821 in Prussia (now Poland) and completed his medical education in Berlin in 1843.

In 1848, Dr Virchow described supraclavicular lymphadenopathy in relation to gastric, ovarian, and pancreatic cancers. He recognized Virchow’s node as the terminus for cancers that had spread via the thoracic duct.

“Thus, particularly in cancer of the stomach, the pancreas, the ovaries, etc., the process gradually spreads from the glands of the lower abdomen to the glands in the posterior mediastinum along the ductus thoracicus and finally involves the jugular glands around the junction of the ductus thoracicus (in the left supraclavicular fossa),” Dr Virchow wrote (translated to English).

In the United States, Virchow’s node is so named because of this description by Dr Virchow. In France, the phenomenon is named “Troisier’s sign” after the French physician Charles Emile Troisier, who reported it in 1889

Dr Virchow’s other scientific contributions include writing one of the first descriptions of leukemia and coining terms to describe thrombosis and embolism.4

One of his major contributions was ascertaining that all human diseases had a cellular basis. Dr Virchow was the first to correctly link the origin of cancers from otherwise normal cells, believing that cancer is caused by severe irritation in the tissues (the “chronic irritation theory”).

Dr Virchow established the journal Archiv für pathologische Anatomie und Physiologie und für klinische Medizin with his colleague, Benno Reinhardt.7 The journal, now known as Virchows Archiv, is the official journal of the European Society of Pathology.

Dr Virchow is also credited with founding the newspaper Die medicinische Reform (Medical Reform) and popularizing the term “social medicine.” He promoted the idea that physicians should be advocates for underserved members of their communities. 

Dr Virchow died of cardiac failure after a traumatic hip fracture in 1902

 

Troisier Sign

In 1889, Charles-Emile Troisier (1844-1919) also reported on the findings in 27 cases of gastric carcinoma and noted a palpable, hard, left supraclavicular node being present.3

 

 

Pathophysiology

How does the abdominal tumor reach the node?
First, the tumor cells must spread to the lymph in the cisterna chyli, which lies anterior to L1 and L2 vertebrae. The lymph containing tumor cells travels upwards along the thoracic duct, which ends at the venous angle between the left internal jugular vein and the subclavian vein.

It has been thought that the cancerous enlargement of the left supraclavicular node at the junction of the thoracic duct and the left subclavian vein, and the tendency of gastric carcinoma to metastasize toward this region are related to tumor emboli migration through the thoracic duct. The thoracic duct is a continuation of the cisterna chyli at the L1 level, which then enters the thoracic cavity through the aortic hiatus and continues in the posterior mediastinum between the aorta and azygos vein. The duct drains lymphatic fluid into the angle of the left subclavian and internal jugular veins. The end node of the thoracic duct is the so-called Virchow node and is located near or at this jugulo-subclavian venous junction. 


Why would the tumor cells move from the duct into the node?

There are several hypotheses:

  • Obstruction causing reflux into the node: if the tumor cells obstruct the duct, the lymph with its constituent cancer cells may reflux into a nearby node that is draining into the duct.
  • Reflux during breathing: Reflux may also occur if lymph flows retrogradely due to the negative pressure during respiration.
  • Direct flow into nodes: Ludwig [1991] writes that the thoracic duct does not obstruct. He states that supraclavicular node enlargement occurs because, in some patients, the thoracic duct divides into branches that end in lymph nodes. Years earlier Zeidman [1955], too, provided experimental evidence to show that obstruction to the duct was not necessary for chest and neck nodes to receive lymph from the thoracic duct. According to Zeidman the thoracic duct has direct branches to lymph nodes. Later Negus et al [1969] studied supraclavicular nodes by lymphography in volunteers. They noted that lymph flowed into the supraclavicular nodes by reflux, confirming that supraclavicular nodes could receive thoracic duct lymph without obstruction.

Complications after supra-clavicular lymph node biopsy (open biopsy)

Complications that could arise from procedures such as supraclavicular lymph node harvest or biopsies include but are not limited to:

  • Carotid and subclavian artery bleeding
  • Chylous fistulas, the leaking of lymph from lymphatic vessels, caused by damage to lymphatics such as the thoracic duct
  • Chylous fistulas are preventable by asking the patient to cough; this will compress the intrathoracic lymphatics leading to distension of lymphatic vessels outside the thorax, resulting in a jet of chyle leaking from places of the defect, allowing their localization and ligation before closing the wound.
  • Damage to the phrenic nerve, which could lead to dyspnea as the phrenic nerve supplies the diaphragm
  • Wound infection
  • Tumor seeding in cases of human papillomavirus-positive head and neck squamous cell carcinoma (HPV-positive HNSCC)

Problems with enlargement of Supra-clavicular Lymphnodes

Enlargement of VN, a significant clinical finding termed Troisier sign, can indicate advanced stage 4 gastrointestinal metastasis, which is associated with a 5-year survival of 4%. Other etiologies include, but are not limited to, lymphoma, breast, esophageal, pelvic and testicular cancers.

Because of its anatomical relations to critical structures such as the phrenic nerve, the subclavian vessels, and the brachial plexus, enlargement of this node can compress these structures and cause various pathologies such as unilateral phrenic neuropathy, which might lead to dyspnea, vascular and neurogenic thoracic outlet syndromes, and Horner syndrome.

Horner syndrome is due to the compression of the lower part of the brachial plexus (C8-T1), leading to the disruption of sympathetic innervation of the eye and usually manifests as four key clinical signs on the ipsilateral side: miosis (constricted pupil), ptosis (droopy eyelid), anhydrosis (decreased sweating) and enophthalmos (sunken eyes).

Thus, the presence of a Troisier sign should be kept in consideration when any of these pathologies are present.

References

  1. Koroulakis A, Jamal Z, Agarwal M. Anatomy, Head and Neck, Lymph Nodes. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513317
  2. Werner RA, Andree C, Javadi MS, Lapa C, Buck AK, Higuchi T, Pomper MG, Gorin MA, Rowe SP, Pienta KJ. A Voice From the Past: Rediscovering the Virchow Node With Prostate-specific Membrane Antigen-targeted 18F-DCFPyL Positron Emission Tomography Imaging. Urology. 2018 Jul;117:18-21. doi: 10.1016/j.urology.2018.03.030. Epub 2018 Apr 4. PMID: 29626569; PMCID: PMC6030443.
  3. Troisier C.E. L'adenopathie sus-claviculaire dans les cancers de l'abdomen. Arch Gén de Méd. 1889;1:129–138. 297-309. [Google Scholar]

 

Generalized Lymphadenopathy

Generalized lymphadenopathy entails lymphadenopathy in 2 or more non-contiguous locations. Localized adenopathy occurs in contiguous groupings of lymph nodes.

MIAMI Mnemonic for Differential Diagnosis of Lymphadenopathy

Malignancies

Kaposi sarcoma, leukemias, lymphomas, metastases, skin neoplasms

Infections

Bacterial: brucellosis, cat-scratch disease (Bartonella), chancroid, cutaneous infections (staphylococcal or streptococcal), lymphogranuloma venereum, primary and secondary syphilis, tuberculosis, tularemia, typhoid fever

Granulomatous: berylliosis, coccidioidomycosis, cryptococcosis, histoplasmosis, silicosis

Viral: adenovirus, cytomegalovirus, hepatitis, herpes zoster, human immunodeficiency virus, infectious mononucleosis (Epstein-Barr virus), rubella

Other: fungal, helminthic, Lyme disease, rickettsial, scrub typhus, toxoplasmosis

Autoimmune disorders

Dermatomyositis, rheumatoid arthritis, Sjögren syndrome, Still disease, systemic lupus erythematosus

Miscellaneous/unusual conditions

Angiofollicular lymph node hyperplasia (Castleman disease), histiocytosis, Kawasaki disease, Kikuchi lymphadenitis, Kimura disease, sarcoidosis

Iatrogenic causes

Medications, serum sickness

Lymphnode groups and their drainge

  • Submandibular nodes typically drain the tongue the lips and the mouth and the conjunctiva
  • Submental nodes typically drain the lower lip portions of the oropharynx and the cheek
  • Jugular lymphadenopathy typically drains the tongue, the tonsils, the pinna, and the parotid gland
  • Posterior cervical adenopathy typically is indicative of scalp, neck, skin of the arms and legs
  • Pectoral thoracic cervical and axillary drainage
  • Suboccipital nodes reflect drainage of the scalp in the head, and preauricular nodes reflect drainage of the eyelids, conjunctiva temporal region, and pinna.
  • Postauricular nodes reflect drainage at the scalp in the external auditory meatus.
  • The right supraclavicular node represents drainage of the mediastinum the lungs in the esophagus
  • Axillary nodes typically create the arm at the thoracic wall and the breast.
  • The epitrochlear nerve roots typically drain the ulnar aspect of the forearm and the hand.
  • Inguinal nodes drain the penis, the scrotum, the vulva, vagina, the perineum, the gluteal region, and the lower abdominal wall and portions of the lower anal canal

 

Characterization of the node morphology itself:

  • Tenderness or pain may result from an inflammatory process or perforation and also may result from hemorrhage into the necrotic center of a malignant node.
  • Consistently firm rubbery nodes may suggest lymphoma; softer nodes are usually the result of infection or inflammatory conditions; hard stonelike nodes are typically a sign of cancer more commonly metastatic than primary.
  • "Shotty" nodes refer to very small, scattered nodes that feel like shotgun pellets under the skin. This configuration is typically is found in cervical nodes of children with viral illnesses
  • The designation of a "matting" configuration of nodes describes the pattern of clustered, seemingly conjoined lymph nodes. This is indicative of tuberculosis

Generalized Lymphadenopathy (Causes)

Common Infective Causation

  • Mononucleosis 
  • HIV
  • Tuberculosis 
  • Typhoid fever 
  • Syphilis 
  • Plague

Malignancies

  • Acute leukemia
  • Hodgkin's lymphoma
  • Non-Hodgkin's lymphoma

Metabolic Storage Disorders

  • Gaucher disease
  • Niemann-Pick disease

Medication Reactions

  • Allopurinol
  • Atenolol
  • Captopril
  • Carbamazepine
  • Cephalosporin(s)
  • Gold
  • Hydralazine
  • Penicillin
  • Phenytoin
  • Primidone
  • Pyrimethamine
  • Quinidine 
  • Sulfonamides
  • Sulindac

Autoimmune Disease

  • Sjogren syndrome
  • Sarcoidosis
  • Rheumatoid arthritis
  • Systemic lupus erythematosus

References:

  1. Freeman AM, Matto P. Adenopathy. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513250/
  2. Gaddey HL, Riegel AM. Unexplained lymphadenopathy: evaluation and differential diagnosis. American family physician. 2016 Dec 1;94(11):896-903.

 

Irish Lymphnodes - Gastric cancer metastases to axillary lymph nodes.

An Irish node is an enlarged left axillary lymph node, often associated with advanced gastric cancer.

Mechanism of spread of tumor from stomach to axillary lymphnodes- very rare for gastric cancer to metastasize to axillary lymph nodes.

The axillary lymph node metastasis of gastric cancer may occur in the following ways:

  1. the first may be that the tumor cells invade the thoracic duct, then invade the blood circulation, and enter the left subclavian lymphatic vessel through the left subclavian vein. And to the axillary lymph node drainage direction countercurrent, resulting in axillary lymph node metastasis.
  2. The second possibility is that the tumor cells invade the lymphatic vessels of the abdominal wall or chest wall, resulting in axillary lymph node metastasis, because the superficial lymphatic vessels of the sub umbilical abdominal wall flow downward into the inguinal lymph nodes, and the supraumbilical lymphatic vessels flow upward into the axillary lymph nodes.
  3. The third possibility is that the tumor cells directly invade the blood circulation and when passing through the axilla, they are captured by the axillary lymph nodes and reproduce and grow in the axillary lymph nodes, resulting in axillary lymph node metastasis.

Axillary lymph node metastasis of gastric cancer is considered to be a kind of distant metastasis, which is related to poor prognosis.

Gastric cancer with axillary lymph node metastasis is very rare. Pathological examination of enlarged lymph nodes is a good method to identify primary tumors, which can improve the accuracy of diagnosis and avoid excessive treatment. At present, surgical resection of enlarged lymph nodes is effective treatment.

References

  1. Zhu Q, Li L, Jiao X, Xiong J, Zhai S, Zhu G, Cheng P, Qu J. Rare metastasis of gastric cancer to the axillary lymph node: A case report. Front Oncol. 2022 Oct 25;12:995738. doi: 10.3389/fonc.2022.995738. PMID: 36387206; PMCID: PMC9641636.

 

 

Epitrochlear lymphadenopathy

 Enlargement of epitrochlear nodes is almost always pathological and usually occurs with disorders causing generalized lymphadenopathy; such
as non-Hodgkin’s lymphoma, chronic lymphocytic leukemia, human immunodeficiency virus infection, Epstein- Barr virus infection, sarcoidosis,
or rarely, syphilis.

Reference:

  1. Pannu AK, Prakash G, Jandial A, Kopp CR, Kumari S. Epitrochlear lymphadenopathy. Korean J Intern Med. 2019 Nov;34(6):1396. doi: 10.3904/kjim.2018.218. Epub 2018 Dec 6. PMID: 30514055; PMCID: PMC6823563.
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