Bilateral Virchow nodes: an unusual finding of pulmonary small-cell neuroendocrine carcinoma metastasis

An enlarged left-sided supraclavicular node is a signal node for cancer metastasis. In such a case, the enlarged lymph node is often referred to as a Virchow node. The left-sided nature of the node is due to the drainage of the thoracic duct. So, the enlargement of a Virchow node is typically associated with malignancies, including gastrointestinal, pulmonary, and genitourinary carcinomas, in addition to lymphomas. This report documents a particularly unusual finding: bilateral Virchow nodes, representing metastasis of small-cell neuroendocrine carcinoma.

Keywords
anatomy; carcinoma, lymph nodes; neoplasm metastasis; neoplasms

Authorship

Matthew J. Zdilla

gross dissection

generation of gross anatomical figures

drafting of the manuscript

West Virginia University School of Medicine, Department of Pathology, Anatomy, and Laboratory Medicine, Morgantown, West Virginia, USAWest Virginia University School of MedicineUSAMorgantown, West Virginia, USAWest Virginia University School of Medicine, Department of Pathology, Anatomy, and Laboratory Medicine, Morgantown, West Virginia, USA

https://orcid.org/0000-0002-2578-1128

Alexander R. Gross

histological evaluation interpretation of pathology

critical revisions

https://orcid.org/0000-0001-8462-1362

Tara Hajarat

histological evaluation interpretation of pathology

critical revisions

https://orcid.org/0000-0003-0410-6809

Jeffrey A. Vos

histological evaluation interpretation of pathology

critical revisions

https://orcid.org/0000-0002-6715-1415

Conflict of interest: The authors have no conflict of interest to declare.

Correspondence Matthew J. Zdilla West Virginia University School of Medicine, Department of Pathology, Anatomy, and Laboratory Medicine (PALM) 64 Medical Center Drive, 26506, Morgantown, West Virginia, USA Phone: +1 304-293-0598matthew.zdilla@hsc.wvu.edu

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (5)

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Figure 1
Anterior view of bilateral supraclavicular regions with sternocleidomastoid muscles reflected and bilateral Virchow nodes exposed. (CCA: right common carotid artery that has been cut and tied for the purpose of embalming; SCM: remnant of sternal head of left sternocleidomastoid; VN: Virchow node).

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Figure 2
Anterolateral views of right- and left-sided supraclavicular regions (A&B and C&D, respectively) regions with sternocleidomastoid muscles reflected and bilateral Virchow nodes exposed or resected to reveal regional anatomical structures. A – Right Virchow node reflected anteriorly. The right phrenic nerve lies intermediate to the anterior scalene muscle and the Virchow node and the subclavian vein is located posterior to the inferior aspect of the Virchow node. B – With the right Virchow node resected, the vagus nerve is identified where the anteromedial aspect of the Virchow node would have otherwise been located. C – The left Virchow node is seen intermediate to the vagus nerve and phrenic nerve. The anterior scalene separates the Virchow node from the brachial plexus. D – With the left Virchow node reflected laterally the vagus and phrenic nerves are identified along the anterior and posterior boundaries of the fossa in which the Virchow node resided. Also seen are vascular structures including the thyrocervical trunk, located medial relative to the in situ position Virchow node and the transverse cervical artery, located posterior to the Virchow node and partly contained within the connective tissue upon the surface of the node (AS: anterior scalene muscle; BP: brachial plexus; CCA: right common carotid artery that has been cut and tied for the purpose of embalming; CNX: vagus nerve; PN: phrenic nerve; SCV: subclavian vein; TCA: transverse cervical artery; TCT: thyrocervical trunk; VN: Virchow node).

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Figure 3
Hilar tumor involving the right lung. Also, anthracosis and emphysema are evident.

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Figure 4
Non-Virchow nodal involvement. A – Pathologically enlarged lymph node located at the junction of the brachiocephalic veins, posterior to the superior vena cava, anterolateral to the brachiocephalic artery. The node is also positioned in the superior mediastinum medial to the lung and inferior to the right-sided Virchow node. B – Reflection of the superior vena cava and brachiocephalic veins reveals a node of particularly large size. C – Para-aortic “midline” adenopathy, unusual for carcinoma metastasis, rather typical of lymphoma. (A: aorta; BCA: brachiocephalic artery; L.BCV: left brachiocephalic vein; R.BCV: right brachiocephalic vein; SVC: superior vena cava; STAR: enlarged lymph node).

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Figure 5
Photomicrograph compilation of H&E-stained Virchow node sections at 100× (A&B), and 400× (C&D). A – Interconnecting nests of hyperchromatic cells in a trabecular pattern. B – Hyperchromatic cells displaying multiple characteristic rosettes, suggestive of small cell neuroendocrine carcinoma. C –Sheet of cells with hyperchromatic nuclei with powdery chromatin with admixed necrosis and numerous mitotic figures, suggestive of small cell neuroendocrine carcinoma. D – Hyperchromatic tumor cells arranged in spoke-and-wheel configuration around central cores comprised of cytoplasmic processes. The rosettes are a feature of small cell neuroendocrine carcinoma.

Figure 1 Anterior view of bilateral supraclavicular regions with sternocleidomastoid muscles reflected and bilateral Virchow nodes exposed. (CCA: right common carotid artery that has been cut and tied for the purpose of embalming; SCM: remnant of sternal head of left sternocleidomastoid; VN: Virchow node).

Figure 2 Anterolateral views of right- and left-sided supraclavicular regions (A&B and C&D, respectively) regions with sternocleidomastoid muscles reflected and bilateral Virchow nodes exposed or resected to reveal regional anatomical structures. A – Right Virchow node reflected anteriorly. The right phrenic nerve lies intermediate to the anterior scalene muscle and the Virchow node and the subclavian vein is located posterior to the inferior aspect of the Virchow node. B – With the right Virchow node resected, the vagus nerve is identified where the anteromedial aspect of the Virchow node would have otherwise been located. C – The left Virchow node is seen intermediate to the vagus nerve and phrenic nerve. The anterior scalene separates the Virchow node from the brachial plexus. D – With the left Virchow node reflected laterally the vagus and phrenic nerves are identified along the anterior and posterior boundaries of the fossa in which the Virchow node resided. Also seen are vascular structures including the thyrocervical trunk, located medial relative to the in situ position Virchow node and the transverse cervical artery, located posterior to the Virchow node and partly contained within the connective tissue upon the surface of the node (AS: anterior scalene muscle; BP: brachial plexus; CCA: right common carotid artery that has been cut and tied for the purpose of embalming; CNX: vagus nerve; PN: phrenic nerve; SCV: subclavian vein; TCA: transverse cervical artery; TCT: thyrocervical trunk; VN: Virchow node).

Figure 3 Hilar tumor involving the right lung. Also, anthracosis and emphysema are evident.

Figure 4 Non-Virchow nodal involvement. A – Pathologically enlarged lymph node located at the junction of the brachiocephalic veins, posterior to the superior vena cava, anterolateral to the brachiocephalic artery. The node is also positioned in the superior mediastinum medial to the lung and inferior to the right-sided Virchow node. B – Reflection of the superior vena cava and brachiocephalic veins reveals a node of particularly large size. C – Para-aortic “midline” adenopathy, unusual for carcinoma metastasis, rather typical of lymphoma. (A: aorta; BCA: brachiocephalic artery; L.BCV: left brachiocephalic vein; R.BCV: right brachiocephalic vein; SVC: superior vena cava; STAR: enlarged lymph node).

Figure 5 Photomicrograph compilation of H&E-stained Virchow node sections at 100× (A&B), and 400× (C&D). A – Interconnecting nests of hyperchromatic cells in a trabecular pattern. B – Hyperchromatic cells displaying multiple characteristic rosettes, suggestive of small cell neuroendocrine carcinoma. C –Sheet of cells with hyperchromatic nuclei with powdery chromatin with admixed necrosis and numerous mitotic figures, suggestive of small cell neuroendocrine carcinoma. D – Hyperchromatic tumor cells arranged in spoke-and-wheel configuration around central cores comprised of cytoplasmic processes. The rosettes are a feature of small cell neuroendocrine carcinoma.

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E-mail: autopsy.hu@gmail.com

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Bilateral Virchow nodes: an unusual finding of pulmonary small-cell neuroendocrine carcinoma metastasis

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[1] Conflict of interest: The authors have no conflict of interest to declare.