Am J Exp Clin Res, Vol. 1, No. 2, 2014 http://www.ajecr.org

American Journal of

Experimental and Clinical Research

Am J Exp Clin Res 2014;1(2):33-34

Case Report

Virchow’s node: A look beyond gut carcinoma

Bharath C*, Komala H M
Department of Pathology, Vijayanagar Institute of Medical Science, Bellary, Karnataka, India

Abstract Virchow’s node, left supraclavicular lymph node contains metastasis of many abdominal visceral malignancies. Urothelial

carcinoma comprises 90% of all primary bladder cancer with metastases usually limited to the pelvic nodes. Though distant lymph node

involvement is rare but cannot be entirely overlooked. Presence of Virchow’s node with bladder tumor is considered as incurable

metastatic disease. A 40 year old male presented with history of fever, intermittent hematuria and burning micturition since one week.

Incidentally left supraclavicular lymph node was found to be enlarged. FNAC showed the features of urothelial carcinoma. Patient was

subjected to further relevant investigations. CT-Scan showed well defined enhancing lesion with intra-luminal extension. Biopsy was done

which revealed primary tumor to be urothelial carcinoma of bladder. Supraclavicular lymph node metastases are rare in this case and

indicate widespread disease with poor prognosis. Conclusion: This case is a rare presentation of urothelial carcinoma metastases to

Virchow’s node. Picking up nodal metastases may influence therapeutic decisions and FNAC may be a useful tool in diagnosing such

metastases with certainty.

Keywords: Virchow’s node, urothelial carcinoma, FNAC, metastases

Introduction

Virchow’s node (left supraclavicular lymph node) may

contain metastases of many thoracic and abdominal

visceral malignancies such as lung, breast, esophageal,

gastric, pancreatic, gynecologic, and prostate cancers [1].

Urothelial carcinoma accounts for 90% of cases of bladder

cancer with metastases usually limited to the regional

pelvic nodes [2]. Metastasis to non-regional lymph nodes

especially cervical lymph nodes is extremely rare

presentation [3]. Only few reports have been published so

far and with poor prognosis [3]. Though distant lymph

node involvement is rare but cannot be entirely overlooked.

Case Report

A 40 year old male presented with history of fever,

intermittent hematuria and burning micturition since one

week. Incidentally left supraclavicular lymph node was

found to be enlarged. Patient was subjected for fine needle

aspiration cytology (FNAC). Cytology showed cellular

smears consisting of atypical epithelial cells in papillary

fragments, monolayered sheets and loose clusters with

both squamous and glandular differentiation. These cells

showed stratification of the nuclei within the fragments.

Cells with eccentrically placed nucleus, spindle cells,

racquet like cells, pyramidal cells, and atypical stripped

nuclei were also seen. It was diagnosed as metastasis of

urothelial carcinoma (Fig.1 and Fig.2).

Patient was subjected to further relevant investigations.

CT scan showed well defined enhancing mass lesion in the

bladder measuring 4.5×4.8 cm arising from anterior wall

with intraluminal extension. Hypodense lesions in both

lobes of liver and right iliac fossa were seen suggestive of

metastases. Biopsy of the bladder mass was done which

revealed primary tumor to be urothelial carcinoma (Fig. 3).

Supraclavicular lymph node metastases are rare in this

case and indicate widespread disease with poor prognosis.

Discussion

Bladder cancer is the most common malignant disease

of the urinary tract [2]. It is commonly a disease of older

age and is more prevalent among men than women [2]. It

is the second most prevalent cancer for men and 10th most

prevalent cancer for women [4]. It has variable metastatic

potential and almost any organ can be involved. Data on

its metastatic pattern are limited [2].

The pattern of

recurrence and metastases are not dependent on the

features of the primary tumor [5].

Common sites of metastatic spread of bladder

carcinoma are regional lymph nodes (90%), liver (47%),

lung (45%), bone (32%), peritoneum (19%), pleura (16%),

kidney (14%), adrenal gland (14%), and the intestine

(13%) [1]. Most common lymph nodes involved are

external iliac, internal iliac and obturator (20%-45%) as

the primary lymphatic drainage of the bladder, and the

common iliac sites as the secondary drainage [3].

The possible route of spread to head and neck region is

by haematogenous route through vertebral veins and by

lymphatic route [3]. The presence of Virchow’s node with
___________________________________________________________

* Corresponding author: Bharath C, MD (bhar5anu@yahoo.co.in).

mailto:bhar5anu@yahoo.co.in

Am J Exp Clin Res, Vol. 1, No. 2, 2014 http://www.ajecr.org

Figure 1 FNAC showing atypical epithelial cells arranged in papillary

fragments (Hematoxylin and eosin stain 10x)

muscle by haematogenous through vertebral veins and by

lymphatics [3]. Presence of Virchow’s node with muscle

invasive bladder tumor is considered as incurable

metastatic disease as the pathological retrograde tumour

cell deposition against the normal drainage of the

node (towards the thoracic duct) imply extensive tumour

occupation of the retro peritoneum.

Study done by Hessan et al. among 207 patients with

metastasis to the head and neck area lymph nodes showed

only 3 cases having metastasis with urothelial origin [5].

Ferlito et al. reported a series of genitourinary tumors and

found this group to be the third most frequent tumor site to

metastasize to the supraclavicular fossa [4].

Figure 2 Cluster of pleomorphic cells showing nuclear overlapping with

coarse chromatin (H&E 45x)

Conclusion

This case is a rare presentation of urothelial carcinoma

metastases to Virchow’s node. Identification of nodal

involvement is important because the presence of nodal

metastasis advances the disease to stage IV [2]. Picking up

Figure 3 Atypical tumor cells in varied pattern diagnosed as urothelial

carcinoma (H&E 40x)

nodal metastases may influence therapeutic decisions and

FNAC can be used as first line investigation in diagnosing

such metastases with certainty.

Conflict of Interest

The authors declare no conflicts of interest.

References

1. Seneviratne LN, Jayasundare JMNRK, Perera ND.

Virchow’s node: An unheard site of metastatic bladder

cancer. Sri Lanka J Urol 10:28-30, 2009.

2. Shinagarel AB, Ramaiya NH, Jagannathan JP,

Fennessy FM, Taplin ME, Van den Abbeele AD.

Metastatic pattern of bladder Cancer: Correlation with the

characteristics of the primary tumor. AJR Am J

Roentgenol 196:117-122, 2011.

3. Tunio MA, AlAsiri M, Bayoumi Y, Fareed M,

Ahmad S. Cervical lymph node metastasis from

transitional cell carcinoma of urinary bladder: Case report

and review of literature. J Solid Tumors 2:59-62, 2012.

4. Ogunyemi O, Rojas A, Hematpour K, Rogers D,

Head C, Bennett C. Metastasis of genitourinary tumors to

the head and neck region. Eur Arch Otorhinolaryngol

267:273-279, 2010.

5. Hessan H, Strauss M, Sharkey FE. Urogenital tract

carcinoma metastatic to the head and neck. Laryngoscope

96:1352–1356, 1986.