Left Supraclavicular (Virchow’s) Node Metastasis Detected Before Diagnosis of the Primary Infradiaphragmatic Tumor

Background and Purpose: Malignant infradiaphragmatic tumors that metastasize to the left supraclavicular (Virchow’s) node are relatively rare. Since Virchow's time, the survival rates of cancer patients have improved because of dramatic research advances in the epidemiology of cancer and the development of screening technologies and treatment methods. However, when metastasis is detected in the left supraclavicular node in patients with head and neck carcinoma, locating the primary cancer remains a difficult and time-consuming challenge. We report three cases of malignant infradiaphragmatic tumors diagnosed following the initial finding of left supraclavicular node (LSN) metastasis after surgery for tongue squamous cell carcinoma (follow-up period, range 18–62 months).Methods: In these cases, adenocarcinoma was diagnosed based on LSN biopsies, and a second primary tumor was found, including cholangiocarcinoma, bladder carcinoma, and prostate carcinoma.Results: CA19-9 and alpha-fetoprotein levels helped to diagnose cholangiocarcinoma. In the bladder carcinoma case, immunopathological examination of the metastatic LSN and bladder lesion showed GATA 3(+), and the tongue squamous cell carcinoma showed GATA 3(-). GATA 3 staining aided in the diagnosis of urothelial bladder cancer with LSN metastasis. In the prostate carcinoma case, PSA levels and weak FDG-PET/CT uptake aided the diagnosis process. This patient underwent bilateral orchiectomy and adjuvant hormonal therapy and survived for 47 months after the diagnosis of LSN metastasis. The other patients died within 1 year.Discussion and Conclusions: These cases suggest that the prognosis of malignant infradiaphragmatic tumors after LSN metastasis depends on the tumor characteristics and that rapid diagnosis is important for providing appropriate treatment.

Virchow’s node as the initial presentation of metastatic prostate cancer: a case series of a common cancer in uncommon location

Prostate cancer is one of the commonest cancers among men contributing significantly to the overall cancer burden globally. Most patients present with lower urinary tract symptoms. Metastasis to supraclavicular lymph nodes is unusual presentation, which has been rarely reported particularly as the primary presentation. We report two rare cases of advanced prostatic adenocarcinoma presenting with firm, non-tender lump in the left supraclavicular region between the two heads of the sternocleidomastoid muscle, (that is Virchow’s node) as initial primary symptom. Examination of the patients revealed an elevated prostatic-specific antigen (PSA) of > 100 ng/ml levels, and the diagnosis was confirmed by histological evaluation and immunostaining with PSA of the supraclavicular lymph nodes and prostate biopsies. This case series emphasizes the importance of considering prostate cancer in the differential diagnosis of male patients with supraclavicular lymphadenopathy.

Second lung malignancy and Richter syndrome in chronic lymphocytic leukemia: case report and literature review

Background: Chronic lymphocytic leukemia (CLL) is the most frequent lymphoproliferative disease. Transformation into Richter disease and occurrence of second malignancies involving the lungs are rare complications. The hallmarks of any thoracic involvement are still unknown. Case presentation: We report a case of a 56-year-old male patient, with history of tobacco smoking, who presented with recurrent hemoptysis, fatigue and weight loss. Physical examination was normal except a slightly enlarged supraclavicular lymph node. Chest x-ray revealed a mediastinal widening due to enlarged paratracheal nodes and a left parahilar infiltrate. Blood tests showed a hyperlymphocytosis and a biological inflammatory syndrome. CT scan showed bilateral mediastinal and axillary lymphadenopathy, as well as left supraclavicular lymphadenopathy, with a left upper lobe alveolar attenuation and a solitary contralateral pulmonary nodule. Examination of Virchow’s node and bone marrow biopsies confirmed metastasis of a pulmonary adenocarcinoma, as well as chronic lymphocytic leukemia with Richter’s transformation. The clinical course was unfavorable since the first days of therapy as the patient passed away in a matter of a few days. Conclusions: Steady surveillance of CLL patients and systematic screening for second solid tumors, particularly lung cancer, and Richter’s transformation seem to be relevant more than ever. Early diagnosis might help us understand the pathways leading to these complications and adapt therapy.

Gastrointestinal Malignancy Presenting with a Virchow’s Node in a Patient with Rothmund-Thomson Syndrome

Rothmund-Thomson syndrome is a genetic disorder with characteristic findings in childhood as well as a predisposition to osteosarcoma, skin cancer, and hematological malignancy. We present the first reported case of duodenal malignancy in a patient with Rothmund-Thompson syndrome. An enlarged Virchow’s node was noted and an advanced duodenal adenocarcinoma was diagnosed shortly thereafter. The features of Rothmund-Thomson syndrome are discussed, as well as current management and screening guidelines for duodenal adenocarcinoma.

Abdominoperineal Resection for Unexpected Distal Intramural Spreading of Rectal Cancer

Introduction: In rectal cancer, distal intramural spread may sometimes occur, but a maximum extent of distal spread of > 6 cm is very rare. Case Presentation: A 65-year-old Japanese male with an advanced rectal cancer tumor with para-aortic lymph node metastasis was admitted. We performed a low anterior resection with lymphadenectomy, but the intraoperative frozen-section analysis of margins revealed malignant cell positivity; we, therefore, performed an abdominoperineal resection. Pathological findings showed that the maximum extent of distal spread was 6 cm. After 12 courses of FOLFOX4 as adjuvant chemotherapy, abdominal computed tomography revealed whole lymph node metastases, including Virchow’s node. Though FOLFIRI + panitumumab was started, he was not eligible for additional chemotherapy after 10 cycles. Conclusion: An intraoperative frozen pathology examination was helpful for the additional resection, when unexpected distal spreading had occurred in rectal cancer. The evidence of a distal negative margin should not be underestimated.