Virchows node: Rare presentation of childhood hepatocellular carcinoma
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《美国医学杂志》
Department of Pediatrics Medicine, Calcutta National Medical College & Hospital, Kolkata, India
Abstract
Cervical (supra-clavicular) lymphadenopathy may not always be due to tuberculosis in children. Hepatocellular carcinoma in children even may present as supra clavicular lymphadenopathy (Virchow's node).
Keywords: Hepatocellular carcinoma, Virchow′s node, Supra-clavicular lymph node
The left supra-clavicular lymph node ( left sided deep cervical group of lymph node) classically described as Virchow's node receives some part of lymphatic drainage from breast, bronchi, abdominal, pelvic organ and testes.[1] Tuberculosis, sarcoidosis and toxoplasmosis are the non-neoplastic causes of supraclavicular adenopathy.[2] It is also frequently involved by metastatic malignancies of abdominal and pelvic organ.[2],[3] Hepatocellular carcinoma is a relatively rare entity in children except in areas in which there is high prevalence of hepatitis B virus infection.[4] Virchow's node as a initial presentation of hepatocellular carcinoma is rare.[5] Hepatocellular carcinoma presented as Virchow's node in children was not reported in world literature. Here we report such a case of hepatocellular carcinoma presented as enlargement of Virchow's node.
Case report
Twelve-year-old girl presented to Outpatient Department with history of low grade fever, anorexia and loss of weight for last four months. On examination she had mild pallor, enlarged left supra-clavicular lymph node of 3 cm × 2 cm which is firm and nontender Figure1.
Her systemic examination revealed mild firm nontender hepatomegaly and mild spleenomegaly. Other systemic examination was essentially normal. Provisional diagnosis of disseminated tuberculosis was made. She was advised to have routine tubercular workup. Which revealed haemoglobin of 10.2 gm%, total leucocyte count of 8540 with normal differential count, ESR of 48, mantoux was negative and chest X-ray was normal. Fine needle aspiration cytology of left supraclavicular lymph node revealed poorly differentiated carcinoma.
Then she was admitted for further workup. This time when she was admitted after about 2 weeks of first OPD visit she also developed icterus. Further investigation was done to search for the primary site of metastatic deposits in left supra-clavicular lymph node.
(Virchow's node). Stool for occult blood was negative. Liver function was deranged with total serum bilirubin of 4.5mg%, SGOT of 140, SGPT of 148, ALP of 639. Alpha feto-protein and serum Hepatitis surface antigen was negative. Coagulation study was within normal limit. Ultra sonography of abdomen showed a heterogenous SOL of right lobe of liver measuring 6cm × 5cm with irregular margin and focal areas of calcification, dialated IHBR and associated para-aortic lymphadenopathy
Figure2. Liver biopsy showed moderately differentiated adenocarcinoma. She was then shifted to pediatric oncology specialty for further management.
Discussion
Virchow's node are mainly reported to be affected with gastric carcinoma in adult[6] and advanced neuroblastoma[7] in children in recent literature. There is few case report of hepatocellular carcinoma and pancreatic adenocarcinoma presented as multiple distant lymphadenopathy including enlargement of Virchow's node[8] in adult.
In one case Kew MC[9] described a case of twenty year old patient presented with hepatocellular carcinoma with Virchow's node enlargement but no mediastinal adenopathy. He postulates that probably malignant cells reached Virchow's node from hepatic node through thoracic duct.[9]
Left supra clavicular lymph node sampled in different pathological studies showed high incidence of metastatic carcinoma of breast,lung, infra-diaphragmatic organs including testes[10] in adult series from differenr hospital.
Left supra-clavicular lymph node sampling in different pathological series in children showed they are most likely to be malignant etiology than other groups of lymph node enlargement.[11],[12] The etiology are mainly due to leukaemic, lymphomatous deposits[13],[14] and rarely due to other metastatic malignancies.
But extensive literature search failed to reveal any reported case of hepatocellular carcinoma in children presented as isolated left supra-clavicular lymph node (Virchow's node) enlargement at presentation.
Conclusion
Left supra-clavicular (Virchow's node) enlargement always should be investigated thoroughly. Even it may be the first presentation of malignancy of any intra abdominal or pelvic organ including hepatocellular carcinoma in children
Contribution
All the authors are involved in the management of patient and drafting of paper. SC will act as guarantor of the paper.
References
1. Snell S. Clinical Anatomy for the Medical Student. Pub; Little Brown & Company; 5th edn. 997.
2. Harrison's Principles of Internal Medicine; Pub; McGraw-Hill; 15th edn. 361.
3. Cervin JR, Silverman JF, loggie BW, Geisinger KR. Virchow's node revisited ; Analysis with clinico-pathologic correlation of 152 fine needle aspiration biopsies of supraclavicular lymph node; Archives of Pathology & Laboratory Medicine 1995; 119(8): 727-730.
4. Hsu HC, Wu MZ, Chang M, Su IJ, Chen DS. Childhood hepatocellular carcinoma develops exclusively in hepatitis B surface antigen carriers in three decades in Taiwan: a report of 51 cases strongly associated with rapid development of liver cirrhosis; J Hepatol 1987; 5: 260-267.
5. Schwarz KD, Schwartz IS, Marchevsky A. Virchow-Troisier's lymph node as the presenting sign of hepato-cellular carcinoma; Mount Sinai J Med, 1982; 49(1): 59-62.
6. Nozawa H, Sekikawa T, Tsukui H, Kina S, Kawahara T, Ono K et al. Gastric cancer with Virchow's and multiple lung metastases showing a remarkable response to preoperative chemotherapy: report of a case. Surg Today 2001; 31(4): 340-345.
7. Abramson SJ, Berdon WE, Stolar C, Ruzal-Shapiro C, Garvin J. Stage IVN neuroblastoma: MRI diagnosis of left supraclavicular Virchow's nodal spread. Pediatr Radiol 1996; 26 (10): 717-719.
8. Toyoda H, Fukuda Y, Koyama Y, Nishimura D, Hoshino H, Katada N et al. Case report: multiple systemic lymph node metastases from a small hepatocellular carcinoma. J Gastroenterol Hepatol 1996; 11(10): 959-962.
9. Kew MC, Virchow-Troisier's lymph node in hepatocellular carcinoma, J Clin Gastroenterology 1991; 13(2): 217-219.
10. Ellison E, LaPuerta P, Martin SE. Supraclavicular masses: results of a series of 309 cases biopsied by fine needle aspiration. Head Neck 1999; 21(3): 239-246.
11. Kumral A, Olgun N, Uysal KM, Corapcioglu F, Oren H, Sarialioglu F. Assessment of peripheral lymphadenopathies: experience at a pediatric hematology-oncology department in Turkey. Pediatr Hematol Oncol 2002; 19(4): 211-218.
12. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg 1999; 34(10): 1447-1452.
13. Redondo Granado MJ, Alvarez Guisasola FJ, Gomez Martin I, Bobillo del Amo H, Blanco Quiros A et al. Diagnostic evaluation of cervical adenopathies in childhood. An Esp Pediatr 1992; 37(3): 233-237.
14. Valdez-Martinez E, Arroyo-Lunagomez E, Landero-Lopez L. Clinical-histopathological diagnostic agreement of lymph node biopsies in a tertiary care hospital. Rev Invest Clin 1998; 50(6): 483-486.(Mondal RK, Dutta A, Basu )
Abstract
Cervical (supra-clavicular) lymphadenopathy may not always be due to tuberculosis in children. Hepatocellular carcinoma in children even may present as supra clavicular lymphadenopathy (Virchow's node).
Keywords: Hepatocellular carcinoma, Virchow′s node, Supra-clavicular lymph node
The left supra-clavicular lymph node ( left sided deep cervical group of lymph node) classically described as Virchow's node receives some part of lymphatic drainage from breast, bronchi, abdominal, pelvic organ and testes.[1] Tuberculosis, sarcoidosis and toxoplasmosis are the non-neoplastic causes of supraclavicular adenopathy.[2] It is also frequently involved by metastatic malignancies of abdominal and pelvic organ.[2],[3] Hepatocellular carcinoma is a relatively rare entity in children except in areas in which there is high prevalence of hepatitis B virus infection.[4] Virchow's node as a initial presentation of hepatocellular carcinoma is rare.[5] Hepatocellular carcinoma presented as Virchow's node in children was not reported in world literature. Here we report such a case of hepatocellular carcinoma presented as enlargement of Virchow's node.
Case report
Twelve-year-old girl presented to Outpatient Department with history of low grade fever, anorexia and loss of weight for last four months. On examination she had mild pallor, enlarged left supra-clavicular lymph node of 3 cm × 2 cm which is firm and nontender Figure1.
Her systemic examination revealed mild firm nontender hepatomegaly and mild spleenomegaly. Other systemic examination was essentially normal. Provisional diagnosis of disseminated tuberculosis was made. She was advised to have routine tubercular workup. Which revealed haemoglobin of 10.2 gm%, total leucocyte count of 8540 with normal differential count, ESR of 48, mantoux was negative and chest X-ray was normal. Fine needle aspiration cytology of left supraclavicular lymph node revealed poorly differentiated carcinoma.
Then she was admitted for further workup. This time when she was admitted after about 2 weeks of first OPD visit she also developed icterus. Further investigation was done to search for the primary site of metastatic deposits in left supra-clavicular lymph node.
(Virchow's node). Stool for occult blood was negative. Liver function was deranged with total serum bilirubin of 4.5mg%, SGOT of 140, SGPT of 148, ALP of 639. Alpha feto-protein and serum Hepatitis surface antigen was negative. Coagulation study was within normal limit. Ultra sonography of abdomen showed a heterogenous SOL of right lobe of liver measuring 6cm × 5cm with irregular margin and focal areas of calcification, dialated IHBR and associated para-aortic lymphadenopathy
Figure2. Liver biopsy showed moderately differentiated adenocarcinoma. She was then shifted to pediatric oncology specialty for further management.
Discussion
Virchow's node are mainly reported to be affected with gastric carcinoma in adult[6] and advanced neuroblastoma[7] in children in recent literature. There is few case report of hepatocellular carcinoma and pancreatic adenocarcinoma presented as multiple distant lymphadenopathy including enlargement of Virchow's node[8] in adult.
In one case Kew MC[9] described a case of twenty year old patient presented with hepatocellular carcinoma with Virchow's node enlargement but no mediastinal adenopathy. He postulates that probably malignant cells reached Virchow's node from hepatic node through thoracic duct.[9]
Left supra clavicular lymph node sampled in different pathological studies showed high incidence of metastatic carcinoma of breast,lung, infra-diaphragmatic organs including testes[10] in adult series from differenr hospital.
Left supra-clavicular lymph node sampling in different pathological series in children showed they are most likely to be malignant etiology than other groups of lymph node enlargement.[11],[12] The etiology are mainly due to leukaemic, lymphomatous deposits[13],[14] and rarely due to other metastatic malignancies.
But extensive literature search failed to reveal any reported case of hepatocellular carcinoma in children presented as isolated left supra-clavicular lymph node (Virchow's node) enlargement at presentation.
Conclusion
Left supra-clavicular (Virchow's node) enlargement always should be investigated thoroughly. Even it may be the first presentation of malignancy of any intra abdominal or pelvic organ including hepatocellular carcinoma in children
Contribution
All the authors are involved in the management of patient and drafting of paper. SC will act as guarantor of the paper.
References
1. Snell S. Clinical Anatomy for the Medical Student. Pub; Little Brown & Company; 5th edn. 997.
2. Harrison's Principles of Internal Medicine; Pub; McGraw-Hill; 15th edn. 361.
3. Cervin JR, Silverman JF, loggie BW, Geisinger KR. Virchow's node revisited ; Analysis with clinico-pathologic correlation of 152 fine needle aspiration biopsies of supraclavicular lymph node; Archives of Pathology & Laboratory Medicine 1995; 119(8): 727-730.
4. Hsu HC, Wu MZ, Chang M, Su IJ, Chen DS. Childhood hepatocellular carcinoma develops exclusively in hepatitis B surface antigen carriers in three decades in Taiwan: a report of 51 cases strongly associated with rapid development of liver cirrhosis; J Hepatol 1987; 5: 260-267.
5. Schwarz KD, Schwartz IS, Marchevsky A. Virchow-Troisier's lymph node as the presenting sign of hepato-cellular carcinoma; Mount Sinai J Med, 1982; 49(1): 59-62.
6. Nozawa H, Sekikawa T, Tsukui H, Kina S, Kawahara T, Ono K et al. Gastric cancer with Virchow's and multiple lung metastases showing a remarkable response to preoperative chemotherapy: report of a case. Surg Today 2001; 31(4): 340-345.
7. Abramson SJ, Berdon WE, Stolar C, Ruzal-Shapiro C, Garvin J. Stage IVN neuroblastoma: MRI diagnosis of left supraclavicular Virchow's nodal spread. Pediatr Radiol 1996; 26 (10): 717-719.
8. Toyoda H, Fukuda Y, Koyama Y, Nishimura D, Hoshino H, Katada N et al. Case report: multiple systemic lymph node metastases from a small hepatocellular carcinoma. J Gastroenterol Hepatol 1996; 11(10): 959-962.
9. Kew MC, Virchow-Troisier's lymph node in hepatocellular carcinoma, J Clin Gastroenterology 1991; 13(2): 217-219.
10. Ellison E, LaPuerta P, Martin SE. Supraclavicular masses: results of a series of 309 cases biopsied by fine needle aspiration. Head Neck 1999; 21(3): 239-246.
11. Kumral A, Olgun N, Uysal KM, Corapcioglu F, Oren H, Sarialioglu F. Assessment of peripheral lymphadenopathies: experience at a pediatric hematology-oncology department in Turkey. Pediatr Hematol Oncol 2002; 19(4): 211-218.
12. Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg 1999; 34(10): 1447-1452.
13. Redondo Granado MJ, Alvarez Guisasola FJ, Gomez Martin I, Bobillo del Amo H, Blanco Quiros A et al. Diagnostic evaluation of cervical adenopathies in childhood. An Esp Pediatr 1992; 37(3): 233-237.
14. Valdez-Martinez E, Arroyo-Lunagomez E, Landero-Lopez L. Clinical-histopathological diagnostic agreement of lymph node biopsies in a tertiary care hospital. Rev Invest Clin 1998; 50(6): 483-486.(Mondal RK, Dutta A, Basu )