LAPORAN KASUS VI

Virchows Node

PENULIS
Wahyu Sholekhuddin
1102009295
PEMBIMBING
dr. Herry Setya Yudha Utama Sp. B MHkes FinaCs

KEPANITERAAN KLINIK ILMU PENYAKIT BEDAH

RUMAH SAKIT UMUM DAERAH ARJAWINANGUN
PERIODE 11 Agustus 2014 18 Oktober 2014
FAKULTAS KEDOKTERAN UNIVERSITAS YARSI
JAKARTA

LEMBAR PENGESAHAN
Nama Mahasiswa
NIM
Bagian

: Wahyu Sholekhuddin
: 1102009295
: Kepaniteraan Klinik Ilmu Penyakit Bedah
FK Universitas YARSI

Judul laporan kasus : Virchows node

Pembimbing

: dr. Herry Setya Yudha Utama Sp. B MHkes FinaCs

Cirebon, Agustus 2014

Pembimbing

dr. Herry Setya Yudhautama Sp. B MHkes

FinaCs

I.

PATIENT IDENTITY
Nama
: Mrs. H
Age
: 54 Years
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Gender
Religion
Job
Education
Address
dates
II.

:
:
:
:
:
:

ANAMNESIS
1. The main complaint
2. Additional complaint
3. History of the disease

Female
Islam
Housewife
13 September 2014

: Mass below left neck region

: :

Patient came to Arjawinangun hospital with complaints contained lump in the

left neck since 1 month ago. patient said that the lump has been there since 1 year
ago. Originally arising lump is same as marble and then getting bigger. Pain in the
bump is not perceived by the patient.
patient says nothing other than a lump in the neck to the left. OS said that
since 4 months ago her body weight decreased. she does not complain of fever,
shortness of breath, nausea or vomiting, and abdominal pain. No bowel and
bladder disorders.
4. History of the past disease :
She never has been like this before
5. History of family disease :
There are no family have the same disease as same as her
III.

PHISYC EXAMINATION
A. General condition : Middle
B. Consiousness
: Compos mentis
C. Vital Sign
: Blood pressure : 110/70 mmHg
Pulse
: 86 x/menit
Respiration
: 22 x/menit
Temperature : 36,4 0 C
D. Generalis state head to toe :
Head : Normocephal
Eyes
: anemic conjungtiva (-/-), icteric of the sclera (-/-), pupil isokor diameter
3 mm/3mm, light reflex (+/+)
Nose : discharge (-), deviation of septum (-), rinorrhea (-)
Ears
: discharge (-), othorrhea (-)
Mouth : dry mucous (-), sianostic (-), coated tongue (-)
Neck : Mass (+) below left region, Lymph node enlargement (+)
Thorax
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Cor
Inspection
Palpation
Percussio

: Ictus cordis (+)

: Ictus cordis palpated
: Rightside cardio teritory border :ICS V Sternalis dextra
Leftside cardio teritory border :ICS VI Midclavicula sinistra
Upside cardio teritory border
:ICS III Parasternalis sinistra
Auscultatation : BJ I-II Normal reguler, Murmur (-), Gallop (-)
Pulmo
Inspection

: Simetry in dynamic and static movement, intercostal retraction (-),

mass (-)
Palpation
: Vocal fremitus right = left, trachea deviation (-)
Percussion : Sonor on the lung cavity
Auscultation : Vesikuler breath sound
Wheezing (-), Ronkhi (-)
Abdomen
Inspection : venectasy (-)
Auscultation : peristaltic sound of bowel (+)
Palpation
: mass (-), liver or lien enlargement (-)
Percussion : Tympani on the 4 quadrant abdoment
Ekstremity
Superior
: deformity (-), edema (-), cyanotic (-), warm
Inferior
: deformity (-), edema (-), cyanostic (-), warm
5. Local region
Regio Fossa supraclavicular
Inspection :
Mass below left neck region has the same color as the neighbour of the neck
skin, venectasy (-).
Palpation :

Mass palpated below left neck region, hard consistency, immobile,

pain (-), circumcript the size 4x5 cm, permukaan rata, scars (-).
IV.
V.

VI.

DIFFERENTIAL DIAGNOSIS
Lymphoma non hodkin
WORK DIAGNOSIS
Nodul Virchows
LABORATORY TEST
- Laboratorium
WBC : 6200
HGB : 11.3
HCT : 97.4
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PLT : 317000
Blood glucose serum: 85
Renal function
Ureum
: 38.3
Kreatinin : 0.56
Uric acid : 3.36
Liver function
SGOT
: 18
SGPT
: 13
HbsAg
: 0.539
VII.

VIII.

THERAPY
Biopsy FNA
PA
Lymphadenoctomy
Chemoterapy and Radioterapy
PROGNOSIS
Quo ad vitam
Quo ad functionam

: ad bonam
: dubia ad malam

VIRCHOWS NODE
A. DEFINITION
Nodules are Virchow's lymph nodes were found in the left supraclavicular fossa (an area
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which is located above the left clavicula). If found an enlarged nodule with a hard
consistency (Troiser's sign) strongly suggests the presence of a malignancy in the abdominal
area, especially gastric cancer, metastatic in limfogen.

B. HISTORY
Nodules Virchow's immortalized his name as inventor Rudolf Virchow is, a German
pathologist, who first described the relationship with the enlarged glands in the gastric
malignancy in 1848 Expert pathological France, Charles Emile Troiser, in 1889 suggested
that the malignancy in the abdominal area can also metastasize to the gland.
C. Anatomy and Histology
Lymph node is a round-shaped organ with a small size as an immune system that is widely
distributed in the whole body and linked by lymphatic vessels. Stored lymph node
lymphocytes B cells, T, and other immune cells. These nodes serve as filters. The nodes also
have clinical significance, can become inflamed or enlarged in various conditions (from
infection to malignancy). Based on clinical signs, can be determined so that it can be
determined the degree of malignancy and prognosis of disease therapeutic action.
Lymph node is surrounded by a fibrous capsule and in the lymph node the fibrous capsule
extends to form trabeculae. Substance of the lymph node is divided into the outer cortex and
inner medulla is surrounded by its constituent regions except the hilum, where the medulla
associated with the surface.
Thin reticular fibers, elastin and reticular fibers form a strong fabric of interwoven reticular
known at the nodes, with included a white blood cells, particularly lymphocytes, a solid
follicles in the cortex. In other places there are sometimes only white blood cells only.
Interwoven reticular structure not only strengthen but also provide surface for adhesion of the
dendritic cells, macrophages and lymphocytes. Interwoven enables the exchange of material
transported through the blood-venule endothelial venules and provides the growth factors and
regulators required for the activation and maturation of immune cells. The amount and
composition of follicles and change in particular when dealing with antigens and form
germinal centers.
Lymph sinus is a channel in which there are wrinkles to lymph nodes by endothelial cells
with fibroblast reticular cells and allows the lymphatic flow, embut through. Sinus
subcapsular sinus is located in the capsule and endoteliumnya continues into afferent
lymphatic vessels. This sinus is also continuing with the same sinuses flanking the trabeculae
inside the cortex (cortical sinuses). Cortical sinuses flanking the trabeculae drain into the
sinuses of the medulla, where the flow of lymphatic flow into the efferent lymphatic vessels.
Multiple branching afferent lymphatic vessels and spread in the capsule carrying lymph to the
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lymph nodes. This lymph enter the subcapsular sinus. The innermost layer of the afferent
lymphatic vessels continued to frown lymphatic sinus cells. Lymph is slowly filtered through
the lymph nodes and eventually the substance reaches the medulla. On his way to meet
beninng sap lymphocytes and their activation may begin as part of the adaptive immune
response. Concave side of the lymph node is called the hilum. Efferent hilum by binding
tightly interwoven reticulum and carries lymph out of the lymph nodes.
cortex
In the cortex, subcapsular sinus flowing into trabecular sinuses and lymph flow to the sinuses
of the medulla. The outer side of the cortex is composed mainly by B cells arranged as
follicles, which can form the germinal center against the antigen, the deeper cortex mainly
composed of T cells of this zone known as the subcortical zone where T cells primarily
interact with the cell-where dendritic cells and reticular densest tangle.
medulla
There are two structures in the medulla names:
o Corda medulla is corda and lymphatic tissues including plasma cells, macrophages and B
cells
o Sinus medulla (or sinusoids) are vessel space that separates corda medulla. Lymph flows
into the medullary sinuses from cortical sinuses, and into efferent lymphatic vessels. Sinus
medulla contains histiiosit (immobile macrophages) and reticular cells.
Lymphatic flow
The flow of lymph through the lymph nodes leading to afferent lymphatic vessels and drains
into the nodes under the capsule in a space called the subcapsular sinus. Subcapsular sinus
flow into trabecular sinuses and finally into medullary sinuses. Pseudopoda crossed sinus
cavity macrophages, which contribute to ensnares foreign particles and as a lymphatic filters.
Sinuses of the medulla met at the hilum and lymph then leaves through the lymph nodes and
efferent lymphatic vessels drain into the subclavian vein, venules postkapiler, cross the wall
through the process of diapedesis.
B cells migrate to the nodular cortex and medulla.
T cells migrate to the cortex (parakorteks).
When lymphocytes recognize an antigen, B cells are activated and migrate to germinal
centers. When antibodies produced by plasma cells are formed, they migrate to the medullary
cords. Stimulation of lymphocytes by antigen accelerated by the migration process 10 times
faster than normal, resulting in characteristic swelling of the lymph nodes. The spleen and
tonsils are lymphoid organs adal have the same functionality as lymph nodes, spleen blood
through the filter more than through the lymph nodes.
distribution
Lymph nodes in the head and neck:
cervical lymph nodes
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Anterior Cervical: glands here, either superficial or deep, lean muscle in the
strenocleidomastoideus. They drain the contents into the throat and posterior pharynx, tonsils,
and thyroid gland.
Posterior Cervical: these glands extending to the posterior sternocleidomastoid but in front of
the trapezius, ranging from as high as the mastoid portion of the temporal bone to the
clavicle. The gland is enlarged, if there is an upper respiratory tract infection.
Tonsils or submandibular: These glands are located below the mandibular angle, along the
bottom of the chin. They flow into the region of the tonsils and pharynx, including the basic
structure of the mouth and the maxillary anterior and molar 1 and 2 They also flow into the
teeth except the mandibular incisors.
Retrofaring: lymph drainage of the soft palate and the third molar.
Sub-mental: these glands located just below the chin. They flow into the central incisors,
floor of the mouth and the base of the tongue.
supraclavicular lymph nodes: these glands running along the clavicle, lateral to the sternum
where the join. They flow into the thoracic and abdominal cavities. Virchow's nodules
lymphatic glands in the supraclavicular limfatiknya receives flow from the entire body via the
ducts thorasikus and is a favorite place for metastatic malignancy.

Lymphatic glands Thorax

Lymphatic glands of the lungs: lymph flow from the lung tissue through subsegmental lymph
nodes, segmental, lobar and interlobar lymph nodes leading to hillus, which is located around
the hilum. The flow of the lymphatic flow to the mediastinal lymph nodes. Mediastinal lymph
nodes: they consist of multiple groups of nodes llimfatik, especially along the trachea, along
the esophagus and between the lung and the diaphragm. In the mediastinal lymph nodes
originating from ducts lymphatic glands which drain the lymph into the left subclavian vein.
Mediastinal lymph nodes along the esophagus are closely related denngan in abdominal
lymph nodes along the esophagus and stomach. This fact facilitates the spread of tumors
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through lymphatic pathways in cases of malignancy of the stomach and part of the
esophagus. Through the mediastinum, the main lymphatic drainage through the abdominal
organs through the duct thorasikus, where the main flow of lymph from the abdomen is to the
gland.

A. CLINICAL MEANING
Malignancy-malignancy in organs can reach an advanced stage before giving symptoms. For
example, gastric cancer may have no symptoms but had metastasized. Point which can be
seen in which the tumor has metastasized is left supraclavicular lymph node. Supraklavkular
lymphatic nodules are left as nodules nodules classic Virchow is located on the left side of the
neck where almost all the body's lymphatic drainage (from duct thorasikus) entered
kesirkulasi through the left subclavian vein. Metastasis thorasikus clog ducts and cause
regurgitation into round nodules into nodules Virchow example. Another concept is that the
nodules supraclavicular nodes in accordance with the final journey along the duct and hence
have an enlarged thorasikus.
B. DIAGNOSIS
The differential diagnosis of an enlarged nodule Virchow was lymphoma, malignant intraabdominal malignancy, breast cancer and infection (in the arm). Similarly, the enlargement of
the right supraclavicular lymph nodes tend to refer to thoracic malignancies such as lung
cancer and esophageal cancers such as Hodgkin's lymphoma.
C. THERAPY
When the size of lymph nodes obtained> 1cm then it is said to be abnormal, and a biopsy
should be done to determine the type of disorder. Lymph node biopsy has two ways: by
simply taking a portion of the node or nodes simultaneously raise one.
techniques
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Incision on the skin surface beneath an enlarged nodes and surrounding tissue carefully
dissected away from the node. Must pay attention to the surrounding nerve tissue, especially
in the area around the neck. To facilitate removal of the nodes, the association is done with a
thread attached to the middle of the node, so that nodes can be removed.

Radiotherapy and Chemotherapy

Measures radiation and chemotherapy can be done if the primary cause of cancer has therapied (eg
resected). Several studies have shown, there is a decrease in the size of lymph nodes, after several
cycles of chemotherapy.

DAFTAR PUSTAKA
1)
2)
3)
4)

Libman H. Generalized lymphadenopathy. J Gen Intern Med 1987;2:48-58.

Morland B. Lymphadenopathy. Arch Dis Child 1995; 73:476-9.
Pangalis GA, Vassilakopoulos TP, Boussiotis VA, Fessas P. Clinical approach
tolymphadenopathy. Semin Oncol 1993;20:570-82.
http://www.dokterbedahherryyudha.com/2012/03/diagnosis-and-managementvirchows-node.html

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