Virchow ’ s Node Not Always Signifies a Primary Gut or Lung Malignancy . Look Further and Farther

Virchow’s node generally signifies metastasis from primary malignancy either in gastrointestinal tract or lung. Apart from the commonly recognized primary sites, 4.5-5% of primary testicular cancers are also known to metastasize to the left supraclavicular lymph node. Amidst the time and space restraint of a busy FNAC practice, one may tend to overlook considering testis as one of the possible primary sites for malignancy while aspirating a left supraclavicular lymph node and interpreting the smears. This case report throws light on the importance of considering primary germ cell tumor of the testis as one of the differential diagnoses, while aspirating a Virchow’s lymph node, especially in a young male patient, besides emphasizing the need for a thorough clinical examination.


Introduction
Presence of Virchow`s nodes generally alerts the clinician and the pathologist alike to suspect and investigate for the primary in the gastro-intestinal tract or lung malignancy.Other than these sites, 4.5%-5% of primary testicular cancers have been reported to have neck metastasis 2 .Neck metastasis from germ cell tumors are relatively rare.Therefore, the clinicians and the pathologists may overlook Metatstatic Germ cell tumor under the differential diagnoses for left supraclavicular lymphadenopathy 6 .But, the possibility of neck metastasis from a primary testicular cancer, in a young male patient, has to be borne in mind always.
The present case report highlights this importance and reinforces the need to include metastatic germ cell tumors in the differential diagnosis of left supraclavicular lymphadenopathy.Besides this, it also stresses on the necessity for thorough history elicitation and detailed clinical examination, however impractical it may seem in a busy FNAC clinic.

Case Report
A 24 year old male patient presented with the history of a swelling in the left side of

Discussion
Neck metastasis from primary testicular malignancies is rare, with a reported incidence of 4-5%. 3 Involvement of the cervical lymph nodes indicates advanced disease.
The cytological features of embryonal carcinoma are less specific and indistinguishable from poorly differentiated malignancies such as high grade carcinoma 1 .This explains why the diagnosis of metastasis from poorly differentiated carcinoma was initially considered in the present case.An index of suspicion to consider mixed germ cell tumors, especially those with a component of embryonal carcinoma, is always required in the diagnosis of these tumors 4 .
The young age of the patient is the other important pointer towards Germ cell tumors 6 .Metastasis from Germ cell tumors occurs in young patients and carcinomas tend to affect elderly patients.
There has been a remarkable advance in the treatment of germ cell tumors and most patients with germ cell tumors, even those with disseminated disease are potentially curable and respond to modern chemotherapy 4 .
The treatment of metastatic carcinomas is generally palliative and the prognosis is dismal.So, a missed diagnosis of metastatic germ cell tumor has serious implications in that, a tumor with a better prognosis is mistaken for the one with a worse prognosis.Hence, it is crucial for the pathologist to be able to consider metastasis from primary germ cell tumor and alert the clinician to such a probability 4 .This emphasizes the fact that, while dealing with neck node metastasis in a male, the possibility of metastatic germ cell tumor should also be considered along with the other commonly known differential diagnoses 5 .

Conclusion
The present study bears a message for the cytologist, to pay due attention to the valuable clues which lie within proper history elicitation and thorough clinical examination, for, the cytological smears alone, don't say it all.

InternationalFig 1 -
Fig 1 -FNAC Smear from the Left Supraclavicular Lymph Node -H&E (40x) -Pleomorphic Tumor Cells in Clusters, Singles and Acinar Pattern with High Nucleo-Cytoplasmic Ratio Irregular Nuclear Borders, Prominent Nucleoli and Moderate Amount of Eosinophilic Cytoplasm