BAB I CASE PRESENTATION I. identity Name: Mrs.

S Age: 27 years Gender: Female Occupation: Housewife Address: Bukung

II. Anamnesis (Alloanamnesis) Main complaints: a lump in the neck Additional complaints: fever History Disease Now: Patient was taken to hospital Arjawinangung with a complaint of a lump in the neck since 1 month ago. The patient also had a fever since 5 days ago. Initially a small lump gradually enlarged. Past history of disease: The patient had never had a disease like this before. patient also denies having diabetes mellitus and hypertension. Family history of disease: Patients admitted in my family no one has ever had the same disease.

III. physical examination Generalist Status General Condition: Moderate Pain Awareness: compost mentis Vital Signs: BP: 120/80 mmHg N: 92 x / min S: 37.8 C

R: 24 x / min Head: Normocephal Eyes: Conjunctiva anemis - / Sclera jaundice - / Pupillary reflex - / Neck: The thyroid was not palpable enlarged KGB: palpable enlarged thoracic: I cast: iktus cordis is not visible P: iktus cordis palpable on ICS V line midclavikula P: cardiac borders easily assessed A: BJ regular I-II, murmurs (-), gallop (-) Pulmo I: symmetrical piston movement in a static state and dynamic P: vocal fremitus at the right and left hemithorax P: resonant to both lung field A: Vesicular, rhonki - / -, wheezing - / Abdomen I: convex, symmetric, surgical wound (+) A: Bowel (+) normal P: Timpani whole abdominal field P: soft, tenderness (+), liver palpable 8 cm, Left Right Superior Extremity: edema (-), warm akral Right inferior Left: edema (-), warm akral Localist status: Lump left neck measuring 5 cm, rubbery, mobile. Examination Support Laboratorium LAB WBC LYM RESULT 8.5 2.8 FLAGS UNIT 10^3/ 10^3/ NORMAL 4.0-12.0 1.0-5.0

MON GRANUL LYM % MON% GRANUL% RBC HGB HCT MCV MCH MCHC RDW PLT MPV PCT POW KGDS : 78 mg/dL

1.5 4.0 36,8 17,0 46.2 4.58 12.5 39.5 86.2 27.3 31.6 12.6 290 8.7 0.252 14.1

10^3/ 10^3/ %

0.1-1.0 2.0-8.0 25.0-50.0 2.0-10.0 50.0-80.0 4.0-6.20 11.0-17.0 35.0-55.0 80.0-100.0

H L

% % 10^6/ g/dl %

Pg g/dl % 10^3/

26.0-34.0 31.0-35.0 10.0-16.0 150.0-400.0 7.0-11.0

% %

0.200-0.50 10.0-18.0

LAB Hematologi (darah rutin) Waktu perdarahan Waktu pembekuan

RESULT

FLAGS

Method

NORMAL

2 4

1-3 menit 2-6 menit

IV. differential diagnosis 1. Hodgin's Lymphoma 2. Virchow's nodule

V. working diagnosis Virchow's nodule

VI. management Medical: RL infusion of 20 drops per minute Cefotaxime 2x1 amp Ketorolac 2x1 amp debridement therapy: Wound toilet

VII. prognosis Ad Vitam: ad bonam Ad Functionam: ad bonam

BAB II A. DEFINITION Nodule was Virchow's lymph node contained in the left supraclavicular fossa (the area located above the left clavicula).If found an enlarged nodule with hard consistency (Troiser's sign) is indicating the presence of a malignancy in the abdominal area, especially gastric cancer, which metastasize to limfogen. B. HISTORY Nodules Virchow's immortalized his name is Rudolf Virchow as the founder, a German pathologist, who first described the relationship with the enlargement of the gland malignancy in the stomach in 1848. Expert pathological France, Charles Emile Troiser, in 1889 suggested that the malignancy in the abdominal area can also metastasize to lymph. C. Anatomy and histology Lymph nodes are round-shaped organ with a small size as an immune system are widely distributed throughout the body and linked by lymphatic vessels. Lymph node cells stored on B lymphocytes, T, and other immune cells. Lymph-node serves as a filter. These nodes also have clinical significance, can become inflamed or enlarged in various conditions (from infection to malignancy). Based on clinical signs, can be determined the degree of malignancy can be determined so that the therapeutic action and disease prognosis. Lymph node is surrounded by a fibrous capsule and in the lymph node the fibrous

capsule extends to form trabeculae.Substance of the lymph nodes are divided into outer cortex and inner medulla is surrounded by a constituent except the hilum area, where the medulla associated with the surface. Thin reticular fibers, elastin and reticular fibers form a strong fabric known as interlacing reticular in the node, with in which there are white blood cells, particularly lymphocytes, in the form of solid follicles in the cortex. Elsewhere there are sometimes only white blood cells only. Not only strengthen the fabric of the reticular structure but also provides a surface for adhesion of dendritic cells, macrophages and lymphocytes.Interwoven enables the exchange of material transported through the blood-venule endothelial venules and provide growth factors and regulators are required for the activation and maturation of immune cells. The amount and composition of the follicles and change in particular when dealing with the antigen and form a germinal center. Lymph sinus is a channel with a crease in it there is lymph node by the endothelial cells with fibroblast reticular cells and allows the lymphatic flow, embut through it. Subcapsular sinus sinuses are located inside the capsule and endoteliumnya continues into afferent lymphatic vessels.This sinus is also continuing with similar sinuses flanking the trabeculae to the cortex in it (cortical sinuses). Cortical sinuses flanking the trabeculae drain into the sinuses of the medulla, where the flow of lymphatic flow to efferent lymphatic vessels. Multiple afferent lymphatic vessels branched and extends inside the capsule bring lymph to the lymph nodes. Lymph node subcapsular sinus is entered. The innermost layer of the afferent lymphatic vessels continued to frown cells of lymphatic sinuses. Lymph is slowly filtered through the substance of the lymph nodes and eventually reach the medulla. On his way to see the sap beninng lymphocytes and their activation may be initiated 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 carry lymph out of the lymph nodes. CortexIn the cortex, the subcapsular sinus flows into trabecular sinuses and lymph flow to the sinuses of the medulla.The outer cortex is composed mainly by B cells arranged as follicles, which can form the germinal centers as against the antigen, the deeper cortex mainly consist of T cells This zone is known as subcortical zone where

T cells primarily interact with dendritic cells and in which the reticular densely interwoven. MedullaThere are two structures in the medulla name:o Corda medulla is corda and lymphatic tissues including plasma cells, macrophages and B cellso medulla sinuses (or sinusoids) are vessel space that separates the medulla corda. Lymph flow to the medulla of the sinus cortical sinus and into the efferent lymphatic vessels. Sinus medulla contains histiiosit (Immobile macrophages) and reticular cells. Lymphatic flowLymph flow to the lymph nodes via afferent lymphatic vessels and lymph flow into the space under the capsule called the subcapsular sinus.Subcapsular sinus flow into trabecular sinuses and finally into a sinus medulla.Sinus cavity was crossed pseudopoda macrophages, which contribute to memperangkap foreign particles and the filter lymphatic. Sinuses of the medulla met in spleen and left hilum and lymph nodes through efferent lymphatic vessels and then flow into the subclavian vein, postkapiler venules, cross the wall through the process of diapedesis. B cells migrate to the nodular cortex and medulla. T cells migrate into the inner cortex (parakorteks). When lymphocytes recognize the antigen, B cells are activated and migrate to germinal centers. When the antibody produced by plasma cells are formed, they migrate to the spinal cord.Stimulation of lymphocytes by antigen migration process is accelerated by 10 times faster than normal, resulting in a characteristic swelling of the lymph nodes. Spleen and tonsils adal lymphoid organ that has the same function as lymph nodes, spleen of blood through the filter more than through the lymph nodes. Distribution Lymph nodes in head and neck: cervical lymph node anterior cervical: glands here, either superficial or deep, back in the muscle strenocleidomastoideus. They drain the contents into the throat and posterior pharynx, tonsils and thyroid gland. Posterior cervical: These glands extending to the posterior sternokleidomastoideus but in front of the trapezius, from the highest part of the mastoid temporal bone to the clavicle. The gland is enlarged when there is infection of the upper airway. Tonsil or submandibular: These glands are located below the mandibular angle, along the bottom of the chin. They flow into the tonsils and pharyngeal region,

including the basic structure of the mouth and the maxillary anterior and molar 1 and 2. They also flow to the mandibular teeth except the incisors. Retrofaring: limf drainage from mole palate and the third molar. Sub-mental: These glands are located just below the chin. They flow into the middle incisors, floor of the mouth and base of the tongue. supraclavicular lymph nodes: these glands run along the clavicle, where the lateral joins the sternum. They flow into the thoracic cavity and abdomen.Virchow's nodule in the supraclavicular lymphatic glands are receiving from all over the body limfatiknya flow through the ductus thorasikus and is a favorite place for metastatic malignancies

Thoracic lymphatic glands Lymphatic glands in the lungs: limf drained from the lung tissue through the lymph nodes subsegmental, segmental, lobar and inter lobar lymph nodes leading to hillus, which are located around the hilum. The flow of lymphatic flow to the

mediastinal lymph nodes. Mediastinal lymph nodes: they consist of a several lymph node groups limfatik, especially along the trachea, along the esophagus and between the lungs and diaphragm. In the mediastinal lymph node glands from lymphatic ducts which drain into the subclavian vein limf the left. Mediastinal lymph nodes along the esophagus programs so closely connected in the abdominal lymph nodes along the esophagus and stomach. This fact facilitates the spread of tumors via the lymphatic pathways in cases of malignancy in the stomach and part of the esophagus. Through the mediastinum, the primary lymphatic drainage through the abdominal organs through the duct thorasikus, where the main flow of the abdomen is limf into the gland.

D. CLINICAL REASONING Malignancy, malignancy of the internal organs can reach an advanced stage before giving symptoms. For example, gastric cancer can be asymptomatic but

already metastasize. Point metastatic at the left side of the

that

it

can be

seen where

the tumor is already

left supraclavicular neck where almost left sub

lymph allthe body's

nodes. Lymphatic nodules lymphatic drainage (from the round nodules to the nodules

supraklavkular left is the classic Virchow nodules because nodules are located on the thorasikus duct) into the clavian vein kesirkulasi through. Metastasis

thorasikus clog ducts and cause nodules Virchow example. Another therefore have an enlarged thorasikus.

regurgitation into

concept is that one of

supraclavicular nodes correspond to the end of the journey along the duct and

E. DIAGNOSIS Differential diagnosis of nodular enlargement of Virchow was lymphoma,

malignant intra - abdominal malignancies, breast cancer and infections (the arm). Similarly, the enlargement of the lymphatic nodes tend to refer to the right supraclavicular thoracic malignanciessuch as lung cancer and esophagealcancers such as Hodgkin's lymphoma.

F.MANEGEMENT Obtained when the size of lymph nodes>1 cm then it is said to be abnormal, and a biopsy should be performed to determine the type of disorder. Lymph node biopsy in two ways: by simply taking a portion ofa lymph node or lifting as well.

Operation Technics Made an incision in the skin below the surface of an enlarged lymph node and surrounding tissue is carefully dissected away from the node. Should pay attention to the surrounding nerve tissue, especially in the area around the neck. To facilitate removal of the node, the association made with yarn that is attached to the center of the node, that node can be removed.

REFERENCES 1. Virchow R. "Zur Diagnose der Krebse in Unterleibe". Med. Reform. 1848; 45: 248 2. Troisier CE. "L'adnopathie sus-claviculaire dans les cancers de l'abdomen". Arch. Gen. de Med. 1889; 1: 129138 and 297309 3. Libman H. Generalized lyphadenopathy. J Gen Intern Med 1987;2:4858 4. Morlan B. Lymphadenopathy. Arch Dis Child 1995; 73: 476-9 5. Pangalis GA, Vassilakopoulus TP, Boussiotis VA, Fessas P. Clinical approach to lymphadenopathy. Semin Oncol 1993; 20; 570-82 6. Mizutani M, Nawata S, Hirai I, Murakami G, Kimura W. Anat Sci Int 2005; 80 (4): 1938 7. http://www.dokterbedahherryyudha.com/2012/03/diagnosis-and-managementvirchows-node.html