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| IMAGES IN ACADEMIC MEDICINE |
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| Year : 2018 | Volume
: 4
| Issue : 2 | Page : 184-186 |
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Metastatic cancer of the umbilicus
Rodrigo Duarte-Chavez1, Nida Mahid1, Renee B Tehrani1, Hesham Tayel1, Santo Longo2, Sudip Nanda1
1 Department of Internal Medicine, St. Luke's University Health Network, Bethlehem, Pennsylvania 18015, USA
2 Department of Pathology, St. Luke's University Health Network, Bethlehem, Pennsylvania 18015, USA
| Date of Submission | 12-Feb-2018 |
| Date of Acceptance | 14-Apr-2018 |
| Date of Web Publication | 30-Aug-2018 |
Correspondence Address:
Dr. Sudip Nanda
Department of Internal Medicine, St. Luke's University Hospital Network, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
USA
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/IJAM.IJAM_5_18
An 89-year-old Hispanic male patient presented to the emergency department with melena, decreased appetite, and weight loss. The physical exam revealed a firm, nontender, irregular nodule under the umbilicus. Computed tomography of abdomen showed a pancreatic head tumor with extensive metastatic disease in the abdominal organs and extension to the umbilicus. Umbilical nodule can sometimes be the only clinical manifestation of advanced metastatic disease, a thorough examination is required in patients that present with umbilical tumors.
The following core competencies are addressed in this article: Patient care, Medical knowledge.
Keywords: Cancer, pancreas, Sister Mary Joseph nodule, umbilicus
How to cite this article:
Duarte-Chavez R, Mahid N, Tehrani RB, Tayel H, Longo S, Nanda S. Metastatic cancer of the umbilicus. Int J Acad Med 2018;4:184-6 |
| Introduction | |  |
The Sister Mary Joseph nodule or Sister Mary Joseph sign refers to a palpable nodule bulging into the umbilicus, usually as a result of metastasis of a malignancy in the pelvis or abdomen. It is present in 1%–3% of abdominal malignancies.[1],[2] Sister Mary Joseph Dempsey (born Julia Dempsey) was Dr. William James Mayo's surgical assistant.[3] She found an association between the presence of umbilical nodes and metastatic intra-abdominal cancer discovered during subsequent surgery and reported these observations to Dr. Mayo.[3],[4] Dr. Mayo initially described the condition as “pants-button umbilicus” in 1928. Later in 1949, Hamilton Bailey acknowledged the role of Sister Mary Joseph in describing this pathology.[5]
| Case Report | | |
An 89-year-old Hispanic male patient presented to the emergency department with complaints of melena, decreased appetite, and weight loss. Physical examination revealed a firm, nontender, irregular nodule under the umbilicus, 1 cm in size [Figure 1]. Initial hemoglobin was 7.8 g/dL. The remaining laboratory studies, including liver function tests, creatinine, electrolytes, coagulation tests, and lactate, were within normal limits. The patient was admitted for acute gastrointestinal (GI) bleeding. Further workup included an esophagogastroduodenoscopy which was normal and colonoscopy which had to be terminated early due to tortuous sigmoid colon. Computed tomography abdomen/pelvis showed a pancreatic head tumor [Figure 2] with extensive metastatic disease in the abdominal organs and extension to the umbilicus [Figure 3]. Hematology/oncology and palliative care services were consulted and, after discussion with the patient and his family, he was transitioned to comfort care given his advanced age and the advanced stage of the disease.
| Discussion | | |
Umbilical tumors are rare and often benign but cannot be differentiated clinically from malignant tumors. Benign tumors have many etiologies comprising granuloma, fibroma, myoma, hemangioma, and endometrioma. Approximately 38% of the umbilical masses are secondary to malignancy, usually metastatic adenocarcinoma.[6],[7] In men, these metastases are often associated with primary malignancies of the GI tract. The most commonly reported primary tumor is the stomach, followed by the colon and pancreas. In women, pelvic malignancies are more common, especially ovarian. Metastasis from the lung and breast, although rare, has also been reported. Metastasis to the umbilicus can occur through contiguous extension from the peritoneum, lymphatics, blood vessels, and embryonic remnants.[7],[8] The different routes of spreading explain the diverse origin of the metastasis.[9]
The Sister Mary Joseph nodule manifests as a firm and irregular nodule or indurated plaque that can become pigmented or highly vascular. Ulceration or fissures can be present and the lesions can become exudative with serous, mucous, or purulent discharge.[2],[8] The suggested diagnostic algorithm recommends starting with fine-needle aspiration biopsy of the tumor if a primary tumor is unknown or cytology if a primary malignancy has already been diagnosed. After biopsy confirms malignancy, imaging and tumor markers should be obtained for staging and prognosis.[6],[7]
Metastatic cancer of the umbilicus is usually associated with extensive metastatic disease in the abdomen and the survival ranges from 1 week to 10 years, with an average survival of 10–22 months after diagnosis in most case series. However, there are reported cases of survival 18 years after diagnosis.[2],[6] The treatment after diagnosis of metastatic cancer of the umbilicus is controversial. Surgery with radiotherapy and chemotherapy has been recommended, but given the poor life expectancy, most cases are treated with supportive therapy.[2],[3],[10]
The age at the time of diagnosis ranges from 18 to 88 years, with an average of 50 years, making our case one of the oldest reported cases of metastatic cancer of the umbilicus.[3]
| Conclusion | | |
An umbilical nodule can sometimes be the only clinical manifestation of advanced metastatic disease. For this reason, a detailed physical examination is necessary in patients that present with umbilical tumors. Early diagnosis coupled with early multidisciplinary treatment can prolong survival in these patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
IRB/Ethics approval is not required because it does not involve human or animal experimental designs.
| References | | |
| 1. | Larbcharoensub N, Pongtippan A, Pangpunyakulchai D, Phongkitkarun S, Lertsithichai P, Dejthevaporn TS, et al. Sister Mary Joseph nodule caused by metastatic desmoplastic small round cell tumor: A clinicopathological report. Mol Clin Oncol 2016;5:557-61.  |
| 2. | Powell FC, Cooper AJ, Massa MC, Goellner JR, Su WP. Sister Mary Joseph's nodule: A clinical and histologic study. J Am Acad Dermatol 1984;10:610-5. |
| 3. | Tun NM, Yoe L. Sister Mary Joseph nodule: A rare presentation of squamous cell carcinoma of the cervix. Ochsner J 2015;15:256-8. |
| 4. | Segovis CM, Dyer RB. The “Sister Mary Joseph nodule”. Abdom Radiol (NY) 2017;42:1610-1. |
| 5. | Steensma DP. Sister (Mary) Joseph's nodule. Ann Intern Med 2000;133:237. |
| 6. | Dubreuil A, Dompartin A, Barjot P, Louvet S, Leroy D. Umbilical metastasis or Sister Mary Joseph's nodule. Int J Dermatol 1998;37:7-13. |
| 7. | Bai XL, Zhang Q, Masood W, Masood N, Tang Y, Cao CH, et al. Sister Mary Joseph's nodule as a first sign of pancreatic cancer. World J Gastroenterol 2012;18:6686-9. |
| 8. | Premkumar M, Rangegowda D, Vyas T, Grover S, Joshi YK, Sharma C, et al. Cholangiocarcinoma presenting as a Sister Mary Joseph nodule. ACG Case Rep J 2016;3:209-11. |
| 9. | Ahmed S, Rashid S, Kue-A-Pai P, Cheungpasitporn W. Sister Mary Joseph's nodule: What lies beneath? N Am J Med Sci 2013;5:252. |
| 10. | Galvañ VG. Sister Mary Joseph's nodule. Ann Intern Med 1998;128:410. |
[Figure 1], [Figure 2], [Figure 3]
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