Sister Mary Joseph's Nodule: Where Umbilicus Holds the Truth!

Abstract

An umbilical metastasis from an internal visceral malignancy is defined as Sister Mary Joseph's nodule (SMJN), and, although a rare finding, it is a very poor prognostic indicator. We describe an interesting case of metastatic colon cancer with SMJN, emphasizing the significance of this classic finding. A 64-year-old female with a history of stage IV colon cancer with palliative right hemicolectomy and left hepatectomy presented to the hospital with nausea and abdominal discomfort. A computed tomography (CT) scan of the abdomen was performed, which showed small bowel obstruction secondary to metastatic tumor mass compressing the duodenum. She refused to undergo any chemotherapy or endoscopic intervention and was eventually discharged on hospice care. During the hospital stay an umbilical ulcerative lesion was also noted, which was violaceous, measuring 4.5 x 4 cm in size, firm in consistency with irregular borders, and tender to touch. Therefore, further history was obtained from the patient about it. Several months ago, she had developed localized swelling around the umbilicus, which gradually enlarged and ulcerated later. She eventually underwent the biopsy of that umbilical lesion, which confirmed it as SMJN with metastasis from the colonic primary. However, the patient refrained from the surgical intervention of the umbilical lesion. SMJN presents as a palpable periumbilical metastatic mass with diameter usually not exceeding 5 cm in size. It can be variable in color from violaceous to reddish brown. Once discovered, such lesions should be worked up with biopsy and imaging studies such as CT scan of the abdomen, as the nodule may be indicative of underlying malignancy or cancer recurrence. Its presence indicates a poor prognosis, with average survival time after diagnosis of SMJN of 10 months.

Keywords: end of life and hospice care; invasive colon cancer; sister mary joseph nodule; umbilical skin metastasis.

Figure 1. Sister Mary Joseph’s nodule, which is violaceous, measuring 4.5 x 4 cm in size with irregular borders in a patient with metastatic colon cancer.

Figure 2. Punch biopsy of the abdominal wall showing glandular structures with comedo necrosis and clusters of carcinoma cells with signet ring cell features and surrounding desmoplastic changes consistent with infiltrating adenocarcinoma (H&E: 40X and 400X; inset: 4X and 40X).

Figure 3. : Immunoprofile showing positivity for CK 20 AND CDX2. These findings are consistent with metastasis of the colonic primary origin.

Figure 4. CT scan of the abdomen showing multiple metastatic abdominal wall implants along the midline anterior abdominal wall, measuring 4.1 cm in the periumbilical region and consistent with known finding of Sister Mary Joseph’s nodule in our patient.

Figure 5. Pie chart showing the primary site of carcinoma in women and men with Sister Mary Joseph’s nodule.