A 57-year-old man with known stage IV metastatic colorectal cancer was referred for evaluation of a slowly enlarging nodule of the umbilicus that had been present for 1 year. Initial findings Upon examination, we noted a vegetative 1.5 cm2 solid, flesh-colored nodule located just superior to the umbilicus. The nodule had a glistening surface, but no ulceration or drainage was present. A large, midline scar extended from the patient’s sternum to the pubic area. Palpation of the abdomen revealed multiple, intra-abdominal masses, along with indurated abdominal contents at the level of the omentum. The nodule was excised for diagnosis. Four months later, the patient returned with severe nausea, vomiting and diarrhea. After viewing dilated loops of small bowel on an abdominal X-ray, the diagnosis of small bowel obstruction was determined. A percutaneous gastronomy tube was placed, and the patient was restricted to a fluid diet. At this point, he elected to implement a do-not-resuscitate order, and he was discharged to hospice care. Pathology Sections from the excisional biopsy specimen show an ulcerated polypoid lesion characterized by large glands within a fibrous stroma. Some of the glands contain neutrophils and necrotic cells, or “dirty necrosis” — a feature characteristic of gastrointestinal adenocarcinomas. These features were consistent with the patient’s primary diagnosis of colorectal cancer. Differential Diagnosis and Prognosis Included in the differential diagnosis of a Sister Mary Joseph’s nodule is adenocarcinoma arising from the vitello-intestinal duct of the urachus, squamous cell carcinoma, granuloma caused by chronic irritation, endometriosis or an enteroteratoma from the everted mucosa of a patent vitello-intestinal duct. In a review of 667 umbilical tumors, Barrow found that the bulk of umbilical growths were due to endometriosis (32.2%) or primary benign tumors (29.7%), while 29.7% were metastatic tumors and 8.4% were primary malignant. The most common primary sites of metastatic tumors involving the umbilicus are the stomach (25%), the ovary (12.4%), the colon and rectum (10%) and the pancreas (7.4%). The site of origin differs according to gender: The most common primary site in men is the stomach, followed by large bowel, pancreas and small bowel. The most common primary site in women is the ovary, followed by the stomach, endometrium, breast, large bowel and pancreas. In about 20% of Sister Mary Joseph’s nodules, a primary site of origin can’t be identified. Historical Significance It was while Sister Mary Joseph was the first surgical assistant of Dr. William Mayo that she observed a subgroup of patients with gastric carcinoma who also had firm masses at their umbilici. These patients generally had poorer outcomes and died of their cancers earlier than patients who didn’t have umbilical masses. Sister Mary Joseph drew Dr. Mayo’s attention to this prognostic indicator, and he then published the finding in 1928, dubbing the nodule the “pants button umbilicus.” It wasn’t until 1949 that Sir Hamilton Bailey suggested that this umbilical sign of intra-abdominal malignancy should be called a Sister Mary Joseph’s nodule in honor of its discoverer. An Important Sign Because up to 30% of the time a Sister Mary Joseph’s nodule is the presenting sign of malignancy, recognizing the nodule may be a physician’s only clue for assigning the correct diagnosis. Although cases of long-term survival following excision of the nodule have been reported, the median survival from the time the nodule first appears is only 11 months.
Sister Mary Joseph Nodule
A 57-year-old man with known stage IV metastatic colorectal cancer was referred for evaluation of a slowly enlarging nodule of the umbilicus that had been present for 1 year. Initial findings Upon examination, we noted a vegetative 1.5 cm2 solid, flesh-colored nodule located just superior to the umbilicus. The nodule had a glistening surface, but no ulceration or drainage was present. A large, midline scar extended from the patient’s sternum to the pubic area. Palpation of the abdomen revealed multiple, intra-abdominal masses, along with indurated abdominal contents at the level of the omentum. The nodule was excised for diagnosis. Four months later, the patient returned with severe nausea, vomiting and diarrhea. After viewing dilated loops of small bowel on an abdominal X-ray, the diagnosis of small bowel obstruction was determined. A percutaneous gastronomy tube was placed, and the patient was restricted to a fluid diet. At this point, he elected to implement a do-not-resuscitate order, and he was discharged to hospice care. Pathology Sections from the excisional biopsy specimen show an ulcerated polypoid lesion characterized by large glands within a fibrous stroma. Some of the glands contain neutrophils and necrotic cells, or “dirty necrosis” — a feature characteristic of gastrointestinal adenocarcinomas. These features were consistent with the patient’s primary diagnosis of colorectal cancer. Differential Diagnosis and Prognosis Included in the differential diagnosis of a Sister Mary Joseph’s nodule is adenocarcinoma arising from the vitello-intestinal duct of the urachus, squamous cell carcinoma, granuloma caused by chronic irritation, endometriosis or an enteroteratoma from the everted mucosa of a patent vitello-intestinal duct. In a review of 667 umbilical tumors, Barrow found that the bulk of umbilical growths were due to endometriosis (32.2%) or primary benign tumors (29.7%), while 29.7% were metastatic tumors and 8.4% were primary malignant. The most common primary sites of metastatic tumors involving the umbilicus are the stomach (25%), the ovary (12.4%), the colon and rectum (10%) and the pancreas (7.4%). The site of origin differs according to gender: The most common primary site in men is the stomach, followed by large bowel, pancreas and small bowel. The most common primary site in women is the ovary, followed by the stomach, endometrium, breast, large bowel and pancreas. In about 20% of Sister Mary Joseph’s nodules, a primary site of origin can’t be identified. Historical Significance It was while Sister Mary Joseph was the first surgical assistant of Dr. William Mayo that she observed a subgroup of patients with gastric carcinoma who also had firm masses at their umbilici. These patients generally had poorer outcomes and died of their cancers earlier than patients who didn’t have umbilical masses. Sister Mary Joseph drew Dr. Mayo’s attention to this prognostic indicator, and he then published the finding in 1928, dubbing the nodule the “pants button umbilicus.” It wasn’t until 1949 that Sir Hamilton Bailey suggested that this umbilical sign of intra-abdominal malignancy should be called a Sister Mary Joseph’s nodule in honor of its discoverer. An Important Sign Because up to 30% of the time a Sister Mary Joseph’s nodule is the presenting sign of malignancy, recognizing the nodule may be a physician’s only clue for assigning the correct diagnosis. Although cases of long-term survival following excision of the nodule have been reported, the median survival from the time the nodule first appears is only 11 months.
A 57-year-old man with known stage IV metastatic colorectal cancer was referred for evaluation of a slowly enlarging nodule of the umbilicus that had been present for 1 year. Initial findings Upon examination, we noted a vegetative 1.5 cm2 solid, flesh-colored nodule located just superior to the umbilicus. The nodule had a glistening surface, but no ulceration or drainage was present. A large, midline scar extended from the patient’s sternum to the pubic area. Palpation of the abdomen revealed multiple, intra-abdominal masses, along with indurated abdominal contents at the level of the omentum. The nodule was excised for diagnosis. Four months later, the patient returned with severe nausea, vomiting and diarrhea. After viewing dilated loops of small bowel on an abdominal X-ray, the diagnosis of small bowel obstruction was determined. A percutaneous gastronomy tube was placed, and the patient was restricted to a fluid diet. At this point, he elected to implement a do-not-resuscitate order, and he was discharged to hospice care. Pathology Sections from the excisional biopsy specimen show an ulcerated polypoid lesion characterized by large glands within a fibrous stroma. Some of the glands contain neutrophils and necrotic cells, or “dirty necrosis” — a feature characteristic of gastrointestinal adenocarcinomas. These features were consistent with the patient’s primary diagnosis of colorectal cancer. Differential Diagnosis and Prognosis Included in the differential diagnosis of a Sister Mary Joseph’s nodule is adenocarcinoma arising from the vitello-intestinal duct of the urachus, squamous cell carcinoma, granuloma caused by chronic irritation, endometriosis or an enteroteratoma from the everted mucosa of a patent vitello-intestinal duct. In a review of 667 umbilical tumors, Barrow found that the bulk of umbilical growths were due to endometriosis (32.2%) or primary benign tumors (29.7%), while 29.7% were metastatic tumors and 8.4% were primary malignant. The most common primary sites of metastatic tumors involving the umbilicus are the stomach (25%), the ovary (12.4%), the colon and rectum (10%) and the pancreas (7.4%). The site of origin differs according to gender: The most common primary site in men is the stomach, followed by large bowel, pancreas and small bowel. The most common primary site in women is the ovary, followed by the stomach, endometrium, breast, large bowel and pancreas. In about 20% of Sister Mary Joseph’s nodules, a primary site of origin can’t be identified. Historical Significance It was while Sister Mary Joseph was the first surgical assistant of Dr. William Mayo that she observed a subgroup of patients with gastric carcinoma who also had firm masses at their umbilici. These patients generally had poorer outcomes and died of their cancers earlier than patients who didn’t have umbilical masses. Sister Mary Joseph drew Dr. Mayo’s attention to this prognostic indicator, and he then published the finding in 1928, dubbing the nodule the “pants button umbilicus.” It wasn’t until 1949 that Sir Hamilton Bailey suggested that this umbilical sign of intra-abdominal malignancy should be called a Sister Mary Joseph’s nodule in honor of its discoverer. An Important Sign Because up to 30% of the time a Sister Mary Joseph’s nodule is the presenting sign of malignancy, recognizing the nodule may be a physician’s only clue for assigning the correct diagnosis. Although cases of long-term survival following excision of the nodule have been reported, the median survival from the time the nodule first appears is only 11 months.
