Sister mary joseph nodule the fungating umbilical mass

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Bryan Lee, DO, IM Co-Chief resident, Larkin Community Hospital, South Miami, FL

Bryan Lee, DO, IM Co-Chief resident, Larkin Community Hospital, South Miami, FL

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  • 1. INTRODUCTION Sister Mary Joseph’s nodule (SMJN) is a metastatic cancer of the umbilicus and is commonly associated with cancers of the gastrointestinal tract and ovaries. This condition was named after Sister Mary Joseph by Dr. Mayo, who during surgical prep observed the association between paraumbilical nodules and metastatic intra- abdominal cancer and later confirmed them at surgery. (Albano et al., 2005). SMJN represents only 10% of all cutaneous metastasis (Al-Mashat et al., 2010). The initial presentation of gastric carcinoma may present as thickening and inflammation of the overlying skin around umbilicus resembling cellulitis, and in mildly overweight individuals these findings may be easily overlooked. (Coll et al., 1999). The mean survival rate with this clinical presentation of metastatic gastric adeno-carcinoma is three and half months. (Hopton et al., 2005). Sister Mary Joseph Nodule: The Fungating Umbilical Mass Bryan Lee, DO, IM Co-Chief resident, Larkin Community Hospital, South Miami, FL CONCLUSION Physicians must include gastrointestinal tumors in differential diagnosis when a patient presents with a non-healing lesions of the abdomen not treatable with antibiotic therapy, in these cases SMJN node may be the only indication of an underlying malignancy. REFERENCES Al-Mashat, F., Sibiany, A., M. (2010). Sister Mary Joseph’s nodule of the umbilicus: is it always of gastric origin? A review of eight cases at differentsites of origin. Indian Journal of Cancer, Vol 47: 65-69. Albano, E., A., Kanter, J. (2005). Sister Mary Joseph’s Nodule, The New England Journal of Medicine, Vol 352: 1913. Coll, D., M., Meyer, J., M., Mader, M., Smith, R., C. (1999). Imagingappearances of Sister Mary Joseph nodule. The British Journal of Radiology, Vol 72: 1230-1233. Dubreuil, A., Dompartin, A., Barjot, P., Louvet, S., Leroy, D. (1998). Umbilicalmetastasis or Sister Mary Joseph’s nodule, InternationalJournal of Dermatology, Vol 37: 7-13. Euanorasetr, C. (2010). Sister Mary Joseph’s Nodule as a Presenting Sign of Recurrent Gastric Carcinoma: A Case Report and LiteratureReview. The Thai Journal of Surgery, Vol 31: 58-62. Flynn, V., T., Spurrett B., R. (1969). Sister Mary Joseph’s nodule. Medical Journal of Australia, Vol 1: 728-730. Gabriele,R., Conte, M., Egidi, F., Borghese, M. (2005). Umbilical metastases: current viewpoint. World Journal of Surgical Oncology, Vol 3: 13. Hopton, B., P., Wyatt, J., I., Ambrose, N., S. (2005). A case of Sister Mary Joseph nodule associated with primary gastric lymphoma. Annals of The Royal College of Surgeons of England, Vol 87 (5): W6-W7. Tan, M., L., M., Padhy, A., K. (2011). Umbilicalmetastaticdeposit from recurrentcholangiocarcinoma:F18-FDG PET–CT findings. Singapore Medical Journal. Vol 52 (11): e236-e238. CASE REPORT A 74-year-old overweight female presented with a 2.0 x 3.0 cm bi-lobed, fungating, irregularly shaped umbilical mass, after being treated with oral and topical antibiotics for a cellulitis. There was a small amount of surrounding erythema but no exudates. The patient had associated anorexia, a dull generalized abdominal and pelvic pain with early satiety, but no perceived weight loss. The patient’s past medical history is significant for hypertension, hyperlipidemia, and previously treated breast abscess and the family history is significant for a father who died of brain cancer. Patient denied use of tobacco, ethanol or illicit drugs. A CT scan abdomen/pelvis W/WO contrast revealed a soft tissue mass involving the gastric fundus and cardia region along with a cystic right adnexal mass. A pelvic ultrasound revealed an enlarged cystic right adnexal mass with internal septations suspicious for cystic ovarian carcinoma. The surgical biopsy of the umbilical mass revealed a tanned, wrinkled and partially desquamated ulcerated mass measuring 5.0 x 4.5 x 3.5 cm. Pathology of this specimen confirmed a well-differentiated metastatic adenocarcinoma consistent with a gastric primary with positive immunoperoxidas, CK7 and focally CDX2 stains, and negative CK20 and ER stains. Serum tumor markers include: CA-125: 53.9, CEA: 6.75, CA-19-9: 495. Endoscopy with a biopsy at the gastroesophageal junction showed a poorly differentiated, infiltrating adenocarcinoma, which was negative for the HER-2 marker. A PET/CT scan for staging confirmed a extensively fluorodeoxyglucose (FDG) avid primary tumor within the gastric fundus and cardia region with numerous metastasis involving the left neck base, left lung, liver, retro-peritoneum, and bilateral inguinal regions