Sister Mary Joseph's nodule is a cutaneous metastasis of intra-abdominal cancers, most commonly from the stomach and ovaries. It presents as a painless nodule on the umbilicus. This case report describes a 74-year-old woman who presented with a fungating umbilical mass after being treated for suspected cellulitis. Imaging and biopsy revealed metastatic adenocarcinoma to the umbilicus from a primary gastric cancer. She was also found to have cystic ovarian carcinoma. Physicians must consider gastrointestinal tumors when non-healing abdominal lesions are not responding to antibiotics.

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