Andreas Larentzakis

Anna Manataki

Bailey

D Lookingbill

Dimitrios Theodorou

Klio Fili

Michael Tibishrani

NJ Khati

R Gabriele

Stylianos Katsaragakis

V Schneider

Vasiliki Bizimi

VG Galvan

English

PubMed

Springer - Publisher Connector

BioMed CentralCases Journal
ssOpen AcceCase Report
Sister Mary Joseph's nodule: Three case reports
Andreas Larentzakis*1, Dimitrios Theodorou1, Klio Fili1, Anna Manataki2, 
Vasiliki Bizimi2, Michael Tibishrani2 and Stylianos Katsaragakis1
Address: 11st Department of Propaedeutic Surgery, Hippokrateion General Hospital, Athens Medical School, University of Athens, Q. Sofias 114 
av., 11527, Athens, Greece and 2Department of Radiology, 'Thriassio' General Hospital, G. Gennimata av., 19600, Attiki, Greece
Email: Andreas Larentzakis* - alarentz@med.uoa.gr; Dimitrios Theodorou - dtheodorou@hippocratio.gr; Klio Fili - dimitheod@netscape.com; 
Anna Manataki - amanat@easy.com; Vasiliki Bizimi - vbizim69@netscape.com; Michael Tibishrani - tibishrani@yahoo.com; 
Stylianos Katsaragakis - skatsar@med.uoa.gr
* Corresponding author    
Abstract
Background: An umbilical metastatic lesion is called 'Sister Mary Joseph's nodule'. It is an
uncommon clinical or radiographic finding, and it is rare as the first sign of a malignant disease.
Case presentation: We report three cases of Sister Mary Joseph's nodule. In the three cases
presented, the primary tumor was an adenocarcinona of the sigmoid colon, a carcinoma of the
bladder, and an adenocarcinoma of the gallbladder, respectively.
Conclusion: The differential diagnosis of an umbilical lesion should always include metastatic
disease apart from benign lesions and primary neoplasms.
Background
An umbilical lesion can be either benign or malignant. A
malignant umbilical mass can represent a primary or met-
astatic lesion. The term 'Sister Mary Joseph's nodule' was
first used by Sir Hamilton Bailey, in 1949 [1], in order to
describe the entity of metastatic umbilical lesions. We
present three cases of Sister Mary Joseph's nodule.
Cases presentation
Case 1
A 62-year old man presented with a growing periumbilical
mass and a mild lower abdominal pain during the last
two months. He had symptoms of fatigue, and loss of
weight and constipation alternating with diarrhea during
the last six months. Patient was receiving medication for
hypertension. On clinical examination there was a slight
tenderness over the lower abdomen and an umbilical
lesion fixed to the underlying tissues. Further evaluation,
revealed anemia (Hct: 30%). Colonoscopy detected a
tumor of the sigmoid colon. Computed tomography (Fig-
ure 1) showed a mass measured 3 cm, with characteristics
of non-homogeneous soft structures, located to the ante-
rior abdominal wall, at the region of the umbilicus,
involving the adjacent portion of rectus abdominis mus-
cle and adipose tissue. Both biopsies of umbilical and sig-
moid tumors revealed the presence of adenocarcinoma.
Considering the advanced stage of the disease, patient
received chemotherapy as primary treatment.
Case 2
A 64-year old female presented with haematuria and dys-
uria during the last 4 months. She had no other medical
or surgical history. The assessment with ultrasound
detected an established left hydronephrosis and a mass at
the left lateral wall of the bladder protruding into its cav-
ity. Cysteoscopic biopsy of the mass showed a transitional
Published: 24 September 2008
Cases Journal 2008, 1:182 doi:10.1186/1757-1626-1-182
Received: 31 May 2008
Accepted: 24 September 2008
This article is available from: http://www.casesjournal.com/content/1/1/182
© 2008 Larentzakis et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
Cases Journal 2008, 1:182 http://www.casesjournal.com/content/1/1/182cell carcinoma. Further assessment with computed tom-
ography (CT-scan) confirmed the presence of the tumor at
the left lateral wall of the bladder, and revealed pelvic
lymph nodes involvement and an umbilical mass meas-
ured 2 cm (Figure 2). Percutaneous biopsy of the umbili-
cal mass also showed transitional cell carcinoma. Patient
underwent cystectomy and chemotherapy.
Case 3
A 54-year old male presented with an umbilical painless
mass. He was receiving medication for diabetes mellitus.
Patient's physical examination revealed no other abnor-
mality. Pathologic examination of percutaneous biopsy
specimen showed malignant epithelial tumor, with char-
acteristics of gall bladder or pancreatic origin adenocarci-
noma. Neither upper gastrointestinal endoscopy nor
colonoscopy detected any abnormality. Computed tom-
ography of the abdomen showed a gall bladder with
increased wall thickness and intraluminal invasive mass,
peritoneal lesions, ascites, and an umbilical mass involv-
ing the adjacent adipose tissue (Figure 3). Patient received
surgical treatment. The pathologic examination of the sur-
gical specimen showed adenocarcinoma of the gallblad-
der. Patient's further treatment was chemotherapy.
Discussion
The occurrence of Sister Mary Joseph's nodule is uncom-
mon, and as first sign of malignancy is rare [2]. The intes-
tinal and genitourinary tracts represent the most
common, but not the only ones, primary malignant sites
[3]. However, the study of an umbilical mass as unique
clinical finding should be directed by the suspicion of
being a metastatic deposit [4], having also in mind the
potential of a primary malignant umbilical lesion or a
benign disease [5]. In addition, an umbilical mass in a
patient with known malignancy, especially of the abdo-
men, should be evaluated as potential spreading of the
primary disease, a fact that can influence the therapeutic
decision making [4,6]. Finally, the approach of surgery
should be under careful consideration in these cases,
because Sister Mary Joseph's nodule represents the spread-
ing of a neoplasm, which is accompanied by low survival
rates [4].
Conclusion
An umbilical mass can represent a benign lesion, such as
a cyst or an abscess, but also a primary or metastatic
malignant tumor. Although not common, the last two
CT-scan of the abdomen: This image shows an umbilical mass mea ured 3 cm, with indefin te arginsFigure 1
CT-scan of the abdomen: This image shows an umbil-
ical mass measured 3 cm, with indefinite margins.
CT-scan of the abdomen: This image shows an oval umbilical mas  measured 2 cmFigure 2
CT-scan of the abdomen: This image shows an oval 
umbilical mass measured 2 cm.
CT-scan of the abdomen: This image shows an umbilical mass mea ured 2.5 cm, involving the adjacent adipose tissueFigure 3
CT-scan of the abdomen: This image shows an umbil-
ical mass measured 2.5 cm, involving the adjacent 
adipose tissue.Page 2 of 3
(page number not for citation purposes)
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entities should be considered in the evaluation and man-
agement of the umbilical masses.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AL contributed to the conception, design and drafting of
the manuscript, as well as to the analysis and interpreta-
tion of data. DT contributed to the conception and design
of the manuscript and revised it critically. KF contributed
to acquisition of data and to the drafting of manuscript.
AM contributed to acquisition of data and to the drafting
of manuscript. VB contributed to acquisition of data and
to the drafting of the manuscript. MT contributed to
acquisition of data and to the drafting of the manuscript.
SK contributed to the conception and design of the man-
uscript and revised it critically. All authors read and
approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
References
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2. Lookingbill D, Spangler N, Sexton FM: Skin involvement as the
presenting sign of internal carcinoma. A retrospective study
of 7316 cancer patients.  J Am Acad Dermatol 1990, 22:19-26.
3. Galvan VG: Sister Mary Joseph's Nodule.  Ann Intern Med 1998,
128:410.
4. Gabriele R, Conte M, Egidi F, Borghese M: Umbilical metastases:
current viewpoint.  World J Sur Oncol 2005, 3:13.
5. Khati NJ, Enquist EG, Javitt MC: Imaging of the umbilicus and
periumbilical region.  Radiographics 1998, 18:413-31.
6. Schneider V, Smyczek B: Sister Mary Joseph's nodule. Diagnosis
of umbilical metastases by fine needle aspiration.  Acta Cytol
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(page number not for citation purposes)


Sister Mary Joseph's nodule: Three case reports

Demonstrations of Physical Signs in Clinical Surgery. 11th edition. John Wright and Sons.

Enquist EG, Javitt MC: Imaging of the umbilicus and periumbilical region. Radiographics

FM: Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients.

Sister Mary Joseph's Nodule. Ann Intern Med

Smyczek B: Sister Mary Joseph's nodule. Diagnosis of umbilical metastases by fine needle aspiration. Acta Cytol

Umbilical metastases: current viewpoint.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2561010

Sister Mary Joseph's nodule: Three case reports

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