Sister Mary Joseph’s Nodule: Rare Umbilical Metastasis

Yehouenou Tessi RT, Amalik S, Behyamet O, Jerguigue H, Latib R and Omor Y

Published on: 2021-03-27

Abstract

Peritoneal carcinomatosis remains a poor prognostic factor in the follow-up of oncology patients. It occurs in the majority of cases in patients with ovarian, gastric and colorectal tumours. It is characterised by the presence of ascites, mesenteric infiltration and peritoneal implants but also rarely an umbilical nodule better known as Sister Mary Joseph’s nodule. They are rare and of fortuitous discovery, of umbilical location and remain of poor prognosis. We report the case of a 58 year old female patient followed for ovarian adenocarcinoma in whom in the follow-up work-up we note the appearance of peritoneal carcinosis with a Sister Mary Joseph’s nodule.   

Keywords

Sister Mary Joseph’s nodule; Metastasis; Ombilical; Carcinomatosis; Peritoneal

Clinical Image

We report the case of a 58 year old patient, followed for ovarian adenocarcinoma tumour, who during her follow-up CT scan was found to have carcinosis nodules underneath carcinosis implants in the form of rounded nodules, in the right and left parieto-colonic gutter, with regular contours, well limited, enhanced after injection of contrast fluid (Figure 1) but also the discovery of an umbilical nodule with regular contours enhanced after injection of contrast fluid (Figure 2). 

Figure 1: Axial section of enhanced abdominal-pelvic CT scan showing enhanced nodules after injection of contrast medium (red arrows) in the right (A) and left (B) parieto-colonic gutter in favour of peritoneal carcinomatosis implants (Patient followed for ovarian adenocarcinoma).

Figure 2 : Axial (A) and sagittal (B) sections of an enhanced abdominal and pelvic CT scan showing an umbilical nodule enhanced (yellow arrow) in a context of peritoneal carcinomatosis in favour of a Sister Mary Joseph nodule in a patient followed for ovarian adenocarcinoma.

In view of the appearance of implants of peritoneal carcinosis in this patient followed for ovarian adenocarcinoma and the umbilical nodule, the Sister Marie Joseph’s nodule was evoked. Peritoneal carcinomatosis is the intraperitoneal dissemination of any tumour whose starting point is not the peritoneum itself. The peritoneal cavity is a frequent site of metastatic spread. They are generally seen in order of frequency in ovarian, gastric and colorectal tumours. The direct signs are ascites with certain characteristics (dense, not very mobile, partitioned, mass effect on the neighbouring digestive structures, hepatic and/or splenic scalloping), tumour peritoneal implants in the form of nodules or masses at the right and left subphrenic level, parieto-colonic gutters, the cul de sac of Douglas and the greater omentum, mesenteric infiltration, invasion of the greater omentum. The appearance or discovery of the nodule of Sister Marie Joseph remains rare as a site of umbilical metastasis. It originated from a remark made by Sister Marie Joseph (1856-1939), an operating assistant, of the presence of umbilical swelling in patients with abdominal or pelvic cancer. Sir Hamilton Bailey paid tribute to Sister Mary Joseph in 1949 when he referred to it as "Sister Mary Joseph's nodule" [1,2] It is a rare umbilical metastasis of digestive or genital tumours (stomach, colorectal, ovaries...), with a poor prognosis [3]. It can appear as a palpable umbilical mass, sometimes ulcerated, which can lead to diagnostic erraticity, hence the need for clinicians to be aware of it and histology can confirm the diagnosis depending on the patient's clinical context and the circumstances of discovery. Some differential diagnoses may be evoked, notably umbilical endometriosis, granulomas, abscesses, eczema, mycoses and certain malignant tumours [1,4]. The mode of dissemination is, as in peritoneal carcinosis, contiguous, hematogenous (rarely) and lymphatic. It can also be a finding or revealing circumstance of a primary digestive or genital tumour. Diagnosis must be made early in order to ensure rapid management and medium- and short- term survival for patients. The average survival after discovery of this metastasis is approximately 11 months [1].

References

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