UMBILICAL METASTASES OR SISTER MARY JOSEPH'S NODULES: A CASE REPORT

Louise Lee MAppSc(MU) BAppSc(MRT) AMS, Sonographer, Medical Imaging Department, Gold Coast Hospital, Southport, Queensland

Umbilical metastases are commonly known as Sister Mary Joseph’s (SMJ) nodules. They account for 30% of all umbilical tumours 1 and are found more frequently in females (60%) than in males (40%)2. This case study describes recurrent SMJ nodules in a patient initially presenting with Dukes’ C carcinoma of the colon.

Case History
In October 1998, a 67 year old male presented with iron deficiency anaemia and a history of minor erosive prepyloric gastritis with helicobacter pylori on biopsy. On colonoscopy a haemorrhagic obstructing carcinoma was identified at the level of the hepatic flexure. There was also mild sigmoid diverticular disease and an additional 5 mm benign sigmoid polyp. Histologically the hepatic flexure lesion was an infiltrating moderately differentiated adenocarcinoma, consistent with a colonic primary. The patient then progressed to surgery, undergoing a right hemicolectomy. At surgery it was noted that the adenocarcinoma invaded through the full thickness of the colon wall extending into the pericolic fat. In addition four out of ten pericolic lymph nodes were effected. This classified the patient as having a Dukes’ C carcinoma of the colon. Further staging showed a clear chest x-ray, no liver metastases on abdominal ultrasound and his blood screen (full blood count, liver function tests and tumour markers) were within acceptable limits. Over the next six months the patient underwent six courses of combination chemotherapy (5FU and folinic acid).

In the twelve months following the chemotherapy the patient continued to be well with normal blood tests, abdominal ultrasounds and colonoscopies. In April 2001 the patient presented with two nodules, one that had arisen in the umbilicus and a subcutaneous one in the lateral margin of his scar. Neither nodule was particularly tender with the patient, on the whole, feeling well. His weight was stable and his bowel motions were normal. His blood screen was essentially normal with the exception of a slightly raised CA 19 of 43 kU/L (normal < 40). Computered tomography (CT) showed an 8 mm lymph node in his chest with no other lesions in his liver or abdomen. Soft tissue thickening of the abdominal wall in the region of the umbilicus was noted. A more detailed assessment of this region was carried out by ultrasound. This showed a lobulated nodule of mixed echogenicity posterior to the umbilicus with a similar appearing area lateral to the patient’s scar. Fine needle aspiration of the subcutaneous nodule and biopsy of the umbilical nodule showed moderately differentiated adenocarcinoma. This was believed to have arisen from his previous bowel cancer. Excision of the two nodules was carried out. The umbilical lesion extended into the calciform ligament. Further chemotherapy was suggested, however the patient declined. For the following twelve months the patient felt well and displayed no symptoms. The tumour marker levels decreased to within normal limits.

In march 2002, a screening CT detected liver lesions and increased thickening of the anterior abdominal wall. Ultrasound was carried out to characterise these areas. Unfortunately the lesions within the liver were hypoechoic and solid in nature, keeping with metastases. Assessment of the anterior abdominal wall demonstrated three clusters of heterogeneous nodular lesions surrounding the umbilicus.

Presently the patient is now starting to be symptomatic with increasing abdominal pain, weight loss, fever and sweats. Ultrasound monitoring of the abdominal wall and liver lesions have demonstrated significant progression of his disease. Liver function tests are now deranged. The patient is to start palliative chemotherapy with the prognosis at this point in time being relatively poor.

Citation
Lee L. Umbilical metastases or Sister Mary Joseph's nodules: A case report. ASUM Bulletin 2002.3:18-19.