Umbilical metastasis of a gallbladder carcinoma:: ⟪Sister Mary Joseph's nodule⟫

Histology and clinical findings: A 63-year-old man presented with a firm and crusting umbilical mass which had developed within several weeks. The tumor was 1.5 cm in diameter. There were no other diseases in the patient's history. Physical examination was normal except the umbilical tumor. Investigations: Histologic examination revealed a malignant epithelial tumor corresponding to a metastasis of an adenocarcinoma which could be a carcinoma of the gallbladder or the pancreas. Initially the following clinical examination of the patient showed no pathological findings: gastroscopy and coloscopy gave no hint for a primary carcinoma. Computed tomography of the abdomen revealed a thickened gallbladder wall with an irregular intraluminal contour suspicious of a gallbladder carcinoma. During surgery the gallbladder showed a clearly thickened wall. There were numerous carcinomatous lesions on the peritoneum. A cholecystectomy was performed and the umbilical metastasis was excised. Diagnosis, treatment and course: Histologic examination revealed a metastatic adenocarcinoma of the gallbladder with tumorous infiltration of the liver tissue and a solitary metastasis in the skin ("Sister Mary Joseph's nodule"). During wound healing there were no complications and the patient was demitted 10 days after surgery. Following a recovery phase at home a palliative chemotherapy was planned. Because the patient's general condition worsened he was readmitted to the hospital. He presented with a considerable anemia and an icterus. Sonography revealed a hilar tumor measuring 4cm in diameter. The intrahepatic bile ducts were congested. A stent was inserted by endoscopic retrograde pancreaticocholangiography. During the following weeks the patient's general condition worsened rapidly and he died 9 months after the skin metastasis had occurred. Conclusion: A rapidly developing umbilical mass ("Sister Mary Joseph's nodule") is suspicious of an underlying metastatic adenocarcinoma. The necessary examination and therapy including excision of the umbilical metastasis is warranted without delay.