Summary: Case 1: An 85-year-old woman presented with a 5-week history of
a painful periumbilical mass. In the past, she had undergone wide local
excision and radiotherapy for carcinoma of the breast. On
examination she had a tender lump deep to the umbilicus. Examination of
her breasts and axillae did not reveal any evidence of local or regional
recurrent disease. Ultrasonography (US) of the lump and computed
tomography (CT) of the abdomen was carried out. Case 2:
A 60-year-old woman presented with a lump involving her umbilicus. Her
past medical history was significant for total abdominal hysterectomy
and bilateral oophorectomy for ovarian cancer. CT of the abdomen was
Sister Joseph’s nodule (metastatic disease to the umbilical region)
Case 1: CT of the abdomen with oral and intravenous
contrast revealed a large metastatic deposit in right lobe of the liver
(Figure 1).Additionally an enhancing nodule was seen involving the
rectus sheath at the level of the umbilicus (Figure 1).
US showed a
hypoechoic lesion, measuring 1.4 x 1.0 cm, deep to the umbilicus
(Figure 2). This corresponds to the nodule seen in Figure 1B.
Axial CT section taken at the level of umbilicus showed a 4.5 x 4 cm,
well defined enhancing dumbbell shaped mass in the anterior abdominal
wall involving the subcutaneous fat planes. It appeared to be arising
from the peritoneum (Figure 3). Distal to the umbilicus another
well-circumscribed enhancing nodule was seen lying within the
subcutaneous tissue of the anterior abdominal wall(Figure 3). There was
no evidence of recurrence of the primary tumor.
Metastatic umbilical nodules are known as Sister Joseph’s nodules
(SJN), named after the brilliant first assistant to Dr. W.J. Mayo of
theMayo Clinic. The presence of an umbilical metastasis indicates a poor
prognosis and is a sign of advanced neoplastic disease.1
These deposits usually arise from primary tumors of the gastrointestinal
tract, pancreas, and ovary. Other primary sites include breast,
gall-bladder, liver,and the endometrium. Histologically most nodules are
adenocarcinomas although squamous cell carcinoma, carcinoid, and
lymphoma have also been reported.2
SJNs present as a
painful fibrous periumbilical lump, usually 0.5 to 2 cm in diameter,
although some can grow as large as 10 cm.Whilst it remains a finding on
clinical examination, imaging investigations, such as US and CT, aid in
differentiating these from a variety of umbilical disorders, such as
umbilical hernia, umbilical endometriosis, papilloma, foreign body
granuloma, epidermoid cyst, omphalith, and primary carcinoma.3
Additionally, owing to the increasing number of cross-sectional imaging
performed in patients under evaluation for malignancies, the
radiologist may be the first to diagnose a periumbilical nodule.
SJNs are seen on US as hypoechoic masses with varying degrees of definition.4
On contrast CT they have been reported to appear as solid well-defined,
enhancing lesions encompassing 3 forms: subcutaneous nodule, dermal
deposits, or peritoneal mass extending into the anterior abdominal wall.5
scanning of the nodule on US can provide easy access for biopsy or fine
needle aspiration cytology. This has been reported as a safe and
reliable diagnostic tool to establish diagnosis and guide further
SJN are metastatic deposits in the periumbilical region. US and CT aid
in differentiating these from other umbilical conditions.Their
superficial location makes them an attractive target for diagnostic
biopsy or fine needle cytology.
- Gabriele R, Conte M, Egidi F, Borghese M. Umbilical metastases: Current viewpoint. World J Surg Oncol. 2005;21;13.
- Tam C, Turner H, Hicks RJ, Seymour JF. Diffuse large B-cell non-Hodgkin’s lymphoma presenting as Sister Joseph’s nodule. Leuk Lymphoma. 2002;43:2055-2057.
Grunewald B, Viggiano J, Chapman E. Widespread intraabdominal carcinoid
tumor presenting as an umbilical metastasis: Diagnosis by fine-needle
aspiration. Diagn Cytopathol. 1996;15:457-458.
- Ching AS, Lai CW. Sonography of umbilical metastasis (Sister Mary Joseph’s nodule): From embryology to imaging. Abdom Imaging. 2002;27:746-749.
- Coll DM, Meyer JM, Mader M, Smith RC. Imaging appearances of Sister Mary Joseph nodule. Br J Radiol. 1999;72:1230-1233.
- Sahai K, Kapila K, Verma K. Fine-needle aspiration cytology of umbilical nodules: “Sister Joseph’s nodule.” Diagn Cytopathol. 2001;25:309-310.