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Forgotten node: A case report

Sister Mary Joseph nodule or node refers to a palpable nodule bulging into the umbilicus and is usually a result of a malignant cancer in the pelvis or abdomen. Traditionally it has been considered a sign of ominous prognosis. Gastrointestinal malignancies, most commonly gastric, colon and pancreatic cancer account for about 52% of the underlying sources. Gynecological cancers, most commonly ovarian and uterine cancers account for about 28% of the sources.


INTRODUCTION
Umbilical metastases (Figure 1), also named Sister Mary Joseph node are well documented in the adult population and most usually associated with gastrointestinal or gynecologic malignancy. The appearance of this node generally indicates a grave prognosis for the patient. malignant process, this case presents a rare, but reported non-malignant lesion [1] .

CASE REPORT
A 41-year-old female visiting from the Caribbean, the island of St. Vincent, presented initially to my office with abdominal pain. The history revealed she had been treated with antibiotics for her abdominal pain. Concurrently, she was prescribed birth control fo r p r esumed en d o metr i o sis fo r 5 m o wi thout change in symptoms. A pelvic ultrasound revealed a leiomyomatous uterus and a 2.3 cm vascular umbilical mass. All laboratory data was within normal limits, except an elevated amylase level of 155, and a CA 19-9 level of 172 (normal < 35); CEA and CA27-29 were also normal. Since abdominal pain increased over the next 2 d she was admitted to the hospital. The CT of the abdomen/pelvis on admission revealed a large mass at the ileocecal junction with intussusceptions into the cecum without evidence of bowel obstruction. Also present were multiple large exophytic intramural and subserosal leiomyomas. Gastroenterology, Gynecology and Oncolog y were consulted. Since an umbilical vascular mass could not be biopsied, a colonoscopy was performed. Colonoscopy did not reveal any intra-luminal mass, however there was a significant intussusception of the ileum into the cecum. No obvious mass could be biopsied. At this time, there was still no diagnosis. It was recommended that an operative intervention was needed to excise the umbilicus for tissue diagnosis and also address the obstruction in the ileo-cecal region.
Umbilical mass and cecal mass with intussusceptions all revealed endometriosis on all frozen sections. A right hemicolectomy was performed. Intra operatively there were diffuse patches of endometriosis involving both ovaries, the cul-de-sac, the serosa of the uterus, and peritoneum. These areas were cauterized using the Bovie.
No malignancy was found in this patient.

DISCUSSION
Cutaneous metastases localized to the umbilicus are named "Sister Mary Joseph nodules". The historical perspective of this node and its namesake is quite interesting. Sister Mary Joseph, born Julia Dempsey in  [2,3] . Metastasis to the umbilicus is very uncommon [4] . When it does occur, the umbilical nodules are usually malignant with the common site being an abdominopelvic tumor [5][6][7] . In Shetty's review [8] of all cases of malignant disease to the umbilicus only 42% originated from either the abdomen or from the pelvis, whereas in Powell's review [9] of umbilical nodules, 32% of the cases were benign neoplasms.
This case demonstrates a non-malignant (benign) lesion that caused a metastatic umbilical nodule. In our case this was endometriosis [10] . Although rare, this nodule ranges in color from dusky red to blue to purplish as in our case. It may change in size during the menstrual cycle and may be tender, and even bleed. The ultrasound demonstrated a vascular umbilical mass. Other benign causes of umbilical nodules are fibroma, keloid, and epithelial inclusion cysts [11] .