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Bilateral ovarian metastases 10 years after treatment of breast cancer

The differential diagnosis of umbilical metastasis includes umbilical hernia, hypertrophic and keloid scarring, seborrhoeic keratosis, pilonidal sinus, pyogenic granuloma, angioma, angiokeratoma, lymphangioma, epidermoid cyst, talc granuloma, foreign body and congenital malformation of the urachus (Patel and Watkins 1992). The incidence of umbilical metastasis is 1–3% in patients with an intra-abdominal or pelvic malignancy, most commonly gastric carcinoma in men and ovarian cancer in women. These nodules are less often associated with endometrial cancer. There are only 28 published case reports to the best of our knowledge, making this the 29th case. Valid mechanisms of metastatic spread from gynaecological cancers include haematogenous, lymphatic or venous spread or contiguous extension from the peritoneal surface. Metastasis may also occur along the ligaments of embryonic origin. It has also been proposed that endometriosis spreads via lymphatic and vascular flow (Insabato and Pettinato 1996). The umbilicus is a recognised site for involvement with endometriosis (Villar’s nodule). Ikeda et al. (2006) published a case report of umbilical metastasis present at the time of diagnosis of endometrial carcinoma. Their patient underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, para-aortic and pelvic lymph node dissections along with resection of the umbilical lesion. Histology revealed foci of endometriosis and metastasis in the lymph nodes and endometrioid adenocarcinoma co-existing with endometriosis in the umbilical lesion. The coincidental finding of endometriosis in our patient is interesting given the proposed shared mechanisms of spread, however in contrast to the above case, our patient had no evidence of metastasis at diagnosis and there were no foci of endometriosis in the excised umbilical nodule which was the sole site of metastasis. Umbilical metastasis may be the presenting sign of an underlying malignancy or may represent recurrence of a previous malignancy. In 15–30% of cases the primary site is unknown, however the presence of an umbilical metastasis indicates a poor prognosis. Mean life expectancy is around 11 months; even less when the lesion appears after treatment of the primary tumour. Aggressive treatment combining a surgical approach with adjunctive therapy may improve prognosis and survival (Piura et al. 2006). Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.