Sister Mary Joseph's Nodule: Umbilical Metastatic Lesions
Umbilical seeding nodules are called Sister Mary Joseph's nodules (SMJN), which represent metastatic deposits to the umbilicus from intra-abdominal or pelvic malignancies.
Definition and History
- The term was coined in 1949 by English surgeon Hamilton Bailey, naming it after Sister Mary Joseph (1856-1939), a superintendent nurse at St. Mary's Hospital (now Mayo Clinic) who first observed the association between umbilical nodules and internal malignancies 1
- These nodules represent metastatic spread to the umbilicus from primary tumors, most commonly in the gastrointestinal tract or reproductive organs
Clinical Characteristics
- Physical appearance:
- Firm nodules measuring 0.5-2 cm, though some can reach up to 10 cm in size 1
- May be painful and ulcerated
- Sometimes present with discharge (pus, blood, or serous fluid)
- Can be the first manifestation of an underlying malignancy or indicate recurrence in patients with previous cancer
Primary Sites of Origin
- In women: Most commonly from ovarian carcinoma 1, 2
- In men: Most commonly from gastric carcinoma 1
- Other common primary sites:
- Colorectal cancer (including cecum) 3
- Pancreatic cancer
- Endometrial cancer
- Other gastrointestinal and gynecological malignancies
Pathophysiology
Tumor spread to the umbilicus can occur through multiple mechanisms 1:
- Lymphatic spread
- Hematogenous spread
- Direct contiguous extension
- Spread along embryologic remnants
Diagnostic Approach
- Fine needle aspiration (FNA) is recommended as a convenient method to confirm diagnosis 2
- Additional workup should include:
- Imaging studies (CT, MRI, PET/CT) to identify the primary malignancy
- Tumor markers appropriate to suspected primary sites
- Biopsy for histopathological confirmation
Differential Diagnosis
- Pseudo-Sister Mary Joseph's nodule (PSMJN): Benign umbilical nodules that can occur in 4:
- Endometriosis
- Fibroma
- Papillomas
- Myxoma
- Keloid
- Omphalith
- Nevi
- Foreign-body granulomas
- Epidermoid cysts
- Intra-abdominal tuberculosis
Prognosis
- Sister Mary Joseph's nodule traditionally indicates advanced malignancy with poor prognosis 1
- Average survival time: approximately 11 months
- Less than 15% of patients survive beyond 2 years
- In selected patients, depending on the primary tumor and general condition, surgery and/or chemotherapy may improve survival
Management Considerations
- Treatment approach depends on:
- Primary tumor type and stage
- Patient's overall condition
- Presence of other metastatic sites
- Options include:
- Systemic chemotherapy
- Targeted therapy based on primary tumor
- Palliative surgery in selected cases
- Supportive/palliative care for symptom management
Sister Mary Joseph's nodule represents an important clinical finding that should prompt thorough investigation for an underlying malignancy, particularly when discovered in patients without a known cancer diagnosis.