Sister Mary Joseph

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Chalya et al.

World Journal of Surgical Oncology 2013, 11:151


http://www.wjso.com/content/11/1/151 WORLD JOURNAL OF
SURGICAL ONCOLOGY

RESEARCH Open Access

Sister Mary Joseph's nodule at a University


teaching hospital in northwestern Tanzania:
a retrospective review of 34 cases
Phillipo L Chalya1*, Joseph B Mabula1, Peter F Rambau2 and Mabula D Mchembe3

Abstract
Background: Sister Mary Joseph’s nodule is a metastatic tumor deposit in the umbilicus and often represents
advanced intra-abdominal malignancy with dismal prognosis. There is a paucity of published data on this subject in
our setting. This study was conducted to describe the clinicopathological presentation and treatment outcome of
this condition in our environment and highlight challenges associated with the care of these patients, and to
proffer solutions for improved outcome.
Methods: This was a retrospective study of histologically confirmed cases of Sister Mary Joseph’s nodule seen at
Bugando Medical Centre between March 2003 and February 2013. Data collected were analyzed using descriptive
statistics.
Results: A total of 34 patients were enrolled in the study. Males outnumbered females by a ratio of 1.4:1. The vast
majority of patients (70.6%) presented with large umbilical nodule > 2 cm in size. The stomach (41.1%) was the
most common location of the primary tumor. Adenocarcinoma (88.2%) was the most frequent histopathological
type. Most of the primary tumors (52.9%) were poorly differentiated. As the disease was advanced and metastatic in
all patients, only palliative therapy was offered. Out of 34 patients, 11 patients died in the hospital giving a mortality
rate of 32.4%. Patients were followed up for 24 months. At the end of the follow-up period, 14(60.9%) patients were
lost to follow-up and the remaining 9 (39.1%) patients died. Patients survived for a median period of 28 weeks
(range, 2 to 64 weeks). The nodule recurred in 6 (26.1%) patients after complete excision.
Conclusion: Sister Mary Joseph’s nodule of the umbilicus is not rare in our environment and often represents
manifestation of a variety of advanced intra-abdominal malignancies. The majority of the patients present at a late
stage and many with distant metastases. The patient's survival is very short leading to a poor outcome. Early
detection of primary cancer at an early stage may improve the prognosis.
Keywords: Sister Mary Joseph’s nodule, Clinicopathological, Pattern, Treatment outcome, Tanzania

Background Clinic. Sister Mary Joseph identified the relationship be-


Sister Mary Joseph’s nodule is a metastatic tumor de- tween umbilical nodules and advanced intra-abdominal
posit in the umbilicus and often represents advanced malignancy [2-4].
intra-abdominal malignancy with dismal prognosis [1]. Sister Mary Joseph’s nodules are usually malignant and
The term “Sister Mary Joseph’s nodule” was coined by Sir the most common primary site is an abdomino-pelvic
Hamilton Bailey in his book, Physical Signs in Clinical tumor. It is estimated that 1 to 3% of the abdomino-pelvic
Surgery, in honor of Sister Mary Joseph, Dr. William malignancies metastasize to the umbilicus [5-7]. In men,
Mayo’s surgical assistant in the early days of the Mayo the commonest primary site is the gastro-intestinal tract
of which the stomach is the single most common entity,
whereas gynecological malignancies – particularly epithe-
* Correspondence: drphillipoleo@yahoo.com
1
Department of Surgery, Catholic University of Health and Allied Sciences-
lial ovarian tumors – are the most common primary sites
Bugando, Mwanza, Tanzania in women. In 15 to 30% of patients, the source of the
Full list of author information is available at the end of the article

© 2013 Chalya et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Chalya et al. World Journal of Surgical Oncology 2013, 11:151 Page 2 of 6
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primary tumor remains unknown [8-10]. The most com- Joseph’s nodule was conducted at Bugando Medical Cen-
mon histological type is adenocarcinoma (75%), more ter. Bugando Medical Center is a tertiary care and teach-
rarely squamous cell carcinoma, followed by undifferenti- ing hospital for the Catholic University of Health and
ated tumors or carcinoids that can metastasize to the Allied Sciences-Bugando (CUHAS-Bugando) in the Lake
umbilicus [11-14]. Sometimes umbilical nodules may be and Western Zones of the United Republic of Tanzania. It
benign (for example, endometriosis, fibroma, epithelial in- is situated along the shores of Lake Victoria in Mwanza
clusion cysts, foreign body granuloma, keloid, myxoma), City. It has 1000 beds and serves as a referral center for
and occasionally it may be a primary malignant tumor of tertiary specialist care for a catchment population of
the umbilicus (for example, melanoma, squamous or basal approximately 13 million people. The hospital has a newly
cell carcinoma, sarcoma) [15]. Benign umbilical nodules established oncology department which provides care for
are called Pseudo Sister Mary Joseph’s nodules [16]. all patients with histopathologically proven cancers. How-
Therefore, a histological or cytological study of the umbi- ever, the department does not provide radiotherapy
licus is not only mandatory, but it also guides the clinician services at the moment due to the lack of this facility at
to search for the potential primary site. our center. As a result, patients requiring this modality of
The presence of an umbilical metastasis indicates a poor treatment have to travel long distances to receive radio-
prognosis and is a sign of advanced malignant disease. therapy at the Tanzania Tumor Center, located a conside-
The survival of these patients has been reported to range rable distance from the study area.
from 2 to 11 months from the time of initial diagnosis The study population included all patients who
[2,6,11,17,18]. Because Sister Mary Joseph’s nodule may presented to Bugando Medical Center with histologically
sometimes be the first and only sign of an internal neo- confirmed Sister Mary Joseph’s nodule during the study
plasm and prognosis is mostly poor, diagnosis has to be period. Patients with incomplete data were excluded
confirmed in the early stages to improve average survival. from the study.
The diagnosis of Sister Mary Joseph’s nodule is usually The details of patients were retrieved from the patient
delayed due to non-specific symptoms that are often files kept in the medical record department, the surgical
misinterpreted as benign umbilical nodules. The lack of wards, operating theatre and histopathology laboratory.
suspicion and general reluctance to perform invasive The data collected included age, gender, clinical presen-
investigations contributes to late diagnosis. The delay in tation, size of umbilical nodules, timing of discovery of
diagnosis and, consequently, treatment leads to the ex- nodules, investigations carried out to look for the primary
tremely poor prognosis associated with this disease. A cancer, sites of origin of primary cancer, therapeutic
high index of suspicion is required in the management options, and duration of survival. The diagnosis of Sister
of Sister Mary Joseph’s nodule and all suspected lesions Mary Joseph’s nodule was confirmed in all patients by
should be biopsied. umbilical biopsy, and a histopathological review showed
The management of Sister Mary Joseph’s nodule in various malignancies metastasizing to the umbilicus.
resource-limited countries like Tanzania poses major Searching for the primary cancer was aided by gastrointes-
therapeutic challenges which need to be addressed. Late tinal endoscopies (that is,oesophagogastroduodenoscopy)
presentation with advanced lesions coupled with a lack and imaging modalities (that is, abdominal ultrasound,
of therapeutic facilities such as adjuvant therapy services computed tomography (CT) scan and barium studies).
are among the hallmarks of the disease in developing Advanced diagnostic investigation such as magnetic res-
countries. The outcome of patients with Sister Mary onance imaging (MRI), endoscopic retrograde cho-
Joseph’s nodule has been poor because the majority of langiopancreatography (ERCP), percutaneous transhepatic
these patients present late to the hospital with advanced cholangiopancreatography (PTC), positron emission to-
stage. This is partly due to paucity of local data regar- mography (PET) and a panel of tumor markers was not
ding this condition and lack of community awareness on done in any of our patients as these facilities are not
the importance of early reporting to hospital for early available at our center. Patients were followed up in the
diagnosis and treatment. This study was conducted to Surgical Outpatient Department and their death and
describe the clinicopathological pattern and treatment recurrence of the disease was documented.
outcome of patients with Sister Mary Joseph’s nodule
treated at our center and to highlight challenges associated
with the care of these patients and proffer solutions for Statistical data analysis
improved outcome. Statistical data analysis was performed using SPSS com-
puter software version 17.0 (SPSS, Inc., Chicago, IL, USA).
Methods Data were summarized in the form of proportions and
Between March 2003 and February 2013, a retrospective frequency tables for categorical variables. Continuous vari-
study of histologically confirmed cases of Sister Mary ables were summarized using median and ranges.
Chalya et al. World Journal of Surgical Oncology 2013, 11:151 Page 3 of 6
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Ethical consideration location of the primary tumor, accounting for 41.1% of


Ethical approval to conduct the study was sought from cases. Adenocarcinoma was the most frequent histo-
the CUHAS-Bugando/Bugando Medical Center joint in- pathological type occurring in 88.2% of patients. Most of
stitutional ethic review committee before the com- the primary tumors (52.9%) were poorly differentiated
mencement of the study (Table 2).
Surgical intervention with or without adjuvant therapy
Results was performed in 28 (82.4%) patients. The remaining 6
During the study period, a total of 34 patients were en- (17.6%) patients were unfit for surgery and only an inci-
rolled in the study. There were 20 (58.8%) males and 14 sional biopsy from the umbilical nodule was taken to
(41.2%) females with a male to female ratio of 1.4:1. The confirm the diagnosis. Table 3 shows the type of surgical
age of patients at presentation ranged from 19 to 73 years procedure performed. Chemotherapy was given to only
with a median age of 46 years. The modal age group was 5 (14.7%) patients who had non-Hodgkin lymphoma,
41–50 years (Figure 1). The vast majority of patients (28, colonic and ovarian carcinoma. Only 1 patient (2.9%)
82.4%) came from the rural areas located a considerable who had squamous cell carcinoma was referred to the
distance from Mwanza City and most of them (30,88.2%) Ocean Road Cancer Institute for possible radiotherapy.
had either primary or no formal education. However, due to final constraints this patient could not
The duration of illness ranged from 1 to 6 months get access to this form of treatment and they were lost
with a median of 3 months and the majority of patients to follow-up.
(25,73.5%) presented between 2 and 4 months of onset Out of 34 patients, 11 patients died in the hospital gi-
of illness. Table 1 shows the distribution of patients ving a mortality rate of 32.4%. The remaining survivors
according to clinical presentation. All patients presented (23 patients) were followed-up the Surgical Outpatient
with umbilical nodules. The nodules were discovered at Department for a period of 24 months. Follow-up of
the initial clinical examination in 26 (76.5%) patients patients among survivors ranged from 3 to 24 months
and in the other 8 (23.5%) patients it was noticed during with a median of 8 months. At the end of the follow-up
surgery. The umbilical nodules were tender and ulcer- period, 14 (60.9%) patients were lost to follow-up and
ated in 20 (58.8%) patients, hard in all, and the median the remaining 9 (39.1%) patients died and their date of
nodule size at presentation was 3cm (range 2 to 5 cm). death was obtained from relatives. The patients survived
The vast majority of patients (70.6%) presented with a for only a few weeks after clinical presentation with
large nodule, >2 cm in size. One patient with an umbi- Sister Mary Joseph’s nodule. They survived for a median
lical nodule reported an operation for colonic cancer 3 period of 28 weeks (range, 2 to 64 weeks). The nodule
years previously. The stomach was the most common recurred in 6 (26.1%) patients after complete excision.

Figure 1 Distribution of patients according to age group.


Chalya et al. World Journal of Surgical Oncology 2013, 11:151 Page 4 of 6
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Table 1 Distribution of patients according to clinical Table 3 Distribution of patients according to the type of
presentation surgical procedure performed (N= 28)
Clinical presentation Frequency Percentage Type of surgical procedure performed Frequency Percentage
Abdominal pain 30 88.2 Umbilical nodule excision 28 100
Abdominal mass 26 76.5 Gastro-jejunostomy 10 35.7
Weight loss 25 73.5 Gastrectomy 5 17.9
Constipation 14 41.2 Hemicolectomy 3 10.7
Vomiting 12 35.3 Salpingo-oophorectomy 2 7.1
Ascites 10 29.4 Cholecystectomy 1 3.6
Rectal bleeding 4 11.7
Hematemesis/ melena 1 2.9 between umbilical nodules and intra-abdominal malig-
Other rare symptoms 6 17.6 nancy [2-4]. Since then, more than 400 cases of Sister
Mary Joseph's nodule have been described in the litera-
Discussion ture [17]. It is estimated that 1 to 3% of patients with
Sister Mary Joseph’s nodule refers to a palpable nodule abdomino-pelvic malignancy could present with a Sister
bulging into the umbilicus as a result of metastasis of a Mary Joseph’s nodule [5-7].
malignant cancer in the pelvis or abdomen [1,5,6]. Sir In this review, the median age of patients at presentation
Hamilton Bailey first described the term “Sister Mary was 46 years, which is lower than the age reported in the
Joseph’s nodule” in 1949 in honor of Sister Mary Joseph literature [6,19]. A study performed in India by Al-Mashat
who was a nurse superintendent and a surgical assistant and Sibiany [19] reported the mean age of patients at diag-
of Dr William Mayo at St Mary's Hospital (presently the nosis to be 50.6 years (range, 18–87 years). Other studies
Mayo Clinic) in Rochester Minnesota, USA from 1890 reported older age at presentation [19,20]. We could not
to 1915. Sister Mary Joseph was the first to note the link establish the reason for this age difference.
Epidemiological studies revealed that Sister Mary
Joseph's nodule predominates in women [20,21]. This
Table 2 Distribution of patients according to nodule size,
observation is at variant with our findings in the present
primary tumor location, histopathological type and
tumor grade study which showed male predominance. The reason for
this gender difference remains unclear.
Study variables Frequency Percentage
The gastrointestinal tract is the most common location
Umbilical nodule size
of the primary neoplasm (35 to 65%), followed by a
• ≤2 cm 10 29.4
gynecological origin (12 to 35%) [1]. The common sites
• >2cm 24 70.6 in decreasing order of frequency are: stomach (25%),
Primary tumor site colorectal (10%), and pancreas (7%) [1,19]. In females,
• Stomach 14 41.2 ovarian cancer is the most common primary site, of
• Colorectum 3 8.8 which serous papillary cystadenocarcinoma is the most
• Pancreas 2 5.9 frequent (34%) [1,11]. As reported in the literature [11],
• Ovary 2 5.9 the stomach was the most common primary site in this
• Gall bladder 1 2.9 study. Primary tumors in many other sites have been
reported to lead to Sister Mary Joseph's nodule, including
• Anus 1 2.9
gallbladder, liver, breast, lung, prostate, penis, peritoneum,
• Unknown 11 32.4
lymphoma, bladder, kidney, endometrium, cervix, vagina,
Histopathological type
vulva, and fallopian tube [11,19]. In 15 to 30% of the cases,
• Adenocarcinoma 30 88.2 the source of the primary site of the tumor is unknown
• Non-Hodgkin's lymphoma 1 2.9 [8-10]. This finding concurs with our study in which the
• Squamous cell carcinoma 1 2.9 primary site was not known in 29.4% of cases.
• Anaplastic carcinoma 1 2.9 Sister Mary Joseph's nodule can be the first manifest-
• Cholangiocarcinoma 1 2.9 ation of an underlying malignancy or an indication of a re-
Tumor differentiation currence in a patient with a previous malignancy [22]. In
• Well differentiated 5 14.7 the present study, 1 patient developed metastatic umbi-
• Moderately differentiated 6 17.6
lical nodule 3 years after laparotomy for colonic cancer.
Al-Mashatand Sibiany [19] reported 1 patient who deve-
• Poorly differentiated 18 52.9
loped Sister Mary Joseph's nodule 3 years after laparo-
• Not documented 5 14.7
scopic cholecystectomy. Direct implantation following
Chalya et al. World Journal of Surgical Oncology 2013, 11:151 Page 5 of 6
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laparoscopy has been reported in the literature to be an- a more anaplastic appearance. In the situation of an ana-
other mode of spread of intra-abdominal tumors to the plastic tumor, immunohistochemical marker studies and
umbilicus [23]. ultrastructural examination may help delineate the tissue
The majority of patients in this study presented late with of origin [27]. In the present study, the diagnosis of pri-
advanced stage of cancer which is in keeping with other mary cancer was performed by gastrointestinal endosco-
studies performed in developing countries [19,22]. Late pies (that is,oesophagogastroduodenoscopy) and imaging
presentation in our study may be attributed to lack of modalities (that is, abdominal ultrasound, CT scan and
awareness of the disease, a low standard of education, a barium studies) and histopathological examination of the
lack of accessibility to healthcare facilities, and a lack of biopsy specimen was performed to confirm the diagnosis.
advanced diagnostic investigations such as MRI and PET Advanced diagnostic investigation such as MRI, ERCP,
and a panel of tumor markers in this region. Late presen- PTC, PET and a panel of tumor markers was not
tation of cases is an area of cancer care in our center that performed in any of our patients as these facilities are not
requires urgent attention. Detecting primary cancer at an available at our center.
early stage contributes to improved chances for successful The most common histopathological type in our pa-
treatment and thus for survival. tients was adenocarcinoma, accounting for 88.2% of cases,
The potential differential diagnosis to be considered which is consistent with that reported in the literature
when evaluating a patient with Sister Mary Joseph's nodule [11,19]. Other histopathological types include non-
includes benign causes such as endometriosis, melanocytic Hodgkin's lymphoma, squamous cell carcinoma, anaplas-
nevi, fibroepithelialpapillomas, dermatofibroma, fibroma, tic carcinoma and cholangiocarcinomawhich is similar to
epithelial inclusion cyst, urachal duct cyst, seborrheic the worldwide experience [11-14,19]. More than 50% of
keratosis, pilonidal sinus, keloid, foreign body, granuloma, tumors in this study were poorly differentiated.
myxoma, omphalitis, polyp, abscess, and umbilical hernia The presence of Sister Mary Joseph's nodules usually
[5,11,24]. Additional differential diagnosis includes pri- signifies an advanced, metastasizing cancer and, therefore,
mary malignant umbilical tumors, which are exceedingly a poor prognosis. The finding of a metastatic nodule at
rare, accounting for 17% of the cases and including mela- the umbilical site almost certainly establishes the inope-
nomas, basal cell carcinomas, squamous cell carcinomas, rability of the patient [28]. This conclusion was disputed
myosarcomas, and adenocarcinomas [5,11]. by others who believe that the existence of Sister Mary
The spread of metastatic cancer to the umbilical region Joseph's nodule is insufficient proof of widespread meta-
has been postulated to occur in several ways. These in- static disease that would prevent an operation. Uncom-
clude direct extension from a contiguous tumor (the most monly, Sister Mary Joseph's nodule may represent a
important), hematogenous (arterial and venous), lymph- solitary metastasis or possibly a primary tumor that has
atic and direct extension along the vestigial remnants of not yet metastasized [29,30].
embryonal ligaments including the round ligament, the Sister Mary Joseph's nodule usually represents wide-
urachus, the vitellointestinal duct remnant, and the obli- spread metastasis and treatment is commonly palliative.
terated vitelline artery [24-26]. In addition, direct implan- Several authors have advocated wide excision with exten-
tation following laparoscopy is another mode of spread of sive search for the primary lesion [30,31], radiotherapy
tumors to the umbilicus [23]. [32], and surgery with adjuvant therapy [26]. Majmudar
Patients with Sister Mary Joseph's nodule often present and colleagues [26] have shown that patients treated
with a painful lump with irregular margins and hard aggressively with both surgery and adjuvant therapy live
consistency. The surface may be ulcerated and necrotic for an average of 17.6 months, which is more than with
with either blood, serous, purulent, or mucous discharge surgery alone (7.4 months), adjuvant therapy alone (10.3
from it. The size of the nodule usually ranges from 0.5 to months), or no treatment (2.3 months). An aggressive sur-
2 cm, although some nodules may reach up to 10 cm in gical approach combined with chemotherapy may improve
size [1,6]. The median size of the nodule in our study was survival [1]. In our series, surgical interventions were of a
3 cm and the vast majority of patients (82.4%) presented palliative nature, without curative intent, as all patients
with large nodule >2 cm in size and more than 70% of had either locally advanced or metastatic disease. Wide
nodules were ulcerated. nodule excision and gastro-jejunostomy were the most
Various imaging modalities can aid in establishing the frequent surgical procedure performed in this study. Adju-
diagnosis, such as ultrasonography, CT, MRI, and PET. vant chemotherapy was given to only 14.7% of cases.
Once Sister Mary Joseph's nodule is discovered, a biopsy – Sister Mary Joseph's nodule has traditionally been consi-
either excisional or fine needle aspiration cytology – is dered a sign of advanced primary malignancy with an asso-
mandatory to establish diagnosis and to find the possible ciated poor prognosis; the average survival time has been
primary site. The histopathological evaluation may show reported to be 11 months with <15% of the patients survi-
characteristics of the underlying tumor, or they may have ving >2 years [19]. In some patients, however, depending on
Chalya et al. World Journal of Surgical Oncology 2013, 11:151 Page 6 of 6
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the state of the primary neoplasm and the patient's general 3. Schwartz IS: Sister Mary Joseph's nodule. N Engl J Med 1987, 316:1348–1349.
condition, surgery and/or chemotherapy may improve sur- 4. Bailey H: Demonstrations of Physical Signs in Clinical Surgery. 11th edition.
Baltimore: Williams & Wilkins; 1949.
vival [1]. In agreement with other studies [19,22], our pa- 5. Steck WD, Helwig EB: Tumors of the umbilicus. Cancer 1965, 18:907–911.
tients survived for a median period of 28 weeks. This very 6. Barrow MV: Metastatic tumors of the umbilicus. J Chron Dis 1966,
short survival is in keeping with the advanced and meta- 19:1113–1117.
7. Dubreuil A, Dompmartin A, Barjot P, Louvet S, Leroy D: Umbilical
static nature of the primary cancer. metastasis or Sister Mary Joseph's nodule. Int J Dermatol 1998, 37:70–73.
The potential limitation of this study is the fact that 8. Galva VG: Sister Mary Joseph's nodule. J Chron Dis 1966, 19:1113–1117.
information about some patients was incomplete in view 9. Falchi M, Cecchini G, Derchi LE: Umbilical metastasis as first sign of cecal
carcinoma in a cirrhotic patient (Sister Mary Joseph nodule). Report of a
of the retrospective nature of the study and this might case. Radiol Med 1999, 98:94–96.
have introduced some bias in our findings. 10. Gabriele R, Borghese M, Conte M, Basso L: Sister Mary Joseph's nodule as
a first surgery of cancer of the caecum: report of a case. Dis Colon
Rectum 2004, 47:115–117.
Conclusion 11. Panaro F, Andorno E, Di Domenico S, Morelli N, Bottino G, Mondello R:
Sister Mary Joseph’s nodule of the umbilicus is not rare in Sister Joseph's nodule in a liver transplant recipient: case report and
our environment and often represents manifestation of a mini-review of literature. World J Surg Oncol 2005, 3:4.
12. Shetty MR: Metastatic tumors of the umbilicus: a review 1830–1989.
variety of advanced intra-abdominal malignancies. The ma- J Surg Oncol 1990, 45:212–215.
jority of the patients present at a late stage with advanced 13. Bank H, Liberman SI: Sister Joseph's nodule and malignant ascites in
disease. The patient's survival is very short leading to a poor multiple myeloma. N Engl J Med 1971, 284:676–677.
14. Tam C, Turner H, Hicks RJ, Seymour JF: Diffuse large B-cell Non-Hodgkin’s
outcome. We believe that if the primary cancer is detected lymphoma presenting as Sister Joseph's nodule. Leuk Lymphoma 2002,
at an early stage, the prognosis may improve. A careful 43:2055–2057.
examination of all umbilical lesions is recommended, espe- 15. Calista D, Fiorentini C, Landi G: Umbilical metastasis from ovarian
carcinoma: Sister Mary Joseph’s Nodule. JEADV 2002, 16:81–94.
cially in those patients with gastrointestinal and genitouri- 16. Amaro R, Goldstein JA, Cely CM: Pseudo Sister Mary Joseph’s nodule.
nary tract malignancies. All umbilical mass lesions should Am J Gastroenterolo 1999, 94:1949–1950.
be biopsied to determine the pathological nature of the le- 17. Piura B: Umbilical metastasis: Sister Mary Joseph's nodule. Harefuah 2006,
145:505–509.
sion. An aggressive surgical approach combined with 18. Khan AJ, Cook B: Metastatic carcinoma of umbilicus: “Sister Mary
chemotherapy treatment may be considered to offer the Joseph’s”. Cutis 1997, 60:297–298.
patient the best survival probability. 19. Al-Mashat F, Sibiany AM: Sister Mary Joseph’s nodule of the umbilicus:
is it always of gastric origin? A review of eight cases at different sites of
Abbreviations origin. Indian J Cancer 2010, 47:65–69.
CT: computed tomography; CUHAS: Catholic University of Health and Allied 20. Touraud JP, Lentz N, Dutronc Y, Mercier E, Sagot P, Lambert D: Umbilical
Sciences; MRI: magnetic resonance imaging; PET: positron emission cutaneous metastasis (or Sister Mary Joseph nodule disclosing an
tomography. ovarian adenocarcinoma. GynecolObstetFertil 2000, 28:719–721.
21. Kolwijck E, Boss EA, van Altena AM, Beex LV, Massuger F: Stage IV epithelial
Competing interests ovarian carcinoma in an 18 year old patient presenting with a Sister
The authors declare that they have no competing interests. The study had Mary Joseph’s nodule and metastasis in both breasts: a case report and
no external funding. Operational costs were met by the authors. review of the literature. Gynecol Oncol 2007, 107:583–585.
22. Schneider V, Smyczek B: Sister Mary Joseph's nodule. Diagnosis of umbilical
metastases by fine needle aspiration. Acta Cytol 1990, 34:555–558.
Authors’ contributions
23. Yusuf M, Azhar R: Umbilical metastasis from oesophageal squamous cell
PLC conceived the study and participated in the literature search, writing the
carcinoma: a case report. The Internet Journal of Gastroenterology. 2004, 3:1.
manuscript, editing and submission of the manuscript. JBM, PFR and MDM
24. Powell FC, Cooper AJ, Massa MC, Goellner JR, Daniel WP: Sister Joseph's
participated in study design, data analysis, manuscript writing and editing.
nodule: a clinical and histologic study. J Am Acad Derm 1984, 10:610–615.
All the authors read and approved the final manuscript.
25. Goodheart RS, Cooke CT, Tan E, Matz LR: Sister Mary Joseph's nodule.
Med J Aust 1986, 145:477–478.
Acknowledgements
26. Majmudar B, Wiskind AK, Croft BN, Dudley AG: The Sister Mary Joseph
We thank all those who participated in the preparation of this manuscript.
nodule: its significance in gynecology. Gynecol Oncol 1991, 40:152–159.
Special thanks go to the staff members of the medical record department,
27. Shwartz RA: Metastatic cancer of the skin. In Skin Cancer Recognition and
theatre, histopathology laboratory and surgical wards for their support
Management. New York: Springer-Verlag; 1998:185–193.
during data collection.
28. Clements AB: Metastatic carcinoma of the umbilicus. JAMA 1952, 150:556–559.
29. Horn JJ, Fred HL, Lane M, Hudgins PT: Umbilical metastases.
Author details
1 Arch Intern Med 1964, 114:799–802.
Department of Surgery, Catholic University of Health and Allied Sciences-
30. O'Leary JL, O'Leary JA: Carcinoma of the umbilicus. Am J Obstet Gynecol
Bugando, Mwanza, Tanzania. 2Department of Pathology, Catholic University
1964, 89:136–137.
of Health and Allied Sciences-Bugando, Mwanza, Tanzania. 3Department of
31. Chatterjee SN, Bauer HM: Umbilical metastasis from carcinoma of the
Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam,
pancreas. Arch Dermatol 1980, 116:954–955.
Tanzania.
32. Charoenkul V, DelCampo A, Derby A, Hodgson WJ, McElhinney AJ: Tumors
of the umbilicus. Mt Sinai J Med 1977, 44:257–262.
Received: 3 May 2013 Accepted: 23 June 2013
Published: 5 July 2013
doi:10.1186/1477-7819-11-151
Cite this article as: Chalya et al.: Sister Mary Joseph's nodule at a
References University teaching hospital in northwestern Tanzania:
1. Gabriele R, Conte M, Egidi F, Borghese M: Umbilical metastases: current a retrospective review of 34 cases. World Journal of Surgical Oncology
viewpoint. World J Surg Oncol 2005, 3:13. 2013 11:151.
2. Trebing D, Göring HD: The umbilical metastasis. Sister Mary Joseph and
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