Bleeding Umbilical Nodule in a 73-year-old… Diagnosis?

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Image Source: The New England Journal of Medicine

A 73-year-old woman came to the emergency department with complaints of bloody exudate from a nodule at the umbilicus for 2 days. The nodule was noticed due to pain around 4 months back and had enlarged ever since. She had never noticed blood oozing from the nodule until 2 days before presenting to the emergency department.

On physical examination, a painful, firm, and erythematous umbilical nodule was noticed, which measured 2 cm in its largest diameter (Panel A). The examination of the pelvis revealed a mass in the pelvis.

On abdominopelvic computed tomography scan, a heterogeneous pelvic mass was identified, which measured 11 cm by 11 cm by 9.5 cm (Panel B, arrow), with moderate ascites, peritoneal carcinomatosis, and a 2.4 cm nodule in the umbilical region (Panel B, arrowhead).

Diagnostic laparoscopy was performed, and biopsy samples were obtained from the pelvic mass, umbilical nodule, and peritoneal implants.

High-grade serous ovarian carcinoma was confirmed on the histopathological evaluation.

Cytoreductive surgery was performed along with adjuvant chemotherapy.

A metastatic umbilical nodule is called  ‘Sister Mary Joseph’s nodule,’ which is a rare but characteristic and important finding of malignancy and usually represents metastatic gynecologic and gastrointestinal cancers. Usually, the Sister Mary Joseph nodule is anywhere between 0.5 cm to 15 cm in diameter, firm, and painful. It may be the only clinical feature present in patients with metastatic malignancy.

Such cases warrant prompt urgent investigations and further assessment. Imaging studies and biopsy (most conveniently from the nodule) remain indispensable in diagnosing the underlying malignancy.

Overall, the prognosis of Sister Mary Joseph nodule is poor as it usually represents advanced or inoperable malignancies, making palliative management the only choice in a majority of the cases.

References

Javier Barambio, M. a. (2019, March 14). An Umbilical Nodule. Retrieved from The New England Journal of Medicine: https://www.nejm.org/doi/full/10.1056/NEJMicm1809024

Tso S, Brockley J, Recica H, Ilchyshyn A. Sister Mary Joseph’s nodule: an unusual but important physical finding characteristic of widespread internal malignancy. Br J Gen Pract. 2013;63(615):551-552. DOI:10.3399/bjgp13X673900

Dar IH, Kamili MA, Dar SH, Kuchaai FA. Sister Mary Joseph nodule-A case report with review of the literature. J Res Med Sci. 2009;14(6):385-387.

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Dr. Arsia Parekh
Dr. Arsia Hanif has been a meritorious Healthcare professional with a proven track record throughout her academic life securing first position in her MCAT examination and then, in 2017, she successfully completed her Bachelors of Medicine and Surgery from Dow University of Health Sciences. She has had the opportunity to apply her theoretical knowledge to the real-life scenarios, as a House Officer (HO) serving at Civil Hospital. Whilst working at the Civil Hospital, she discovered that nothing satisfies her more than helping other humans in need and since then has made a commitment to implement her expertise in the field of medicine to cure the sick and regain the state of health and well-being. Being a Doctor is exactly what you’d think it’s like. She is the colleague at work that everyone wants to know but nobody wants to be. If you want to get something done, you approach her – everyone knows that! She is currently studying with Medical Council of Canada and aspires to be a leading Neurologist someday. Alongside, she has taken up medical writing to exercise her skills of delivering comprehensible version of the otherwise difficult medical literature. Her breaks comprise either of swimming, volunteering services at a Medical Camp or spending time with family.

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