UMBILICAL

MASS AS THE SOLE PRESENTING

SIGN

Introduction
A firm umbilical mass with pain and
cough impulse as the only presenting sign
often misleads us into thinking about it as an
obstructed umbilical hernia instead of it being
a secondary spread of tumor from some other
organ. Also, such cases have been rarely
documented in the literature in the past. It is a
late manifestation of a malignant disease and
represents an advanced stage of the
tumor(Wronski, Klucinski, & Krasnodebski,
2014).

Description
An 86-year-old female presented to

the ER with chief complaints of periumbilical
pain and constipation for 3 days. Patient gives
an associated history of swelling arising from
the umbilicus from last 53 years following the
last child birth and she has not undergone any
treatment for swelling. Patient has no
associated history of weight loss or loss of
appetite. She gives a past history of vaginal
hysterectomy before 30 years for
uncontrolled bleeding per vagina. On physical
examination, she has a 3 x 3 cm swelling over
umbilicus. The swelling was of the same color
as of the surrounding skin, firm in
consistency, slightly painful cough impulse
was present but non reducible.

An abdominal sonography was
ordered which was suggestive of 35 x 22mm The patient was operated on the next
sized solid cystic lesion with solid component day. An elliptical incision was kept around the
showing vascularity and specks of calcium umbilicus and the mass was resected out
noted in left paraumbilical region and along with the umbilicus and the skin
Paraumbilical hernia with herniating bowel
loops and omentum A CT scan was advised by
the radiologist to rule out obstructive hernia.
The CT scan showed umbilical hernia with
herniating omentum with enhancing solid
cystic levels in it and the presence of hydatid
cysts in liver.
overlying it. suggestive of possibility of carcinoma, which
might be metastatic, and the pathologist
further advised to search for primary tumor.
A detail physical examination of
patient was done following which no clinical
signs of any type of malignancy was elicited.
Patient was discharged on post-operative day
3 and was asked to follow up after 4 days. The
patient was asked for follow up with tumor
reports (CA-125, CEA and CA 19-9) and
mammography. On follow up the levels of CA-
125 turned out to be 91(Normal 0-37) and
other tumor markers were in normal limit.
Mammography didnt show any significant
Peroperatively firm to hard mas which changes.
contained omentum, no bowel loops were
trapped in the sac, no other anomalies was Discussion
seen in examination of small intestine or large A firm umbilical swelling with
intestine or any other solid abdominal organs. cough impulse and a history of constipation
The resected mass was sent for since 2 days leads to several possible
histopathological examination. differential diagnosis like obstructed
umbilical hernia, granuloma, attachments of
the urachus, granuloma, omphalomesenteric
duct developmental abnormalities and benign
or malignant tumor in this
patient(Crescentini, Deutsch, Sobrado, &
Arajo, 2004). Most of the cases have benign
lesions but there is also a rare chance of the
tumor being malignant(Chatterjee SN & Bauer
HM, 1980). The spread of the tumor can occur
in several different ways. Metastasis to the
umbilicus can occur due to the proximity of
the tumor to the umbilicus or may be a
hematogenic or lympatic spread or via
umbilical ligaments. Peritoneal metastasis is
the most common form of spread of tumor.
Backward flux from the lymphatics in axilla,
inguinal or para-aortic nodes can also cause
umbilical involvement. Communication
between lateral thoracic veins and internal
mammary veins with the portal circulation
can
also lead to the spread of tumor(Powell,
The HPE report of the patient resected Cooper, Massa, Goellner, & Su, 1984). Thus,
mass showed adipose tissue being infiltrated theoretically all the types of tumors,
by malignant tumor cells arranged in sheets, irrespective of their position and the site of
groups and nests having pleomorphic, primary origin, can spread to the umbilicus
hyperchromatic vesicular nuclei with but the most prevalent primary sites are
prominent nucleoli. Areas of calcification intra-abdominal.
were also seen. These findings were
 Tumor markers should always be
assessed in such cases where a malignancy is
suspected. CA-125 is a frequently used tumor
marker in suspected cases of ovarian cancer
and around 90% of women with advanced
ovarian cancer have elevated levels of CA-125
in their blood serum. Similarly, CEA is
measured in suspected cases of colorectal
cancer and CA 19-9 in suspected cases of
pancreatic cancer.
A metastatic nodule known as Sister
Mary Joseph Nodule which presents as a firm,
indurated mass around the umbilicus
suggests a co-relation between umbilical
swelling and internal malignancy(Khan &
Cook, 1997)(Crescentini et al., 2004). The
commuted tomography shows a contrast-
enhancing tumor in the umbilicus but the
radiologists because of the rarity of the tumor
often miss it. The gross view of the Sister
Mary Joseph nodule on physical examination
is also deceptive since the skin over the lesion
might be normal as seen in this case. Also,
these nodules are not painful like some other
inflammatory lesions. The patient in this case
also did not notice this nodule and presented
to the ER with pain because of the obstructed
hernia and not because of the nodule over
umbilicus.

Conclusion:
Detection of such firm hypoechoic
mass in the umbilicus without any gross or
sonographic features of inflammation
demands further evaluations including CT
scan, tumor markers and examination of
surrounding organs and should give rise to
the suspicion of it being a Sister Mary Joseph
nodule. The site of the origin of primary
tumor and other metastasis should also be
searched for(Crescentini et al., 2004).








Bibliography:

Chatterjee SN, & Bauer HM. (1980). Umbilical metastasis from carcinoma of the pancreas.
Archives of Dermatology, 116(8), 954955. doi:10.1001/archderm.1980.01640320104025

Crescentini, F., Deutsch, F., Sobrado, C. W., & Arajo, S. de. (2004). Umbilical mass as the sole
presenting symptom of pancreatic cancer: a case report. Revista Do Hospital Das Clnicas, 59(4),
198202. doi:/S0041-87812004000400008

Khan, A. J., & Cook, B. (1997). Metastatic carcinoma of umbilicus: Sister Mary Josephs nodule.
Cutis, 60(6), 297298.

Powell, F. C., Cooper, A. J., Massa, M. C., Goellner, J. R., & Su, W. P. (1984). Sister Mary Josephs
nodule: a clinical and histologic study. Journal of the American Academy of Dermatology, 10(4),
610615.

Wronski, M., Klucinski, A., & Krasnodebski, I. W. (2014). Sister Mary Joseph Nodule: A Tip of an
Iceberg. Journal of Ultrasound in Medicine, 33(3), 531534. doi:10.7863/ultra.33.3.531