On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.84 no.3 Rio de Janeiro July 2009
WHAT IS YOUR DIAGNOSIS ?
Themis Getsos CollaI; Louise LovattoII; Rodrigo Pereira DuquiaIII
IIntern and second-year resident physician,
Department of Dermatology of Santa Casa de Porto Alegre Porto Alegre
IIDermatologist at Santa Casa de Porto Alegre Porto Alegre (RS), Brazil
IIIMaster of Epidemiology Universidade Federal de Pelotas (UFPel) Pelotas (RS), Brazil. Dermatologist at Santa Casa de Porto Alegre Porto Alegre (RS), Brazil
A 56-year-old man was hospitalized with a history of diffuse abdominal pain. Cutaneous examination revealed an erythematous to violaceous, infiltrative nodule of the umbilicus. Histologic examination demonstrated poorly differentiated adenocarcinoma. Abdominal tomography showed advanced pancreatic cancer with metastatic involvement of the liver and the diagnosis of pancreatic adenocarcinoma with umbilical metastasis - Sister Mary Joseph's nodule.
Keywords: Neoplasm metastasis; Pancreas; Umbilicus
Fifty-six-year-old man with liver cirrhosis secondary to chronic alcoholism was admitted with diffuse abdominal pain and jaundice. Routine laboratory tests were ordered and they presented normal results; a paracenthesis diagnosed spontaneous bacterial peritonitis that was treated with antibiotics. The patient underwent esophagogastroduodenoscopy, which showed varices on the stomach fundus and body; and a total abdominal echography showed a diminished liver with irregular contour, compatible with liver cirrhosis and the presence of ascitis; the retroperitoneum could not be visualized.
During hospitalization in a clinical unit, dermatological assessment of the umbilical lesion was ordered. Upon examination, the patient presented a mildly painful umbilical nodule, erythematous to violaceous, with keratotic areas, measuring 2x2 cm (Figure 1). A biopsy revealed metastasis of poorly differentiated adenocarcinoma (Figure 2). Immunohistochemical analysis was positive for cytokeratin 7 and CA 19.9, suggesting that the site of the primary tumor was either the pancreas or biliary tract (Figure 2). A total abdominal CT scan identified an expansive lesion on the body of the pancreas, probably of neoplastic ethiology, with metastatic dissemination to the liver (Figure 3). The patient was referred to the clinical oncology department, which decided for palliative care due to his clinical instability, with death after ten days.
Umbilical metastasis, also called Sister Mary Joseph nodule is a rare form of tumor presentation. It usually is secondary to intra-abdominal tumors, but metastases from other sites like the lung and breast have also been reported in the literature.1-3 Among intra-abdominal tumors, the most frequent locations are the stomach, in men, and ovaries, in women. Pancreas cancer is the fifth most frequent site, behind intestine tumors and unknown origin tumors.4 This signal may precede the diagnosis of the primary lesion in up to 30% of the cases, as herein presented.
Sister Mary Joseph (SMJ) was born on May 14, 1856, in Salamanca, New York. Her parents were Irish immigrants who moved Minnesota after the Civil War. At the age of 22, she joined the Third Regular Order of the Congregation of Our Lady of Lourdes, in Rochester, Minnesota.5 The main objective of that order was to establish St Marys Hospital, which was built by William W. Mayo, father of the Mayo brothers. SMJ received formal nursing training and was mentored by Edith Graham, the first nurse in Minnesota.5 In three years, SMJ was appointed superintendent of the hospital. At that time, she was already involved in the clinical care to patients and was the first surgical assistant to Dr. William Mayo.5 She was the firs person to note that the presence of a paraumbilical nodule, which frequently was the only physical sign of an intra-abdominal malignancy, and which indicated an advanced stage of the disease.5 In 1949, Hamilton Bailey mentioned in the 11th edition of his textbook "Physical Signs in Clinical Surgery" the sign identified by SMJ, giving her credit for the finding.
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2. Inadomi T. Sister Mary Joseph's nodule: a clue to finding pancreatic cancer in a patient previously affected by gastric cancer. Eur J Dermatol. 2005;15:492-4 [ Links ]
3. Baratta A, Gorin RJ, Costa R. Sister Mary Joseph nodule: a case report. Cutis. 2007;80:469-72 [ Links ]
4. Crescentini F, Deutsch F, Sobrado CW, Araujo S. Umbilical mass as the sole presenting symptom of pancreatic cancer: a case report. Rev Hosp Clin Fac Med Sao Paulo. 2004;59:198-202 [ Links ]
5. Piura B, Meirovitz M, Bayme M, Shaco-Levy R. Sister Mary Joseph's nodule originating from endometrial carcinoma incidentally detected during surgery for an umbilical hernia: a case report. Arch Gynecol Obstet. 2006;274:385-8 [ Links ]
Themis Getsos Colla
Av. Lageado, 1396 - 402
90460 110 Porto Alegre RS
Tel./Fax: 51 9191 7703
Conflict of interest: None
Financial funding: None
How to cite this article: Colla TG, Lovatto L, Duquia RP. Caso para diagnóstico. Metástase umbilical de carcinoma pancreático (Sister Mary Joseph Nodule). An Bras Dermatol. 2009;84(3):297-8.