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Endometrial cancer presenting as a paraumbilical hernia containing a Sister Mary Joseph nodule Uei Pua ⁎, Lawrence Quek Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore
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Article history: Received 21 May 2009 Received in revised form 29 May 2009 Accepted 15 June 2009 Keywords: Endometrial cancer Paraumbilical hernia Sister Mary Joseph nodule Umbilical metastasis
Umbilical metastasis, also known as a Sister Mary Joseph nodule (SMJN), is a rare entity; at first encounter its significance may not be appreciated fully. SMJN is often the first manifestation of an underlying malignancy or may herald tumor recurrence of a previous malignancy. An 82-year-old woman presented with a 2-week history of pain and erythema in the paraumbilical region. Physical examination revealed an indurated irreducible paraumbilical lump, mild abdominal distension, and hyperactive bowel sounds. Computed tomography of the abdomen and pelvis revealed a paraumbilical hernia with herniation of omental fat (Fig. 1; straight arrow). What was not appreciated at the time of the scan was the presence of an enhancing soft-tissue mass and surrounding inflammatory change in the inferior aspect of the hernia sac (Fig. 1; curved arrow). The uterus was markedly enlarged and filled with fluid (Fig. 1, “U”), with irregular thickening of the uterine wall. Ultrasound evaluation was recommended. There was no evidence of bowel obstruction or other intra-abdominal lesion. The patient subsequently underwent mesh repair of the paraumbilical hernia. Intraoperatively, a soft tissue mass adherent to the herniated omental fat was found. Histology of the excised tissue showed moderately differentiated adenocarcinoma with surrounding omental fat. Immunohistologic staining was positive with cytokeratin 7 (CK7), but negative with cytokeratin 20 (CK20) and thyroid transcription factor-1 (TTF-1), which suggested ovarian or uterine origin. On retrospective review of the CT image, the operative and pathologic findings correlated with the soft tissue found within the hernia sac. Furthermore, ultrasound of the pelvis (not shown) confirmed the presence of irregular uterine wall excrescence and masses. Subsequently, the patient disclosed postmenopausal bleeding of 6-months duration and an enlarged uterus was found on pelvic examination. Tumor markers including serum CA125 were not elevated. Endometrial cancer was confirmed by curettage and the patient was treated with medroxyprogesterone for metastatic endometrial cancer. SMJN is typically described in cases of gastric carcinoma, but metastasis of gynecological origin—especially ovarian cancer—is most
⁎ Corresponding author. Department of Diagnostic Radiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433. Tel.: +65 9754 7525; fax: + 65 6759 9940. E-mail address:
[email protected] (U. Pua).
Fig. 1. Sagittal CT image showing a paraumbilical hernia with omental fat within the hernia sac (straight arrow). An enhancing soft-tissue mass is seen in the inferior aspect of the hernia sac (curved arrow), which was subsequently diagnosed as a Sister Mary Joseph nodule. The uterus (U) is enlarged and fluid-filled with irregular thickening of the uterine wall.
common among women. Umbilical metastasis from endometrial cancer is rare, with fewer than 30 cases reported in the literature [1]. Possible routes of metastasis include the rich lymphatic and vascular anastomoses around the umbilicus and transperitoneal route. The present case highlights the need for careful evaluation of paraumbilical lesions since umbilical metastasis can coexist with benign conditions such umbilical hernia [1,2]. Biopsy should be considered in suspicious paraumbilical lesions because SMJN is often the first sign of intra-abdominal malignancy. Conflict of interest The authors declare that they have no conflicts of interest. References [1] 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(6):385–8. [2] Gabriele R, Conte M, Egidi F, Borghese M. Umbilical metastases: current viewpoint. World J Surg Oncol 2005;3(1):13.
0020-7292/$ – see front matter © 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2009.06.011
