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Electronic Clinical Challenges and Images in GI Umbilical Mass
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Question: An 80-year-old man presented to our surgery unit with a 6-month history of a growing umbilical lesion. He also had symptoms of fatigue, loss of weight, and constipation over the past year. The patient was taking medication for glaucoma and hypertension as well as hormonal therapy for prostate cancer. His past history was significant for cerebral ischemia without infarction 5 years ago and choledocholithiasis treated with endoscopic retrograde cholangiopancreatography and sphincterotomy 2 years ago. Physical examination revealed a 2.5-cm, hard, fixed, painless nodule protruding through the umbilicus (Figures A and B). There were no other abdominal masses and no regional lymphadenopathy. Laboratory studies performed in outpatient setting showed a mild anemia (115 g/L); serum chemistries, electrolytes, white blood cell count, platelet count, coagulation factors, and total prostate-specific antigen values were normal. A biopsy of the umbilical mass was performed. What is your clinical suspicion?
See the GASTROENTEROLOGY web site (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. RAFFAELE LOMBARDI DAJANA CUICCHI BRUNO COLA Department of General Surgery and Organ Transplantation General Surgery Unit S. Orsola-Malpighi Hospital University of Bologna Bologna, Italy
Conﬂicts of interest The authors disclose no conﬂicts. © 2010 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2009.11.070
GASTROENTEROLOGY 2010;139:e9 – e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 139, No. 5
Answer to the Clinical Challenges and Images in GI Question: Image 5: Adenocarcinoma Pathologic examination of biopsy of the umbilical lesion showed a moderately differentiated adenocarcinoma that was positive for CK20 and negative for CK7 expression. On the basis of these results colonoscopy was performed, revealing a severe malignant stricture at the level of the left colic flexure (Figure C). Clinical staging by computed tomography (CT) confirmed the presence of an umbilical mass infiltrating the rectus sheaths (Figure D, arrow) and a left-sided colonic stricture (Figure E, arrow), and revealed multiple metastases on the right liver (Figure F). A diagnosis of stage IV moderately differentiated adenocarcinoma of the colon was made. Considering the risk of large bowel obstruction, palliative segmental colonic resection together with a wide excision of the cutaneous metastasis were performed. A fluorouracil-based chemotherapy was started 1 month after discharge. At 9 months from diagnosis, the patient is clinically well but CT scan revealed the appearance of multiple small pulmonary nodules. Umbilical metastasis may be a clinical sign of different intra-abdominal, pelvic, or thoracic malignant diseases. It is also known as “Sister Mary Joseph’s nodule” in recognition of a Dr William J. Mayo’s surgical assistant, who first noticed the association between umbilical nodules detected during preoperative scrub and abdominal malignant findings at laparotomy. The most common primary lesion is a gastrointestinal or gynecologic carcinoma.1 Spread to the umbilicus may occur through lymphatic drainage, hematogenous dissemination, contiguous extension, iatrogenic implantation, or embryologic remnants.2 Sister Mary Joseph’s nodule can be the first sign of an unknown cancer and is usually associated with advanced metastatic disease. Therefore, the prognosis is generally poor with an average survival time of ⬍1 year.3 Differential diagnosis comprises umbilical hernia, benign lesions (ie, epidermoid cysts, omphalitis, foreign body granuloma), endometriosis, and skin malignancies. Histologic examination usually enables the final diagnosis and CK20/CK7 immunohistochemical profiles may strongly suggest the site of the primary tumor. References 1. Galvan VG. Sister Mary Joseph’s nodule. Ann Intern Med 1998;128:410. 2. Dubreuil A, Dompmartin A, Barjot P, et al. Umbilical metastasis or Sister Mary Joseph’s nodule. Int J Dermatol 1998;37:7–13. 3. Gabriele R, Conte M, Egidi F, et al. Umbilical metastases: current viewpoint. World J Surg Oncol 2005;3:13. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).