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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.109 no.2 Madrid feb. 2017 



Sister Mary Joseph's nodule as initial pancreatic cancer manifestation

Nódulo de la hermana María José como primera manifestación de cáncer pancreático


Key words: Sister Mary Joseph's nodule. Umbilical metastasis. Pancreatic neoplasms.

Palabras clave: Nódulo de la hermana María José. Metástasis umbilical. Neoplasias pancreáticas.


Dear Editor,

Skin metastasis is a rare sign usually reflecting a carcinoma of unknown origin. The incidence of umbilical skin metastasis secondary to intra-abdominal tumors is extremely low, and very rarely an initial manifestation of pancreatic cancer (1). Pancreatic cancer accounts for 7-9% of Sister Mary Joseph's nodules (2,3).


Case report

We report the case of an 85-year-old female patient who presented with umbilical pain over a ten day period, associated with an indurated growth, approximately 2 x 3 cm in size, adhered to deep planes, with erythematous skin. These symptoms were apparently consistent with incarcerated umbilical hernia, and prompted an urgent surgical procedure for removal (Fig. 1).



The pathology study revealed dermal infiltration by a malignancy including a central area with atypical irregular glands, abundant mitoses, and desmoplastic stroma, surrounded by peripheral areas of moderately differentiated squamous cell carcinoma. Gland tumor cells expressed an immunohistochemical profile initially consistent with pancreatic origin.

In view of these findings a CT scan was performed, which revealed a pancreatic tail tumor, 50 x 49 mm in size, with irregular borders, infiltration of adjacent fat, and central necrosis posteriorly in contact with the splenic vein and anteriorly touching the left colon, as well as multiple hepatic metastases.

Palliation was chosen given the patient's age and the extent of her disease.



Umbilical skin metastasis is a pathology-based diagnosis; a biopsy should be initially obtained, supported by imaging techniques to reveal the primary tumor. Umbilical hernia is the primary diagnosis that must be ruled out for this condition (4). Once diagnosed, umbilical skin metastasis has an ominous prognosis, which may be improved with multidisciplinary treatment (5).


Cristina Vallejo-Bernad1, María Carmen Casamayor-Franco1 and Sofía Hakim-Alonso2
Departments of 1General and Digestive Surgery, and 2Pathology.
Hospital Universitario Miguel Servet. Zaragoza, Spain



1. Bai XL, Zhang Q, Masood W, et al. Sister Mary Joseph's nodule as a first sign of pancreatic cancer. World J Gastroenterol 2012;18:6686-9. DOI: 10.3748/wjg.v18.i45.6686.         [ Links ]

2. Ozaki N, Takamori H, Baba H. Sister Mary Joseph's nodule derived from pancreatic cancer. J Hepatobiliary Pancreat Sci 2011;18:119-21. DOI: 10.1007/s00534-010-0296-y.         [ Links ]

3. Espinel J, Pinedo E, Ojeda V, et al. Sister Mary Joseph's nodule. Rev Esp Enferm Dig 2016;2:97.         [ Links ]

4. López-Corral F. Nódulo de la hermana María José y cáncer de páncreas. Semergen 2011;37(8). DOI: 10.1016/j.semerg.2011.04.006.         [ Links ]

5. Psarras K, Symeonidis N, Baltatzis M, et al. Umbilical metastasis as primary manifestation of cancer: A small series and review of the literature. J Clin Diagn Res 2014;8(10):ND17-9. DOI: 10.7860/JCDR/2014/9690.4997.         [ Links ]