A 63‐year‐old Puerto Rican man with a history of benign prostatic hyperplasia, hypertension, and chronic kidney disease presented with sudden onset of difficulty urinating and high blood pressure. On the day of presentation, the patient noticed difficulty urinating associated with penile swelling and discomfort. His left leg is chronically swollen, but was noted to have increased in size in the 2–3 days prior to admission. On admission, the patient was afebrile and hypertensive. On exam, patient was noted to have an “irreducible umbilical hernia,” firm and nodular, measuring 4.3 cm. Labs were most notable for a creatinine of 5.9, far above his baseline. Retroperitoneal ultrasound demonstrated severe hydronephrosis. Abdominal CT revealed a 10Qcm mass posterior to the bladder, a 5‐cm mass in the inguinal canal, a 5.2‐cm mass inferior to the right hepatic lobe, and a 3.3‐cm mass in the retroperitoneum. Biopsy of the umbilical nodule was consistent with malignant peritoneal mesothelioma (MPM). Chemotherapy was initiated, but the patient ultimately elected to pursue further treatments near family in Puerto Rico and was discharged from our care.
The umbilical lesion with which the patient presented was a so‐called Sister Mary Joseph (SMJ) nodule, indicative of underlying abdominal malignancy. Named for Sister Mary Joseph, the first assistant for Dr. William Mayo at the Mayo Clinic in the early 1900s, these umbilical nodules were often noted to be associated with advanced abdominal malignancies. Primary malignant nodules in the umbilical area are extremely rare. SMJ nodules are generally metastatic and are seen in 1%–3% of all intra‐abdominal and pelvic malignancies; they are the first and only sign of an underlying neoplasm in up to 30% of cases. The site of origin of malignancy remains unknown in more than 30% of cases as well. SMJ nodules are mainly adenocarcinomas, with half of the cases stemming from GI cancers such as the stomach, colon, or pancreas. An umbilical nodule from metastatic mesothelioma is exceedingly rare, and to our knowledge there are only two case reports of a primary localized malignant mesothelioma in the umbilical area. Approximately 10% of mesotheliomas are found in the abdomen, but rarely do they involve the umbilicus. In the United States, only about 400 cases are diagnosed annually. We were not able to determine whether the umbilical nodule in our patient was the primary source, as further biopsies of his other abdominal tumors were deferred.
The Sister Mary Joseph nodule is important to recognize as heralding previously undiagnosed advanced abdominal malignancy.
To cite this abstract:Sankey C, Zhang K. The Sister Mary Joseph Nodule As Presentation of Advanced Malignant Peritoneal Mesothelioma. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 455. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/the-sister-mary-joseph-nodule-as-presentation-of-advanced-malignant-peritoneal-mesothelioma/. Accessed April 25, 2019.