|LETTER TO THE EDITOR
|Year : 2017 | Volume
| Issue : 1 | Page : 29-30
Sister Mary Joseph's nodule: Two rare cases of inoperable gallbladder cancer
AK Jha1, SK Jha1, R Kumar2, U Kumar1
1 Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
2 Department of Gastroenterology, Paras HMRI Hospital, Patna, Bihar, India
|Date of Web Publication||1-Dec-2017|
Dr. A K Jha
Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jha A K, Jha S K, Kumar R, Kumar U. Sister Mary Joseph's nodule: Two rare cases of inoperable gallbladder cancer. Indian J Cancer 2017;54:29-30
Secondary umbilical malignancy also known as Sister Mary Joseph's nodule (SMJN) is a cutaneous sign of advanced cancer. Gallbladder cancer presenting with SMJN is rare. We describe two cases of SMJN in gallbladder cancer.
The first case was a 67-year-old male who presented with pain abdomen, anorexia, and umbilical nodule [Figure 1]a. The investigations revealed raised alkaline phosphatase (590.6 U/L) and cancer antigen 19-9 (301.1 U/ml). Computed tomography scan revealed irregular thickening of gallbladder wall with liver parenchymal invasion, porta hepatis infiltration, and mild dilated bile ducts [Figure 2]. Peritoneal metastatic nodules and enhancing umbilical nodule were noted. Fine needle aspiration cytology (FNAC) of the umbilical nodule showed malignant cells [Figure 3]. Curative surgical resection was not possible; therefore, patient is receiving chemotherapy and symptomatic treatment.
|Figure 1: Sister Mary Joseph's nodule; (1a) First case and (1b) Second case|
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|Figure 2: Contrast enhanced computed tomography showing irregular thickening of gallbladder wall with invasion of adjacent liver parenchyma|
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|Figure 3: Fine needle aspiration cytology of umbilical nodule showing malignant cells (Giemsa, ×400)|
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The second case was a 50-year-old female who presented with pain abdomen, abdominal distension, icterus, pallor, hepatomegaly, ascites, and umbilical nodule [Figure 1]b. The investigations showed anemia, leukocytosis, increased bilirubin, and raised alkaline phosphatase. Ultrasound revealed a gallbladder fossa mass (size 77 mm × 44 mm) infiltrating into liver and dilated bile ducts. Ascites, right-sided pleural effusion, peripancreatic lymph nodes, and umbilical nodule were also noted. FNAC of the umbilical nodule revealed metastasis. General symptomatic therapy was advised.
SMJN is described as a malignant umbilical tumor usually associated with advanced intraabdominal malignancy. It is mostly seen in metastasizing cancer and therefore denotes a poor prognostic sign. The occurrence of SMJN as the first sign of malignancy is very rare. The stomach (23%), ovary (16%), colon (15%), and pancreas (10%) are most common primary site. Gallbladder cancer is endemic in the Gangetic belt of India. Only handful cases of SMJN have been described in gallbladder malignancy. Gallbladder cancer presenting with SMJN as first sign is rare.,, Typical presenting features of gallbladder cancer were absent in first case. Second case had clinical features of disseminated malignancy.
It is important to identify an umbilical metastasis because it suggests inoperability of tumor. Surgery with curative intent is not possible in gallbladder cancers presented with SMJN.,,, The patients presented with SMJN are usually a candidate for palliative treatment. Recent reports have shown better survival with a combination of surgery and adjuvant chemotherapy.
The possible mechanism of tumor spread to umbilicus could be through vascular route, lymphatic channels, contiguous extension, or embryologic remnants in the anterior abdominal wall.
In conclusion, gallbladder cancer presenting with SMJN is very rare. The presence of SMJN is an indicator of inoperable gallbladder cancer.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]