Umbilical metastases: Real-world data shows abysmal outcome

Sister Mary Jospeh's nodule as metastasis of colorectal cancer. Systematic review of the literature and meta-analysis

INTRODUCTION AND IMPORTANCE

Metastatic cancer of the umbilicus is an uncommon and rare presentation.

CASE PRESENTATION

Our interest for the clinical outcomes of umbilical metastases from colon cancer arose after a 60-years old lady with ulcerated umbilical lesion came to our clinic. She was seen in several other clinics, and the diagnoses of infection of the umbilical region and/or of umbilical hernia were made. She was asymptomatic and in good clinical conditions. A complete evaluation led to the diagnosis of adenocarcinoma in the caecum with umbilical metastasis. During the hospital admission she underwent emergency colectomy for acute obstruction. An uneventful right colectomy was performed, but the lady died 21 months after surgery for diffuse metastases.

CLINICAL DISCUSSION

We performed a literature review of reports describing patients with umbilical metastases. Median survival rate was 7 months from the time of diagnosis of the umbilical metastasis (5 months in clinical reports and 8 months in autopsy studies). Observed survival rates were higher for patients with primary ovarian cancer (18 months), and endometrium (9 months). Median survival rate was 8 months in case of primary colon cancer. Chemotherapy and surgery allowed acceptable survival and quality of life in 8 patients with umbilical metastasis from colon cancer.

CONCLUSION

Clinical experience suggests that an aggressive approach may offer to selected groups of patients with umbilical metastasis from abdominal cancer acceptable quality of life and improved survival probabilities.

Radiation Therapy for Sister Mary Joseph's Nodule: A Review

Purpose

Umbilical metastasis, known as Sister Mary Joseph's nodule (SMJN), is a manifestation of advanced malignant disease. Patients with SMJN usually require supportive care or palliative systemic chemotherapy. However, with the increasing number of older and infirm patients, radiation therapy for SMJN is needed more frequently. Therefore, we conducted this review to provide insights into radiation treatment for this rare condition.

Methods and Materials

We searched PubMed on October 16, 2022, and obtained 275 articles that described SMJN or metastatic tumors within or near the umbilicus, as well as 255 case reports or case series (298 patients) and 20 reviews, original articles, or other study types, 1 of which also described a case.

Results

The prognosis of patients with SMJN is extremely poor. However, some patients can survive for more than 2 years. The primary organs of the umbilical metastasis are mainly in the gastrointestinal tract, including the stomach, colon, and pancreas. In addition to these organs, the ovaries, uterine corpus, and breasts are the major organs affected in women. Metastasis may be divided into 4 types according to the tumor location and mechanism of the extension: within the umbilicus, not within although existing near or adjacent to the umbilicus, in the umbilical or paraumbilical hernia sac, and iatrogenic disease. Only 7 reports described patients who received radiation therapy in detail. The patients were divided into 2 groups: a relatively long course and high total dose (approximately 45 Gy) group, and a short course and low total dose group.

Conclusions

Umbilical metastasis, known as SMJN, is a rare disease and is divided into 4 types based on the location of the disease and extent mechanism. Although the prognosis of the disease is poor, some patients survive for more than 2 years. Only 7 case reports precisely described radiation therapy. Half of the patients were treated with a short course, whereas the other half were treated with relatively high doses of up to 45 Gy.

Long-term survival of the Sister Mary Joseph nodule originating from breast cancer: A case report

BACKGROUND

A Sister Mary Joseph nodule (SMJN) is an uncommon cutaneous metastasis found in the umbilicus, indicating an advanced malignancy. SMJNs typically originate from intra-abdominal sources, rarely from breast cancer. Diagnosis suggests a poor prognosis with a median survival of approximately 8 mo after detection. Managing patients with SMJNs is challenging, as most receive limited palliative care only. The optimal strategy for long-term survival of these patients remains unclear.

CASE SUMMARY

A 58-year-old female, previously diagnosed with right breast cancer 17 years ago and underwent breast-conserving surgery, adjuvant radiotherapy, and endocrine therapy, presented with a 2-cm umbilical nodule. Thirteen years previously, metastases were detected in the right supraclavicular, infraclavicular, hilar, and mediastinal lymph nodes. An umbilical nodule emerged four years before the date of presentation, confirmed as a skin metastasis of primary breast cancer upon excisional biopsy. Despite initial removal, the nodule recurred and grew, leading to her referral to our hospital. The patient underwent extensive excision of the umbilical tumor and immediate abdominal wall reconstruction. Endocrine therapy was continued postoperatively. Five years later, no local recurrence was observed, and the patient continued to work full-time, achieving over 9 years of survival following SMJN diagnosis.

CONCLUSION

This case study aimed to identify the optimal strategy for achieving extended survival outcomes in patients with SMJN through comprehensive treatment. We presented a case of the longest survival in a patient after undergoing a multidisciplinary treatment regimen. Our findings underscore the significance of adopting a multimodal treatment approach comprising timely and wide excision along with adjunctive therapy. This approach can control the disease, prolong survival, and improve the quality of life in patients with SMJN.

Cholangiocarcinoma Resembling IgG4-related Sclerosing Cholangitis

A 66-year-old man diagnosed with immunoglobulin G4-related sclerosing cholangitis (IgG4-SC) with diffuse intrahepatic bile duct stenosis and elevated serum IgG4 levels was referred for a further examination because of elevated serum carbohydrate antigen 19-9 levels despite treatment with corticosteroids. An umbilical nodule was found on a physical examination and a biopsy showed adenocarcinoma. Although several imaging studies revealed no changes from prior studies, bile cytology collected by endoscopic retrograde cholangiopancreatography showed adenocarcinoma. Consequently, the patient was diagnosed with cholangiocarcinoma resembling IgG4-SC after detecting an umbilical metastasis, also known as Sister Mary Joseph's nodule.

Dedifferentiated umbilical metastases from low grade endometrioid endometrial adenocarcinoma complicated by super-obesity: A case report

INTRODUCTION

Umbilical metastases are uncommon and rarely associated with endometrial cancer. In this report we describe a unique case of a patient with low-grade endometrioid adenocarcinoma (EAC) who developed an umbilical metastasis containing dedifferentiated endometrial carcinoma, in the context of super-morbid obesity with a body mass index (BMI) of 80 kg/m².

PRESENTATION OF CASE

A 55-year-old female with atypical endometrial hyperplasia was treated with progestogens whilst attempting weight loss prior to definitive surgery, given the impact of her obesity on surgical risk. She progressed to grade 1 EAC of the uterus and then to metastatic disease in the umbilicus and inguinal lymph nodes. After adequate weight loss, cytoreductive surgery was completed via robotic hysterectomy and bilateral salpingoophorectomy (BSO) and resection of metastatic disease. Differing histological grades were seen across all disease sites with dedifferentiated endometrial carcinoma at the umbilicus. Immunohistochemistry suggested a common uterine origin due to loss of MLH1 and PMS2 proteins.

DISCUSSION

There are no clear management pathways for the rare umbilical metastases related to endometrial cancer. Our patient's significant obesity complicated their clinical course and highlights the risks of progestogen therapy whilst attempting weight loss prior to definitive surgery for low-grade EAC. Differing grades of disease across metastatic sites in EAC is rare and may reflect the recently recognized intratumoral genetic heterogeneity in endometrial cancers.

CONCLUSION

Management of umbilical metastases should be individualized to patient factors and local resources. More research is needed into pathways of care for women with low grade EAC with obesity preventing routine surgical management.

Indurated erythema of abdominal skin: An unusual presentation of metastatic endometrial carcinoma-Case report with literature review

Carcinoma erysipelatoides (CE) is a rare clinical manifestation of cutaneous metastasis, which mimics inflammatory conditions such as erysipelas. Depending on the site of the originating tumour, unusual manifestations involving different sites of the body may occur. We herein report a case of a 60-year-old female patient with metastatic endometrial carcinoma presenting as CE of the abdominal skin and the inguinal folds. Even though the diagnosis of advanced malignancy had been established before and she was currently receiving chemotherapy (carboplatin and paclitaxel), the clinical appearance closely resembled fungal (candidal intertrigo) and consecutively bacterial (erysipelas) infection, which resulted in treatment with antimycotics and antibiotics at first. Dermatohistopathological examination of skin biopsies revealed a diffuse and nodular infiltrate of pleomorphic atypical tumour cells with strong expression of cytokeratin 7 and PAX8, also detectable within lymphatic vessels. Therapy comprised antiseptic ointments to prevent superinfection, palliative electron beam radiation and supportive care. Since there were no targetable KRAS-, NRAS- and BRAF-gene mutations, systemic therapy was switched to checkpoint inhibition (pembrolizumab) in combination with lenvatinib. The overall prognosis of cutaneous metastasis of endometrial carcinoma is dismal with most patients succumbing to disease within few months. Similarly, our patient died after 3 months due to sepsis in the course of malignant pleural effusion. We aim to highlight the possibility of unusual sites of CE and the risk of respective clinical misdiagnoses.

Umbilical nodule - A not always innocuous abdominal finding

ABSTRACT

Sister Mary Joseph's nodule is an umbilical nodule found in patients with metastatic abdominal cancers. It is quite rare finding and needs a high index of suspicion for diagnosis. Detection of Sister Mary Joseph's nodule should warrant widespread search for abdominal carcinoma and it universally carries quite poor clinical prognosis. Here, we describe the case of a 28-year-old patient who presented with Sister Mary Joseph's Nodule and was found to have metastatic signet ring cell gastric carcinoma on investigation. A brief discussion about this rare condition is also presented.

Sister Mary Joseph's Nodule From Renal Cell Carcinoma: A Case Report

Sister Mary Joseph’s nodules (SMJNs) are umbilical skin metastases of various abdominopelvic malignancies, and they rarely originate from renal cell carcinomas. Radiotherapy is typically used to treat the nodules as a palliative intention. We report a rare case of SMJN that originated from clear cell renal cell carcinoma, which was treated with external beam radiation therapy (EBRT) and interstitial brachytherapy (ISBT).

A 74-year-old male patient with a history of left renal cell carcinoma developed an umbilical nodule which was diagnosed as SMJN. The patient underwent EBRT (30 Gy in 10 fractions) and ISBT (12 Gy in two fractions), leading the nodule to complete resolution. This case report might support that radiotherapy, including ISBT, is effective for the treatment of SMJN from renal cell carcinoma.

Metastasis in the gallbladder: does literature reflect reality?

BACKGROUND

Metastases to the gallbladder (GBm) are rare and pose a unique diagnostic challenge because they can mimic a second primary tumor. This study aimed to gain insight into the clinicopathological and epidemiological characteristics of GBm.

METHODS

A comprehensive literature review was performed (literature cohort) and compared with a nationwide cohort of GBm patients diagnosed between 1999 and 2015 in the Netherlands, collected via two linked registries (population cohort). Overall survival (OS) was estimated by Kaplan-Meier. Hazard ratios were determined by a Cox proportional hazard model.

RESULTS

The literature cohort and population cohort consisted of 225 and 291 patients, respectively. In the literature cohort, melanoma was the most frequent origin (33.8%), while colorectal cancer was the most frequent origin in the population cohort (23.7%). Prognosis was poor with median OS ranging from 6.0 to 22.5 months in the literature and population cohorts, respectively. Age, timing of GBm (synchronous/metachronous) and primary tumor origin were independent prognostic factors for OS.

DISCUSSION

Metastases to the gallbladder are rare and carry a poor prognosis. Differences between both cohorts can be attributable to the biased reporting of tumor types that are more easily recognized as GBm because of distinct histological features.

Umbilical Endometriosis: A Systematic Literature Review and Pathogenic Theory Proposal

Umbilical endometriosis represents 30–40% of abdominal wall endometriosis and around 0.5–1.0% of all cases of endometriosis. The aim of this systematic review is to revisit the epidemiology, signs, and symptoms and to formulate a pathogenic theory based on literature data. We performed a systematic literature review using the PubMed and Embase databases from 1 January 1950 to 7 February 2021, according to the PRISMA guidelines. The review was registered at PROSPERO (CRD42021239670). Studies were selected if they reported original data on umbilical endometriosis nodule defined at histopathological examination and described as the presence of endometrial glands and/or stromal cells in the connective tissue. A total of 11 studies (10 retrospective and one prospective), and 14 case series were included in the present review. Overall, 232 umbilical endometriosis cases were reported, with the number per study ranging from 1 to 96. Umbilical endometriosis was observed in 76 (20.9%; 95% CI 17.1–25.4) of the women included in studies reporting information on the total number of cases of abdominal wall endometriosis. Umbilical endometriosis was considered a primary form in 68.4% (158/231, 95% CI 62.1–74.1) of cases. A history of endometriosis and previous abdominal surgery were reported in 37.9% (25/66, 95% CI 27.2–49.9) and 31.0% (72/232, 95% CI 25.4–37.3) of cases, respectively. Pain was described in 83% of the women (137/165, 95% CI 76.6–88.0), followed by catamenial symptoms in 83.5% (142/170, 95% CI, 77.2–88.4) and bleeding in 50.9% (89/175, 95% CI 43.5–58.2). In the 148 women followed for a period ranging from three to 92.5 months, seven (4.7%, 95% CI 2.3–9.4) recurrences were observed. The results of this analysis show that umbilical endometriosis represents about 20% of all the abdominal wall endometriotic lesions and that over two thirds of cases are primary umbilical endometriosis forms. Pain and catamenial symptoms are the most common complaints that suggest the diagnosis. Primary umbilical endometriosis may originate from implantation of regurgitated endometrial cells conveyed by the clockwise peritoneal circulation up to the right hemidiaphragm and funneled toward the umbilicus by the falciform and round liver ligaments.

Umbilical metastases: Real-world data shows abysmal outcome

Umbilical metastases form a clinical challenge, especially when they represent the first sign of malignant disease and the primary tumor is unknown. Our study aims to generate insight into the origin and timing of umbilical metastasis, as well as patient survival, using population‐based data. A nationwide review of pathology records of patients diagnosed with an umbilical metastasis between 1979 and 2015 was performed. Data was collected from the Nationwide Network and Registry of Histopathology and Cytopathology (PALGA) and the Netherlands Cancer Registry. Kaplan‐Meier analyses and log‐rank testing were used to estimate overall survival and a Cox proportional hazard model was used to determine multivariable hazard ratios. A total of 806 patients with an umbilical metastasis were included. There were 210 male (26.1%) and 596 female (73.9%) patients. Distribution of umbilical metastases was different between male and female patients due to the high incidence of umbilical metastases originating from the ovaries in females. They most frequently originated from the ovaries in female patients (38.8%) and from the colon in male patients (43.8%). In 18% of cases no primary tumor could be identified. Prognosis after diagnosis of an umbilical metastasis was dismal with a median survival of 7.9 months (95% confidence interval 6.7‐9.1). The origin of the primary tumor was an independent prognostic factor for overall survival. In conclusion, umbilical metastases relatively rare, mainly originating from intraabdominal primary tumors. Survival is dependent on the origin of the primary tumor and poor overall survival rates warrant early recognition.

What's new?

Umbilical metastases are a rare consequence of malignant disease that pose unique clinical challenges. Very little is known about these metastases, especially regarding incidence and survival. This population‐based analysis of more than 800 patients in the Netherlands shows that the distribution in umbilical metastases differs between males and females. In females, metastases most commonly originated from the ovaries, while in males, the colon was most common. Umbilical metastases, however, were linked to a variety of primary tumors and were frequently diagnosed synchronously with the primary tumor. While prognosis was poor overall, survival was influenced by primary tumor origin.