Metastatic vs primary malignant neoplasms affecting the umbilicus: clinicopathologic features of 77 tumors

Intra-Abdominal Malignant Melanoma: Challenging Aspects of Epidemiology, Clinical and Paraclinical Diagnosis and Optimal Treatment—A Literature Review

According to European consensus-based interdisciplinary guidelines for melanoma, cutaneous melanoma (CM) is the most deadly form of dermatological malignancy, accounting for 90% of the deaths of skin cancer patients. In addition to cutaneous melanoma, mucosal melanoma occurs in four major anatomical sites, including the upper respiratory tract, the conjunctiva, the anorectal region, and the urogenital area. As this cancer type metastasizes, a classification used in the current medical literature is the distinction between secondary lesions and primary malignant melanoma of the abdominal cavity. Given that malignant melanoma is the most common cancer that spreads to the gastrointestinal tract, different imaging modalities compete to diagnose the phenomenon correctly and to measure its extension. Treatment is primarily surgery-based, supported by immunotherapy, and prolongs survival, even when performed at stage IV illness. In the end, special forms of malignant melanoma are discussed, such as melanoma of the genito-urinary tract and amelanotic/achromic melanoma. The importance of this present literature review relies on yielding and grouping consistent and relevant, updated information on the many aspects and challenges that a clinician might encounter during the diagnosis and treatment of a patient with intra-abdominal melanoma.

Metastatic Pancreatic Adenocarcinoma to Umbilical Skin

Sister Mary Joseph nodule (SMJN) is a rare metastasis to umbilical skin originating from internal tumors including the stomach, ovary and large intestine and less commonly from pancreatic cancers. We report an uncommon case of metastatic pancreatic adenocarcinoma to umbilical skin.

An 85-year-old female presented with a 1.8 cm protrusion of the right lateral umbilicus. The CT scan showed a 3.5 cm pancreatic lesion, peritoneal carcinomatosis and abdominal lymphadenopathy.

Histology examination revealed atypical infiltrative glandular structures. Immunohistochemistry showed positive CK7, negative CDX2 and P53 with mutated patterns. These were consistent with metastatic adenocarcinoma most consistent with pancreatobiliary or upper GI origin.

CK7 expresses in the ductal cells in pancreatic ductal adenocarcinoma. While CDX2 is positive in intestinal-type adenocarcinoma, it is negative in pancreatic ductal adenocarcinoma. The diagnosis of adenocarcinoma is rendered based on the presence of a pancreatic lesion in CT scan, positive CK7 and negative CDX2 in umbilical nodule tumor cells in the current patient.

SPECT/CT-Guided Surgical Removal of a Positive External Iliac Sentinel Node in Primary Umbilical Melanoma: Report of a Case, and Up-to-Date Review of the Literature

Primary umbilical melanoma is rare tumor, representing about 5% of all umbilical malignancies.The lymphatic drainage from the tumor is challenging and can be to inguinal, axillary and retroperitoneal nodes. Dynamic and static lymphoscintigraphy with single-photon emission tomography/computed tomography (SPECT/CT) and sentinel lymph node biopsy (SLNB) is a widely validated technique in patients with clinically localized melanoma to search for and quantify nodal spread of cutaneous melanoma. Moreover, it offers the surgeon the preoperative information about the number and location of the sentinel lymph nodes (SLNs), which makes SLNB easier and quicker. This is the first report of an ulcerated thick melanoma of the umbilicus metastasizing only to an external iliac lymph-node without involvement of superficial inguinal SLNs. The preoperative high-resolution ultrasound (HR-US) examination of the regional lymph node field had been normal. This case-report shows how addition of SPECT/CT to planar imaging in a patient with clinically localized umbilical melanoma can help avoid incomplete SLNB when a deep SLN is not removed. A literature review of umbilical melanoma is also provided.

Cutaneous Metastases in Ovarian Cancer

Skin metastases in ovarian cancer are uncommon, but their incidence may be increasing due to improved survival rates. Skin metastases can be divided into umbilical metastases, which are known as Sister Joseph nodules (SJNs) and are associated with peritoneal metastasis, and non-SJN skin metastases, which usually develop within surgical scars and in the vicinity of superficial lymphadenopathy. As most skin metastases develop after specific conditions, recognition of preceding metastatic diseases and prior treatments is necessary for early diagnosis of skin lesions. The prognosis of skin metastases in ovarian cancer varies widely since they are heterogeneous in the site of lesion and the time of appearance. Patients with SJNs at initial diagnosis and patients with surgical scar recurrences without concomitant metastases may have prolonged survival with a combination of surgery and chemotherapy. In patients who developed skin recurrences as a late manifestation, symptoms should be treated with external beam radiotherapy and immune response modifiers. Immune checkpoint blockade can enhance anti-tumor immunity and induce durable clinical responses in multiple tumor types, including advanced chemoresistant ovarian cancer. With the use of radiation therapy, which enhances the systemic anti-tumor immune response, immune checkpoint blockade may be a promising therapeutic strategy for distant metastasis, including skin metastasis.

Primary Cutaneous Umbilical Melanoma: The Michigan Experience

BACKGROUND

Primary cutaneous umbilical melanoma is rare. Thorough information regarding its characteristics and treatment, including use of sentinel lymph node biopsy (SLNB) staging, is difficult to obtain. The unique anatomy of the umbilicus adds to the complexity of diagnosing and treating melanoma at this site.

OBJECTIVE

To improve understanding of diagnosis and treatment of primary cutaneous umbilical melanoma through presenting 7 new cases and reviewing 39 cases in the literature.

MATERIALS AND METHODS

The University of Michigan melanoma database query and review of the literature regarding reported cases of primary umbilical melanoma.

RESULTS

In 7 new and 39 previously reported cases of primary cutaneous umbilical melanoma, we describe signs and symptoms, histopathologic features, differential diagnosis, relevant anatomical considerations, and definitive treatment including SLNB when applicable.

CONCLUSION

Our series, combined with a thorough literature review and compilation of findings, provides a better understanding and appreciation of melanoma in the unique anatomical site of the umbilicus, with a reminder to carefully examine the umbilicus during a full skin examination in patients at risk of melanoma. Primary umbilical melanoma presents and can be appropriately treated similarly to cutaneous melanoma in other sites, with attention to relevant anatomy.

Sister Mary Joseph Nodule as a Cutaneous Manifestation of Metastatic Appendiceal Adenocarcinoma: Case Report and Literature Review

Sister Mary Joseph nodule (SMJN) is an uncommon pattern of superficial periumbilical tumor metastasis, with the primary tumor most commonly associated with gynecological or gastrointestinal origins. This manifestation can represent extensive tumor development from any of the intra-abdominal or pelvic structures. Therefore, SMJN carries a poor prognosis, with a two-year survival rate of only 13.5 percent regardless of the etiology of primary cancer. In this case, a 67-year-old man with metastatic mucinous adenocarcinoma of the appendix involving the umbilicus presenting more than five years after the initial cancer diagnosis is reported. The features of patients with metastatic appendiceal carcinoma presenting as SMJN are also reviewed. With the inclusion of our patient, there are six patients who have documented SMJN due to appendiceal carcinoma: two men, two women, and two patients without demographic data. The patients ranged from the ages of 31 to 68 years, with a median age of 56.5 years at cancer diagnosis and 59 years at SMJN diagnosis. In 75 percent of the cases, SMJN was the initial clinical manifestation of a previously unsuspected appendiceal carcinoma and presented clinically one to seven months (median of five months) before the pathologic confirmation of the metastatic appendiceal carcinoma. The likelihood of SMJN presenting as the initial clinical feature of appendiceal cancer may increase in patients with extensive intraperitoneal metastasis in the form of pseudomyxoma peritonei or carcinomatosis. Therefore, the observation of a solitary umbilical nodule should prompt an investigation for an underlying primary neoplasm, as the prognosis after tumor metastasis to the umbilicus is poor.

Umbilical Lesions: Clinicopathologic Features of 99 Tumors

Background. Umbilical lesions are rare, and can be benign or malignant. This retrospective study was conducted to assess the epidemiological, clinical, and histologic characteristics of umbilical masses. Methods. Cases of umbilical masses from January 1994 to August 2016 were retrieved from our institution’s pathology databases, and their clinicopathological features were reviewed. Results. There were a total of 99 cases of umbilical masses, 78 women (78.8%) and 21 men (21.2%). Of these, 59 were malignant (59.6%) and 40 were benign (40.4%). Among the malignant cases, 48 were women with a mean age of 65 years and 11 were men with a mean age of 66 years. All malignant lesions were secondary tumors. Twenty-five patients (42.3%) had a metastatic tumor to the umbilicus with an average of 7 months from the original diagnosis (12 gynecological, 8 pancreatic/gastrointestinal, 2 lymphomas, and a case each of breast, prostate, and melanoma). Of the patients with a benign diagnosis, 30 were women (75%) with a mean age of 52 years and 10 were men (25%) with a mean age of 43 years. The benign lesions included epidermal inclusion cysts (15/40), endometriosis (11/40), lipomas (3/40), neurofibromas (3/40), fibromas (3/40), abscesses (2/40), and 1 case each of tubular apocrine adenoma, serous cystadenoma, and calcified nodule. Conclusion. The most common metastatic tumors to the umbilicus are from the adjacent organs with the gynecologic tract as the most frequent primary followed by the gastrointestinal system. Primary malignant tumors of the umbilical region are rarely identified in clinical practice.

Sister Mary Joseph nodule: a diagnostic challenge

We present the case of a 72-year-old woman who presented with, to our knowledge, the largest reported Sister Mary Joseph lesion in the literature. Often associated with a poor prognosis, the patient went on to have a wide local excision of the lesion and has made a full recovery 2 years after the nodule initially developed. Histological examination confirmed the presence of underlying endometrial cancer and the patient subsequently underwent a total hysterectomy and bilateral salpingo-oopherectomy.

Skin metastases in epithelial ovarian and fallopian tube carcinoma

This study aimed to investigate the clinical features and outcomes of skin metastasis in ovarian and fallopian tube carcinomas.We studied patients with epithelial ovarian or fallopian tube carcinoma who developed skin metastasis from 2001 through 2012, and were also treated with chemotherapy and/or surgery.Skin metastases were classified as umbilical metastasis (Sister Joseph nodule [SJN]) and nonumbilical metastasis. Patients who developed skin metastases at paracentesis sites were excluded.Of the 206 patients treated, 12 (5.8%) developed skin metastasis: 7 developed SJN, and 5 developed nonumbilical metastasis. Six patients had serous carcinoma, 3 had clear cell carcinoma, 2 had endometrioid carcinoma, and 1 had adenocarcinoma. Four patients out of the 7 who developed SJN had skin metastasis at initial diagnosis, and all 4 patients had SJN with concomitant peritoneal dissemination. Of the 4 patients, 3 received chemotherapy, and their survival ranged from 22 to 42 months. Of the 7 patients who developed SJN, 3 patients with stage IIIC disease developed an SJN at recurrence and were treated with surgery and/or chemotherapy. Their survival duration after recurrence ranged from 26 to 43+ months. Five patients developed nonumbilical metastases 3 to 53 months (median 34 months) after initial diagnosis: 3 cases occurred in incisional scars of primary surgery, and 2 in subcutaneous metastasis in the other sites. Survival after recurrence ranged from 56 to 140+ months in 3 patients with incisional scar recurrence, and it was 5 months in 2 other patients.Sister Joseph nodule developed only in patients with peritoneal dissemination, and most patients with SJN survived for >24 months. Nonumbilical metastases occurring in incisional scars of primary surgery may carry a favorable prognosis.

Sister Mary Joseph Nodule as a First Manifestation of a Metastatic Ovarian Cancer

A 76-year-old female presented to our hospital with a 2 cm firm, nontender, protuberant umbilical nodule. She received treatment with antibiotics for suspected granuloma, with no improvement after two months. High levels of CA125 as well as an ovarian cyst and intrathoracic and intra-abdominal lesions on imaging studies made us suspect an ovarian cancer with a Sister Mary Joseph nodule (SMJN) and other metastases. A bilateral salpingo-oophorectomy and umbilical and omentum tumor resections were performed and a metastatic ovarian serous adenocarcinoma was diagnosed by histopathology. After surgery, the patient received chemotherapy with paclitaxel, carboplatin, and bevacizumab; however paclitaxel allergy was observed. As a result, chemotherapy continued with carboplatin and bevacizumab every three weeks for a total of 6 courses. Currently, she is still undergoing treatment with bevacizumab and CA125 levels have been progressively decreasing. SMJN is a rare umbilical metastasis which needs to be considered as a differential diagnosis in the presence of an umbilical tumor for prompt treatment initiation.

Primary peritoneal carcinoma presenting as a Sister Mary Joseph's nodule: A case report and review of the literature

Sister Mary Joseph's nodule is sometimes the first sign of an internal malignancy, including gastrointestinal, gynecological, or malignancy of unknown primary. It is rarely the sole presentation of a primary peritoneal cancer. In this report, we present the case of a 70-year-old female with umbilical drainage and a computed tomography scan consistent with solitary umbilical nodule. Excision of the nodule revealed adenocarcinoma of likely müllerian origin. Surgical staging did not show any evidence of malignancy with the exception of pelvic washings. She was considered to have primary peritoneal adenocarcinoma and was treated with adjuvant chemotherapy.

[Sister Mary Joseph nodule revealing digestive and ovarian carcinoma: report of 4 cases]

Le nodule de Sœur Marie-Josèphe est une métastase ombilicale d'une tumeur le plus souvent intra-abdominale. C'est un signe clinique rare dont l'incidence est de 1-3% de toutes les néoplasies abdomino-pelviennes, avec un pronostic péjoratif du fait de son retard diagnostique. Nous rapportons quatre observations d'une métastase cutanée ombilicale révélatrice d'un adénocarcinome dont deux pancréatiques, un gastrique et un d'origine ovarienne. Le but de notre travail est de montrer à travers ces quatre cas cliniques, l'intérêt de l'imagerie (tomodensitométrie, échographie) et de la biopsie dans la démarche diagnostique. A travers ces quatre observations nous insistons aussi sur les difficultés diagnostiques et thérapeutiques que pose cette tumeur dans nos pays à ressources limitées.

Clinicopathologic features and surgical management of primary umbilical melanoma: a case series

Background

Primary umbilical melanoma is an uncommon tumor that is poorly described in the medical literature. The umbilical region is a particular anatomic site owing to the presence of embryonal remnants, which can be a potential metastatic pathway, as well as the braided lymphatic network drainage. Hence, primary malignant neoplasms affecting the umbilicus require a different and more radical surgical approach compared with other melanomas.

Case presentation

In this report, we describe a series of three patients of Caucasian ethnicity who presented with primary umbilical melanoma at the National Cancer Institute of Naples, Italy. All patients underwent wide excision of the tumor including the underlying peritoneum. No surgical complications, either immediate or delayed, were observed in any of the patients. Sentinel lymph node biopsy was negative in two cases. Two of the patients developed metastatic disease and died after systemic medical therapy. The other patient is currently in follow-up, and remains disease-free after 21 months.

Conclusions

The umbilicus has vascular and embryological connections with the underlying peritoneum, so that early visceral involvement is more likely to occur with primary umbilical melanomas. As such, tumor resection including the underlying peritoneum is required to avoid local relapse, whilst sentinel lymph node biopsy appears to be of poor diagnostic value.

Lesions of the umbilicus: what the minimally invasive gynecologic surgeon needs to know about the belly button

The umbilicus is viewed as a portal by the laparoscopic surgeon, a doorway to the real business at hand. However, the umbilicus itself may be the site of a variety of lesional conditions. Some of these may be iatrogenic, caused by prior surgical interventions, such as endometriosis or seeding of a malignant neoplasm. Some may be the initial presenting complaint. This review discusses umbilical lesions that may be encountered by the minimally invasive gynecologic surgeon.

Sister Mary Joseph's Nodule as a First Manifestation of Primary Peritoneal Cancer

Sister Mary Joseph's nodule metastasis is a rather rare finding. The primary malignancy in women is usually ovarian, endometrial, gastric, or pancreatobiliary tree cancer. We present a case of an 87-year-old patient with Sister Mary Joseph's nodule metastasis caused by a primary peritoneal malignancy. Through a literature search, we also discuss the pathophysiology, diagnostic approach, management, and prognosis of such a condition.

Sister Mary Joseph's nodule associated with rare endometrial squamous cell carcinoma

BACKGROUND

Umbilical metastasis (Sister Mary Joseph's nodule) is a rare physical sign seen only in 1-3 % of patients with an intra-abdominal and/or pelvic malignancy. Here, we present a case of Sister Mary Joseph's (SMJN) nodule originating from a primary squamous cell carcinoma of the endometrium, a rare histological subtype.

CASE HISTORY

SMJN was detected in a 30-year-old woman after a preoperative CT scan for a suspected umbilical hernia. Subsequent laparotomy and histopathological examination confirmed endometrial squamous cell carcinoma metastasizing to the umbilical region.

CONCLUSION

The SMJN may be the first presenting sign of an intra-abdominal and/or pelvic malignancy and may co-exist with an umbilical hernia. Therefore, malignancy should be considered one of the differentials of an umbilical mass.