Cholangicarcinoma Presenting as a Sister Mary Joseph Nodule

Sister Mary Joseph's nodule: A rare metastasis of hilar cholangiocarcinoma: A new case report and review of the literature

Introduction

Sister Mary Joseph's Nodule (SMJN) is a rare clinical sign of metastatic abdominal malignancies, particularly cholangiocarcinoma, with limited reported cases in the literature. SMJN is associated with poor prognosis, often indicating advanced disease with widespread metastasis.

Case presentation

we present a new case report of SMJN in a 46-year-old patient who presented with ten days of right upper quadrant pain, obstructive jaundice, and fever. Physical examination revealed obstructive jaundice with scratchy lesions in the trunk and tenderness in the right upper quadrant, along with a two-centimeter protuberant, tender ulcerated umbilical nodule. Despite previous management with antibiotics and local care, the nodule had been progressively growing over a month. Imaging studies revealed a hilar cholangiocarcinoma with extensive local invasion and multiple distant metastases, including cutaneous involvement at the umbilicus. Biopsies of the umbilical lesion confirmed metastatic adenocarcinoma of the biliary tree. Palliative measures, including biliary stent placement and chemotherapy, were initiated.

Discussion

SMJN is a rare but notable cutaneous manifestation associated with advanced intra-abdominal malignancies. Although often linked to gastric, pancreatic, and ovarian cancers, it is uncommonly reported with cholangiocarcinoma. SMJN typically signifies a late-stage, metastatic progression, with prognosis largely determined by the underlying primary cancer's aggressiveness and the extent of metastasis. In this case, SMJN presented alongside other symptoms of advanced disease, such as obstructive jaundice and extensive local invasion, underscoring its prognostic significance. Recognition of SMJN is essential for prompt diagnosis and initiation of palliative interventions in patients with suspected metastatic disease. This case adds to the limited literature on cholangiocarcinoma-associated SMJN and highlights the need for awareness among clinicians regarding atypical metastatic presentations, which may facilitate earlier diagnosis and tailored care strategies.

Conclusion

This case emphasizes the importance of recognizing SMJN as a rare but crucial indicator of advanced cholangiocarcinoma. It highlights the clinical challenges posed by metastatic cholangiocarcinoma and underscores the need for a comprehensive approach to palliative care in patients with SMJN.

Benign Umbilical Tumors Resembling Sister Mary Joseph Nodule

BACKGROUND

When physicians see an umbilical nodule, most of them instinctively recall the Sister Mary Joseph nodule. Therefore, dermatologists need to recognize umbilical dermatoses that can be mistaken for the Sister Mary Joseph nodules. This study aimed to describe the different kinds of benign umbilical tumors as well as elucidate the factors that can be used to distinguish the Sister Mary Joseph nodule from these tumors.

METHODS

The "benign umbilical tumor" group included 19 patients, whereas the "Sister Mary Joseph nodule" group comprised 30 patients (2 from our department, 28 from PubMed search). We compared the clinical and dermoscopic findings between 2 groups.

RESULTS

In the "benign umbilical tumor" group, the most common diagnosis was dermatofibroma (5/19), followed by keloid (3/19), and soft fibroma (3/19). These tumors had various colors (red, brown to black, and flesh colored) and exhibit characteristic surface changes (eg, verrucous changes in epidermal nevi and verrucae). Conversely, most Sister Mary Joseph nodules have an erythematous color, oozing or ulceration on the surface, and nearby satellite lesions. Furthermore, the dermoscopic findings of Sister Mary Joseph nodules showed a polymorphous vascular pattern and a white or milky-red, amorphous area. Benign lesions showed different dermoscopic patterns: pigment networks with white areas (dermatofibromas), thrombosed capillaries (verrucae), and the "pore sign" (epidermal cysts).

CONCLUSIONS

Various cutaneous tumors can be mistaken for the Sister Mary Joseph nodule when they develop on the umbilicus; the clinical and dermoscopic differences found in this study may be useful for establishing a differential diagnosis.

Recurrent Cholangiocarcinoma Presenting as Sister Mary Joseph Nodule After Liver Transplantation

Hilar cholangiocarcinoma, also known as Klatskin tumor, is the most common type of cholangiocarcinoma. It usually has a lymphatic spread and is rarely associated with an umbilical nodule, also known as Sister Mary Joseph nodule. We report a case of a 53-year-old Caucasian man with hilar cholangiocarcinoma. The patient had an inoperable tumor and was referred to our center for liver transplantation. Post liver transplantation, the patient presented with a recurrence of the carcinoma in the umbilical region. The patient was found to have Sister Mary Joseph nodule. It carries a poor prognosis, and our patient succumbed to the illness in four months. Cholangiocarcinoma carries a poor prognosis. Surgical resection and liver transplantation with neoadjuvant chemoradiation are the preferred treatment strategies. Association of cholangiocarcinoma with umbilical metastasis is rare, and our patient had an even rarer presentation in the form of recurrence with umbilical nodule post-liver transplantation. We want to increase the awareness of the rare presentation, association, and recurrence of hilar cholangiocarcinoma in the form of umbilical nodule post-liver transplantation.