Elderly woman with painless hardened umbilical nodule

An 87-year-old woman presented to the emergency room with 3-day history of severe abdominal pain, gross abdominal distention and absolute constipation, in addition to mental confusion and lowering of consciousness level in the last 12 hours. She had past history of appendectomy and left oophorectomy 40 years ago. Patient's daughter reported a painless hardened nodule in the umbilical region for 45 days. The umbilicus nodule had been diagnosed as an umbilical hernia by the general practitioner and the patient was awaiting outpatient evaluation by a general surgeon. Examination revealed a blood pressure of 140/86 mmHg, a heart rate of 108 beats/min, and oxygen saturations of 96% on room air; positive findings included marked abdominal distension, generalized abdominal tenderness without peritonitis, tinkling bowel sounds and a painless erythematous-umbilical nodule measuring 2.2x1.8cm (A). Laboratory testing was remarkable for elevated white blood cells at 15,180/mm3, C-reactive protein of 66.2 mg/dl, and serum CA125 of 139.9 Units/ml. Computed tomography scan of the abdomen and pelvis showed ovarian mass with extrinsic compression of intestinal loops with significant dilatation upstream of the obstruction point; an umbilical nodule was present (B, C). In view of patients with acute abdominal condition exploratory laparotomy was performed and intraoperatively moderate ascites, severe intestinal loops distension and a large and unresectable ovarian mass were observed. Ascitic fluid analysis was positive for atypical cells and histopathology of the umbilical nodule showed solid low-grade carcinoma with numerous atypical mitoses, karyorrhexis and abundant necrosis. After the discussion with patient's caregivers, palliative care was started and unfortunately the patient died 14 days after the surgery. Sister Mary Joseph nodule is an eponym to describe cutaneous metastasis of an underlying abdominal malignancy to the umbilical cicatrix. This ominous finding is uncommon although accurate sign of advanced primary visceral cancer.