Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Case Report
doi: 10.4103/0378-6323.55396
PMID: 19736432

Sister mary joseph's nodule: A case of umbilical cutaneous metastasis with signet ring cell histology

Valid Bagher Zadeh, Randhir Kadyan, Adel Al-Abdulrazzaq, Sultan Al-Otaibi, Amr Sarhan, Nabeel Najem
 Department of Dermatology, Adan Hospital, Kuwait

Correspondence Address:
Valid Bagher Zadeh
Department of Dermatology, Adan Hospital
How to cite this article:
Zadeh VB, Kadyan R, Al-Abdulrazzaq A, Al-Otaibi S, Sarhan A, Najem N. Sister mary joseph's nodule: A case of umbilical cutaneous metastasis with signet ring cell histology. Indian J Dermatol Venereol Leprol 2009;75:503-505
Copyright: (C)2009 Indian Journal of Dermatology, Venereology, and Leprology


The metastasis of a visceral malignancy to the umbilicus is known as "Sister Mary Joseph's nodule". It is a rare clinical sign indicating advanced, metastasizing intraabdominal cancer. We report a 50-year-old man who developed metastatic skin cancer in the form of semicircular indurated plaque on top of which was a firm mobile rounded nodule at the umbilical area. Histopathological examination demonstrated diastase-resistant periodic acid-Schiff and mucicarmine positive signet ring cells, suggesting gastric carcinoma. Immunohistochemical staining showed that these cells were positive for cytokeratins and epithelial membrane antigen, suggesting epithelial origin.
Keywords: Cutaneous metastasis, Sister Mary Joseph′s nodule, Signet ring cell


Umbilical metastasis (Sister Mary Joseph′s nodule), named by Hamilton Bailey after Sister Mary Joseph, is a rare physical sign encountered in 1−3% of the patients with intraabdominal and/or pelvic malignancy, with gastric carcinoma being the most common origin in men and ovarian carcinoma in women. [1],[2],[3],[4],[5] Signet ring cells, when seen in a metastatic skin deposit, may indicate that the primary tumor is from the stomach or colon. We report a patient whose metastatic skin cancer was characterized by many mature signet ring cells invading the dermis.

Case Report

A 50-year-old man presented with a single asymptomatic skin lesion around the umbilicus of one-month duration. Examination revealed erythematous semicircular indurated plaque attached to the lower part of the umbilicus which was neither painful nor tender. On top of the plaque, there was a single erythematous firm mobile rounded nodule about half centimeter in diameter [Figure - 1]. Abdominal palpation did not reveal liver, spleen or lymph node enlargement. His full blood count and blood biochemistry studies were normal. No abnormalities were seen on urine and stool examination. Chest X-ray did not show any significant findings. Alpha-fetoprotein, carcinoembryonic antigen, prostate-specific antigen, CA 125 and CA 19-9 were all within normal limits. Histopathological examination revealed variable fibrosis and diffuse chronic inflammatory infiltrate in the dermis. Lower and deep dermis showed few clusters of pleomorphic small cells with hyperchromatic nuclei, many of which showed signet ring appearance [Figure - 2]. These signet ring cells were not digested with diastase and were positive both for periodic acid-Schiff (PAS) reagent and mucicarmine. Immunohistochemical studies showed that these cells were positive for cytokeratins (CK) and epithelial membrane antigen (EMA) [Figure - 3] and [Figure - 4]. They were negative for vimentin, S-100 protein, gross cystic disease fluid protein-15 (GCDFP-15; BRST-2), and leukocyte common antigen (LCA; CD45) staining. These features define the epithelial origin of the neoplastic cells. The patient was referred to Kuwait Cancer Control Center (KCCC), where abdominal computerized tomographic scan and ultrasound, fluoroscopy and endoscopic examination revealed a gastric carcinoma.


Sister Mary Joseph (1856−1939), who was superintendent nurse at St. Mary′s Hospital in Rochester, MN, US (at present, the Mayo Clinic), observed that patients with intraabdominal and/or pelvic malignancy occasionally have an umbilical nodule indicating umbilical metastasis. Consequently, in 1949, the English surgeon Hamilton Bailey in his famous textbook "Demonstrations of physical signs in clinical surgery" coined the term "Sister Mary Joseph′s nodule" for umbilical metastasis. [1]

Although skin metastasis is rare and ranges between 5% and 9%, it is estimated that 1% to 3% of abdomino-pelvic tumors metastasize to the umbilicus. Metastatic tumors of the umbilical region, constitute 83% of all malignant umbilical tumors and are much more common than primary malignant tumors of this area. [2],[3],[4],[5] The histologic nature of metastatic umbilical tumors usually suggests adenocarcinoma; however, there have also been reports of umbilical metastases from sarcoma, mesothelioma, and melanoma. [6],[7] In men, gastrointestinal tract is the most common location of the primary neoplasm that metastasizes to the umbilicus, whereas in women gynecological neoplasms particularly ovarian cancer is the most common primary site. [2],[3],[4]

Sister Mary Joseph′s nodule may be painful and ulcerated, sometimes with pus, blood or serous discharge. It is usually a firm nodule measuring 0.5−2 cm, although some nodules may reach up to 10 cm. [4] Since Sister Mary Joseph′s nodule is usually a reflection of an underlying widespread malignancy, patients with this sign have a poor prognosis with life expectancy of less than one year. [8]

Signet ring cells contain a large amount of mucin because of the production of mucin without an outlet. The nucleus, pressed to one side of the cell, appears crescent-shaped and the cell looks like a signet ring. These cells are seen in mucous-producing carcinomas such as those from the stomach, colon, and bladder. [9] In gastric carcinoma, which is classified histologically into adenocarcinoma, mucoid carcinoma and diffuse carcinoma, the frequency of signet ring cell carcinoma ranges between 2−3.4%. [10],[11] However, 16−20% of skin metastases from stomach cancers are from signet ring carcinomas, suggesting that this histological type has either a greater tendency towards distant metastasis or greater likelihood of becoming differentiated in the skin than in the stomach. [12]


We are thankful to Dr. Munish Joneja (Department of Histopathology at Radiology, Nuclear Medicine and Laboratory Center, YIACO Medical Co., KSCC) for the histopathological and immunohistochemical studies.

Bailey H. Demonstrations of physical signs in clinical surgery. 11 th ed. Baltimore: Williams and Wilkins; 1949. p. 227.
[Google Scholar]
Steck WD, Helwig EB. Tumors of the umbilicus. Cancer 1965;18:907-15.
[Google Scholar]
Barrow MV. Metastatic tumors of the umbilicus. J Chron Dis 1966;19:1113-7.
[Google Scholar]
Dubreuil A, Dompmartin A, Barjot P, Louvet S, Leroy D. Umbilical metastasis or Sister Marry Joseph's nodule. Int J Dermatol 1998;37:7-13.
[Google Scholar]
Khan AJ, Cook B. Metastaic carcinoma of umbilicus: "Sister Mary Joseph's nodule". Cutis 1997;60:297-8.
[Google Scholar]
Shetty MR. Metastatic tumors of the umbilicus: A review 1830-1989. J Surg Oncol 1990;45:212-5.
[Google Scholar]
Bank H, Liberman SI. Sister Joseph's nodule and malignant ascites in multiple myeloma. N Engl J Med 1971;284:676-7.
[Google Scholar]
Sugarbaker PH. Sister Mary Joseph's sign. J Am Coll Surg 2001;193:339-40.
[Google Scholar]
Inoue Y, Johno M, Kayashima K, Kako H, Ogawa M, Ono T. Metastatic skin cancer; a case with signet ring cell histology. Br J Dermatol 1996;135:634-7.
[Google Scholar]
Kubo T. Histologic appearance of gastric carcinoma in high and low mortality countries: Comparison between Kyushu, Japan and Minnesota, U.S.A. Cancer 1971;28:726-34.
[Google Scholar]
Maehara Y, Sakaguchi Y, Moriguchi S, Orita H, Korenaga D, Kohnoe S, et al . Signet ring cell carcinoma of the stomach. Cancer 1992;69:1645-50.
[Google Scholar]
Kageyama M, Komatsu H, Kato Y. Metastatic skin cancer to the scrotum from gastric cancer. Hifubyoh-shinryoh 1990;12:589-92.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections