Clinical Picture
An ominous sign from Sister Mary Joseph
Lancet 2018; 392: 776
Department of Dermatology,
Peking Union Medical College
Hospital, Chinese Academy of
Medical Sciences and Peking
Union Medical College, Beijing,
China (J-W Liu PhD, D-L Ma PhD)
Correspondence to:
Dr Dong-Lai Ma, Department of
Dermatology, Peking Union
Medical College Hospital,
Chinese Academy of Medical
Sciences and Peking Union
Medical College, Beijing 100730,
China
mdonglai@sohu.com
776 www.thelancet.com Vol 392 September 1, 2018
Jia-Wei Liu, Dong-Lai Ma
A 39-year-old man presented to our hospital with a
2-month history of painful nodules in his umbilicus. He
had been diagnosed with gastric ring cell carcinoma of
the stomach with extensive metastasis 9 months earlier.
An ill-defined, firm, indurated plaque, with multiple
nodules in and around the umbilicus (figure), was found
on examination. A skin biopsy sample showed extensive
infiltration of the dermis by signet ring cells (figure). A
diagnosis of Sister Mary Joseph’s nodule was made: the
lesion in the umbilicus was caused by metastases from
the gastric carcinoma. A CT scan of his abdomen showed
thickening of the gastric wall and a mass forming
posteriorly (figure). He was given intravenous chemo­
therapy every 2 weeks: fluorouracil 2400 mg/m²,
oxaliplatin 70 mg/m², and docetaxel 50 mg/m², for eight
cycles. He was then given one cycle of the combined oral
treatment, 25 mg/m² twice a day, of tegafur, gimeracil,
and oteracil for 28 consecutive days; this was followed by
14 days of rest. However, the primary tumour remained
unchanged. The patient decided not to continue with
chemotherapy and died of multiorgan metastasis
4 months later.
A B
Figure: Sister Mary Joseph’s nodule
An ill-defined, firm, indurated plaque, with multiple nodules in and around the umbilicus (A).Haematoxylin and eosin staining of a skin biopsy sample shows
extensive infiltration of the dermis by signet ring cells (indicated by arrows). Original magnification x 200 (B). Abdominal CT scan shows thickening of the gastric wall
and a mass (circled) forming posteriorly (C).
Sister Mary Joseph’s nodule—a condition generally
associated with a poor prognosis—refers to the umbilical
metastasis of an abdominal malignancy. Stomach and
colon cancers are the most common sources of the
condition in men, and in women the ovaries are most
frequently the origin. In up to 30% of cases, the umbilical
nodule may be the first and only sign of an advanced
intra-abdominal malignancy. Clearly, many other diseases
can present with umbilical lesions—including hernias,
endometriosis, urachal duct cysts, abscesses, pyogenic
granuloma, lymphangioma, and epidermoid cysts. The
English surgeon Sir Hamilton Bailey named the sinister
malignant manifestation after Sister Mary Joseph
(1856–1939), a nurse at St Mary’s Hospital in Rochester,
MN, USA, who noted the association between peri­
umbilical nodules and intra-abdominal cancer.
Contributors
J-WL was the patient’s attending physician and he wrote the initial draft
of the report. D-LM also wrote and reviewed the manuscript. Both
authors read and approved the final version. Written consent for
publication was obtained from the patient’s spouse.
© 2018 Elsevier Ltd. All rights reserved.
C