An Interesting Case of Sister Mary Joseph’s Nodule Revealed by ¹⁸F-FDG PET

A 61-year-old postmenopausal female patient presented with recent intense abdominal pain, accompanied by weight loss and bowel transit disturbances. Abdominal ultrasonography revealed a large subcutaneous nodule measuring 2 cm, along with a suspicious abdominopelvic mass. Colonoscopy showed a rectosigmoid mass that was difficult to traverse; biopsy results confirmed rectosigmoid adenocarcinoma. Computed tomography (CT) of the thorax, abdomen, and pelvis identified a locally advanced rectosigmoid mass, lumbo-aortic lymphadenopathy, and a suspicious hepatic mass in segment VII.

A positron emission tomography-CT using ¹⁸F-fluorodeoxyglucose, performed for operability assessment, showed a large tumor mass involving rectosigmoid and uterus, measuring 102 mm × 79 mm × 56 mm (SUV_max = 20.7) [Figure 1a, red arrow]; multiple hypermetabolic lumbo-aortic lymphadenopathies (SUV_max = 3.6–17.2) [Figure 1b, yellow arrow], two secondary hypermetabolic hepatic lesions in segments V and VII (SUV_max = 3.1–14.0); small suspected pathological hypermetabolic pulmonary nodules (SUV_max = 1.2–2.7); and a large subcutaneous umbilical nodule measuring 22.5 mm × 20 mm (SUV_max = 7.5), consistent with a Sister Mary Joseph’s nodule [Figure 1a and c, white arrow].

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Figure 1 ¹⁸F-FDG PET-CT of our patient. Panel a: Fusion image in sagittal section showing a large tumor mass involving rectosigmoid and uterus (SUVmax = 20.7) (red arrow). Panel b: Computed Tomography in axial section showing an hypermetabolic lumbo aortic lymphadenopathy (SUVmax = 3.6–17.2) (yellow arrow). Panel C: Fusion image in axial section showing a large subcutaneous umbilical nodule measuring 22.5 mm × 20 mm (SUVmax = 7.5), consistent with a Sister Mary Joseph’s nodule (white arrow)

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The Sister Mary Joseph’s nodule is a rare umbilical metastatic lesion, occurring in 1%–3% of digestive adenocarcinomas (gastric 25%, colon 10%, and pancreas 7%) and more rarely in melanoma or gynecological cancers.[12] First described in 1928 by Sister Mary Joseph, a nurse, in a patient with gastric adenocarcinoma, it represents the hidden part of the iceberg.[34] Its presence is associated with poor prognosis and necessitates thorough etiological investigation, often leading to palliative care due to the frequent association with diffuse metastatic disease.[5]

In nonneoplastic contexts, differential diagnoses include benign conditions such as botryomycoma, omphalitis, hernias, or umbilical manifestations of Crohn’s disease or endometriosis.[6] Although rarely reported in the literature, the Sister Mary Joseph’s nodule holds important prognostic value and should not be underestimated in clinical evaluation.