BACKGROUND: Umbilical metastases from a malignant neoplasm, also termed Sister Mary Joseph's nodule, are not commonly reported in the English literature, and they have usually been considered as a sign of a poor prognosis for the patient. The present article reports on the current view point on umbilical metastasis besides discussing the epidemiology, clinical presentation, pathophysiology and treatment. METHOD: A search of Pubmed was carried out using the term 'umblic*' and 'metastases' or metastasis' revealed no references. Another search was made using the term "Sister Joseph's nodule" or sister Joseph nodule" that revealed 99 references. Of these there were 14 review articles, however when the search was limited to English language it yielded only 20 articles. Articles selected from these form the basis of this report along with cross references. RESULTS: The primary lesions usually arise from gastrointestinal or genitourinary tract malignancies and may be the presenting symptom or sign of a primary tumour in an unknown site. CONCLUSION: A careful evaluation of all umbilical lesions, including an early biopsy if appropriate, is recommended. Recent studies suggest an aggressive surgical approach combined with chemotherapy for such patients may improve survival.

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Objective: The coexistence of hyperthyroidism and thyroid cancer is considered a rare event. With the aim of assessing the clinical relevance of this association, we have retrospectively analyzed the incidence of thyroid cancer in 425 hyperthyroid patients seen and treated by surgery in our institutions. Methods: Among these hyperthyroid patients, we observed 241 (56.7%) cases of multinodular toxic goiter, 120 (28.3%) of uninodular toxic goiter and 64 (15%) cases of Graves’ disease. Results: Thyroid cancer was diagnosed in 7 (1.65%) hyperthyroid patients. Histological examination revealed the presence of papillary carcinoma in 5 cases and follicular carcinoma in 2 cases. Neoplasia was detected in 4 patients with nodular toxic goiter and in 3 with uninodular toxic goiter. None of the patients with Graves’ disease had thyroid cancer. During the follow-up of 74 months (range 4–154), there were no deaths or any recurrences. Conclusion: Although the occurrence of thyroid cancer in hyperthyroid patients is a rare event, the presence of a ‘cold’ nodule in a hyperfunctioning thyroid should be carefully evaluated to exclude the presence of concurrent malignancy.

Key words: Sister Mary Joseph; Umbilical metastasis; Cecum cancer]C utaneous metastases of malignant neoplasms are not common, occurring between 0.7 and 9 percent of autopsy evaluations. 1 Those to the umbilicus, also known as Sister Mary Joseph's nodule, are even more rare and represent only 10 percent of all secondaries to the skin. 2 These nodules usually arise from the gastrointestinal or genitourinary tract and may represent the first sign of a previously unknown primary tumor. This case demonstrates a Sister Mary Joseph's nodule caused by an unknown primary cancer of the cecum. REPORT OF A CASEA 66-year-old female presented with a six-month history of umbilical lump, initially with a diameter of 0.5 cm, covered by erythematous skin. This was initially treated with conservative measures by a dermatologist, who three months later performed a biopsy. Histology showed cutaneous metastasis caused by a primary occult adenocarcinoma.Five months after the onset of the umbilical lesion, although the diagnostic work-up was still in progress, the patient required an emergency admission for intestinal obstruction. Physical examination of the abdomen showed an erythematous umbilical nodule (diameter of 1.5 cm) with irregular and ill-defined edges, attached to the underlying layers, and of fibrous consistency (Fig. 1). At laparotomy, there was a cecal neoplastic lesion attached to the anterior peritoneum in the umbilical area. A right colectomy with complete excision of the umbilical lesion was performed. Histology of the operative specimen showed a moderately differentiated adenocarcinoma. The skin and subcutaneous tissue specimen presented a central raised lesion consisting of metastases of the primary adenocarcinoma. Pathologic staging was pT3 pN2 pM1. After discharge, the patient received six courses of doxorubicin and died 21 months after surgery. DISCUSSIONUmbilical neoplastic nodules are rare and can be caused by 1) primary tumor (38 percent of cases), 2) endometriosis (32 percent), and 3) metastases (30 percent).

Our analysis suggests that cesarean section and hernia repair, performed in one session, avoids need for readmission to hospital, is safe, effective, and well accepted. It neither increases the complication rate nor prolongs the hospital stay, with clear advantages for both the patients and the hospital budget.