The British Journal of Radiology, 72 (1999), 1230±1233
Pictorial review
Imaging appearances of Sister Mary Joseph nodule
1
D M COLL, FFR, RCSI, 1J M MEYER, MD, 1M MADER, MD and 2R C SMITH, MD
1
Department of Radiology, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195 and
2
Yale University Hospital, New Haven, Connecticut, USA
Abstract. Sister Mary Joseph nodules are metastatic deposits in the periumbilical area. The
purpose of this review is to demonstrate umbilical anatomy, discuss modes of metastatic spread,
the various imaging appearances and their relevance to the radiologist.
The term ``Sister Mary Joseph nodule'' refers to
metastatic malignancy of the periumbilical region.
This term was coined by Sir Hamilton Bailey in
recognition of Sister Mary Joseph, a ®rst assistant
to Dr William Mayo in the early days of the
Mayo Clinic [1]. While preparing the abdomen
prior to surgery, she observed that patients with
advanced intraabdominal malignancy often had
umbilical nodules.
Metastatic tumours of the umbilicus are much
commoner than primary neoplasms and are
usually adenocarcinoma [2]. In a large review by
Barrow [3], the commonest origins were stomach,
ovary, colon and pancreas.
A palpable periumbilical nodule may be the
earliest clinical manifestation of an underlying
malignancy. Rather than an actual nodule, there
may only be thickening and in¯ammation of the
overlying skin resembling cellulitis. Although
these ®ndings may be evident on physical
examination, they are easily overlooked in even
mildly obese patients. Owing to the large number
of cross-sectional imaging studies performed in
patients with known or suspected malignancies,
the radiologist may be the ®rst to diagnose a
periumbilical nodule. The purpose of this review
is to demonstrate the different radiological
appearances of Sister Mary Joseph nodules and
their relevance to the radiologist.
Umbilical anatomy
The rectus sheath, which surrounds each rectus
abdominis muscle, is formed by fusion of the
aponeuroses of the external oblique, internal
oblique and transversus abdominis muscles. The
linea alba is formed by midline fusion of the right
Received 1 March 1999 and in revised form 27 May
1999, accepted 28 June 1999.
Address correspondence to Dr Deirdre Coll,
2 Mans®eld Grove Road, Unit 270, East Haven, CT
00512, USA.
1230
E 1999 The British Institute of Radiology
and left rectus sheaths and extends from the
xiphoid process to the symphysis pubis. The
umbilicus consists of a puckered scar through the
linea albea at the former site of attachment of the
umbilical cord. The transversalis fascia lies deep
to the linea alba and just super®cial to the
peritoneum. The fascia umbilicalis is a thickening
of the transversalis fascia, which supports the
¯oor of the umbilicus. These ®ndings are
illustrated in Figure 1.
There are several ligaments, or peritoneal folds,
consistently found in adults that connect with the
umbilicus and that contain remnants of the
obliterated fetal structures. The median umbilical
ligament, or urachus, is the obliterated allantois,
which formerly connected the umbilicus to the
bladder. The medial umbilical ligaments represent
the obliterated umbilical arteries. The ligamentum
teres, the most inferior aspect of the falciform
ligament, contains the obliterated umbilical vein.
An additional ligament connecting the umbilicus
to the ileum is sometimes present and represents
an obliterated remnant of the vitelline duct, which
connected the yolk sac to the midgut.
Vascular supply and lymphatic drainage
There is a rich vascular supply to the anterior
abdominal wall including the periumbilical region.
The main arteries are the inferior epigastric and
deep circum¯ex iliac (branches of the external iliac
artery) and the superior epigastric (a branch of
the internal thoracic artery). Venous drainage is
into a network of veins that radiate from the
umbilicus to the axillary vein above via the lateral
thoracic vein and the femoral vein below via the
super®cial epigastric vein. Small paraumbilical
veins connect with the portal system along the
ligamentum teres. The super®cial lymphatic drain-
age of the periumbilical region connects with the
axillary nodes above and the inguinal lymph
nodes below. Deep lymphatic drainage is into the
internal thoracic, external iliac and abdominal
The British Journal of Radiology, December 1999
Pictorial review: Sister Mary Joseph nodule
paraaortic nodes. Tumours in the chest, abdomen
or pelvis are a source of metastases to the
umbilicus as a result of its connection with
multiple embryological remnants and its extensive
vascular and lymphatic communications [4].
However, the commonest source of umbilical
metastases is contiguous extension from the
anterior peritoneal surface [5].
Location and appearance
Whatever the source of umbilical metastases,
the Sister Mary Joseph nodule may occur as a
dermal, subcutaneous or peritoneal deposit. The
differential diagnosis of an umbilical nodule
includes metastasis, umbilical hernia, endometrio-
sis, primary carcinoma, lymphangioma, pilonidal
sinus and granuloma.
Dermal nodule
In this patient with uterine carcinosarcoma, a
super®cial deposit is noted within the intradermal
layers (Figure 2).
Subcutaneous nodule
This patient with breast carcinoma shows an
enhancing subcutaneous nodule without visible
connection to the underlying abdominal wall
musculature or peritoneal cavity (Figure 3).
Haematogeneous or lymphatic spread was
thought likely.
A mixed cystic and solid nodule was found in a
patient with ovarian carcinoma (Figure 4). While
(a)
Figure 1. A 50-year-old man demonstrating normal umbilical anatomy on CT. (a) The aponeuroses of the exter-
nal oblique (open arrow), internal oblique (straight arrow) and transversus abdominus (curved arrow) are well
seen. The linea alba (arrowhead) is seen as the midline fusion of the right and left rectus sheaths. The most
superior portion of the umbilicus is seen. (b) A more inferior image shows the umbilicus penetrating the linea
alba (arrow).
The British Journal of Radiology, December 1999
there was no hernia, the lesion was inseparable
from the abdominal wall musculature and site of
previous laparotomy. The tumour presumably
spread either via direct invasion through the thin
wall at the incision site or resulted from tracking
of tumour cells into the incision at surgery.
Associated with ventral hernia
Two patients with ovarian carcinoma had
metastatic disease within their ventral hernias.
In the ®rst patient, omental cake protruding into
the hernia (Figure 5) produced a clinically pal-
pable mass. The other patient had nodular
tumour in®ltration of the hernia sac (Figure 6).
Both cases were consistent with peritoneal spread
of disease.
Peritoneal deposits
The periumbilical tissues comprise the thinnest
part of the abdominal wall. In this patient with
breast carcinoma and ascites but negative cytol-
ogy, ultrasound-guided biopsy of a lesion in the
hepatic dome was requested. This would have
been technically dif®cult. At the time of biopsy,
palpation of the abdomen demonstrated mild
nodularity in the umbilical region. Ultrasound
(Figure 7a) showed a small peritoneal-based
nodule located a few centimetres beneath the
skin surface. This was readily accessible to
ultrasound-guided biopsy, which con®rmed meta-
static adenocarcinoma. Retrospective review of
the CT scan showed an abnormality in the
region, which had been previously overlooked
(Figure 7b).
(b)
1231

Figure 2. A 62-year-old woman with prior hysterec-
tomy for uterine carcinosarcoma. Contrast enhanced
CT demonstrates solid intradermal periumbilical
nodule. The nodule is located several centimetres
away from the omental disease (arrow), which is in-
separable from the rectus muscle (arrowhead).
Figure 3. A 74-year-old woman with metastatic breast
carcinoma. Contrast enhanced CT demonstrates solid
subcutaneous periumbilical nodule (arrow).
Figure 4. A 37-year-old woman with metastatic ovar-
ian carcinoma. Contrast enhanced CT demonstrates a
cystic mass with an enhancing nodule in a subcuta-
neous periumbilical location. The mass is inseparable
from the rectus muscle although no direct communi-
cation with the peritoneal cavity is seen.
1232
D M Coll, J M Meyer, M Mader and R C Smith
Figure 5. A 77-year-old woman presented with pal-
pable periumbilical mass. Contrast enhanced CT
demonstrates omental cake (arrow) within an umbili-
cal hernia accounting for the palpable mass. A pelvic
mass and diffuse omental disease consistent with
metastatic ovarian carcinoma were seen on other
images.
Figure 6. A 77-year-old woman presented with anae-
mia and ascites. Post contrast CT demonstrates
enhancing nodularity (arrow) of umbilical hernia out-
lined by ascites. A pelvic mass and diffuse omental
disease consistent with metastatic ovarian disease
were seen on other images.
The British Journal of Radiology, December 1999
Pictorial review: Sister Mary Joseph nodule

(a) (b)

Figure 7. A 57-year-old woman with a history of breast carcinoma and nodularity in the umbilical region on phy-
sical examination. (a) Ultrasound of periumbilical region demonstrates a 1 cm nodule just deep to the right rectus
muscle in the area of palpable nodularity. Biopsy under direct ultrasound guidance showed metastatic breast car-
cinoma. (b) Unenhanced CT demonstrates a 1 cm nodule (arrow) along the peritoneal surface of the abdominal
wall near the umbilicus. This was found only in retrospect.

Conclusion
Sister Mary Joseph nodule is usually associated
with advanced metastatic disease. In a series
reported by Steck and Helwig [6] there was an
average of 10 months survival after appearance of
the lesion. To our knowledge the nodules have
only been described in the clinical literature. Here
we describe the various imaging appearances.
Relevance to the radiologist is two-fold. First,
careful scrutiny of the periumbilical region is
indicated to avoid ascribing a metastatic implant
to a ventral hernia or the normal increased
density of the umbilicus. Second, lesions in this
region are super®cial and may provide the easiest
access for diagnostic biopsy or ®ne needle
aspiration [7].
References
1. Flynn VT, Spurrett BR. Sister Mary Joseph's nodule.
Med J Aust 1969;1:728±30.
2. Brady LW, O'Neill EA, Farber SH. Unusual site for
metastases. Semin Oncol 1977;4:59±64.
3. Barrow MV. Metastatic tumors of the umbilicus.
J Chron Dis 1966;19:1113±7.
4. Glover RP, Waugh JM. The retrograde lymphatic
spread of carcinoma of the rectosigmoid region: its
in¯uence on surgical procedures. Surg Gynecol
Obstet 1946;82:434±48.
5. Powell FC, Cooper AJ, Massa MC, Goellner, Daniel
Su WP. Sister Mary Joseph nodule: a clinical and
histologic study. J Am Acad Dermatol 1984;
10:610±15.
6. Steck WD, Helwig EB. Tumors of the umbilicus.
Cancer 1965;18:907.
7. Gupta RK, Lallu SD, McHutchison AG, Prasad J,
Fauck R. Fine needle aspiration cytology of Sister
Mary Joseph's nodule. Cytopathology 1991;2:311±4.

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