Fine needle aspiration of Sister Mary Joseph’s nodule R. K. G U P T A , S. L A L L U , A. G. R. M c H U T C H I S O N A N D J. P R A S A D * Dc.partru2ent.y of Cytology and *Surgerj%,Wellington Hospital and School of Medicine, Wellingron. New Zealand Accepterl,forpublication 23 Muy 1991

GUPTA R. K., LALLU

s., MCHUTCHISON A. G. R. A N D PRASAD J. (1991) Cytopathology 2,311-3 14

Fine needle aspiration of Sister Mary Joseph’s nodule A case of Sister Mary Joseph’s nodule (umbilical metastasis) is described from a primary adenocarcinoma of the transverse colon. Needle aspiration cytology made the diagnosis which was confirmed by immunocytochemical localization of CEA, B72.3, EMA, and cytokeratin in the tumour cells. Extensive mucus production in the tumour cells was demonstrated by alcian blue and mucicarmine stains. Keywords: fine needle aspiration, cytology, metastasis, umbilicus, Sister Mary Joseph’s nodule

INTRODUCTION Metastatic tumour deposits in the umbilicus are not uncommon’32.These are popularly known as ‘Sister Mary Joseph’s nodule’ in recognition of an astute nurse credited with the observation that such a nodule often indicates an internal malignancy’,334. Although there are reviews and case studies of umbilical metastases4 1 2 , only recently has a case been published in which the diagnosis was made by fine needle aspiration (FNA)’. In this communication we report another case in which the diagnosis was made by FNA and confirmed by the application of immunocytochemical stains on the aspirated material. CASE R E P O R T A 68-year-old Caucasian male presented with a 10 week history of colicky abdominal pain, distension, vomiting, constipation and increasing flatulence. He was cachetic with gaseous distension of the abdomen. X-rays of the abdomen suggested large bowel obstruction and barium enema showed an obstructing tumour in the mid-transverse colon. Rectal examination was negative. The faeces were positive for occult blood. A 2 x 1.5 cm hard nodule was noted in the umbilicus. FNA of the nodule was performed using a 22 gauge needle, and the needle washings collected in 30% ethyl alcohol in physiological saline. Filters were Correspondence: Dr R. K. Gupta, The Cytology Unit. Wellington Hospital, Wellington, New Zealand.

3 12 R. K . Gupta et al.

Figure 1. Filter preparation from needle aspirate showing groups of malignant cells. Papanicolaou stain.

x

675.

Figure 2. Cell block preparation from needle aspirate showing histological features of

metastatic adenocarcinoma. Haematoxylin & eosin stain. x 450.

prepared and these were reported to contain tumour cells consistent with a mucus-producing metastatic adenocarcinoma. A primary lesion in the large bowel was suspected. In view of the acuteness of the patient’s symptoms, laparotomy was performed and an obstructing tumour was found in the mid-transverse colon with extensive metastatic deposits in the peritoneum, omentum, small bowel, pelvis and liver. The tumour was considered inoperable and in view of the patient’s poor condition a palliative colo-colic bypass was performed. A biopsy of a deposit from the peritoneal surface was taken which showed a mucus producing adenocarcinoma similar to that reported in the aspirated material.

Cytologicaljndings Filters (Schleicher and Schuell) were prepared from the samples and stained by the Papanicolaou method. Cell blocks were also prepared and stained with haematoxylin and eosin. In addition, cytospin preparations were made. The specimens were found to contain numerous

Sister M a r y Joseph 's nodule

3 I3

Figure 3. Cell block preparation from needle aspirate showing positive immunostaining of EMA. x936.

tumour cells consistent with a moderately dif'erentiated adenocarcinoma. The tumour cells had a basophilic cytoplasm indicating the presence of mucus. This was confirmed using alcian blue and mucicarmine stains. The nuclei of the malignant cells were large, oval, lobulated and hyperchromatic and had moderately coarse chromatin, irregular nuclear membranes and one or more irregular nucleoli (Figures 1 and 2 ) . Similar appearances were noted in the histological sections of the biopsy taken at operation. Itiiit~unot~~~toc.l~emic~aI~fin~in~.s

For immunocytochemical studies, cytospin preparations were made from the aspirated material. In addition, sections from the cell block were also utilized. Immunostaining for carcinoembryonic antigen (CEA), epithelial membrane antigen (EMA), cytokeratin and B72.3 (a known marker for adenocarcinoma) were performed utilizing commercially available antibodies (A 1 15 for CEA, R P N 1 I30 for EMA, CAM 5.2 for cytokeratin; all supplied by Dako and B72.3; supplied by Bio Med) and an immunoperoxidase label. The malignant cells stained an intense diffuse brown colour with diamino benzidine with all four markers (Figure 3). Known positive and negative controls were used during all procedures. DISCUSSION Metastatic tumour deposits in the umbilicus usually indicate an advanced internal malignancy of gastrointestinal or gynaecological origin'^'."^". Rarely, they may be due to a primary tumour of another organ. Metastatic nodules in the umbilicus due to primary skin cancer and to multiple myelomatosis have also been described. The exact route of metastasis is unknown; however, spread via the lymphatics, paraumbilical veins, urachus remnants, vitelline intestinal duct and vitelline artery has been suggested. ACKNOWLEDGEMENT The authors gratefully acknowledge the excellent technical assistance of Mr Robert Fauck.

3 14 R. K. Gupta et al. REFERENCES I Cullen TS. Embryology. Anaiomy and Diseases of rhc Umhilicus. Philadelphia: W. B. Saunders, 1916; Il8-l58. 2 Goodheart RS, CookeCT,Tan E, MatzLR. Sister Mary Joseph’s nodule. M KJ ~Ausr 1986; 145: 477-8. 3 Bailey H . Demonsrruiion of Physical Signs in Climical Surgery, 13th edn. Baltimore: Williams and Wilkins. 1960; 356. 4 Coulson WF. Surgical Pathology, 2nd edn. Philadelphia: J. B. Lippincott, 1988; 3224. 5 Schneider V. Smyczek B. Sister Mary Joseph’s nodule. Diagnosis of umbilical metastases by fine needle aspiration. Acra Cyiol1990; 3 4 555-8. 6 Ali F, Bauer HM. Umbilical metastasis of an endometrial carcinoma: a case report. J Am Acad Drrmarol1985; 12: 887-8. 7 Bank H, Liberman S1. Sister Joseph’s nodule and malignant ascites in multiple myeloma. N Engl J Mctl 1971; 284 676.

8 Brustman L, Seltzer V. Sister Joseph’s nodule: seven cases of umbilical metastases from gynecologic malignancies. Gynerol Oncoll984; 19: 155-62. 9 Caballero LR, Lopez FV, Caballero CR, Hernando SU, Lopez MS, Yus ES, Moro BH. Metastatic umbilical cancer-Sister Mary Joseph’s nodule: report of two cases. J Dermarol Surg Oncol1988; 1 4 664-7. 10 Key JD, Shephard DAE, Walters W. Sister Mary Joseph’s nodule and its relationship to diagnosis of carcinoma of the umbilicus. Minn Med 1976; 59: 561-6. 11 Powell FC, Cooper AJ, Massa MC, Goellner JR, Su WPD. Sister Mary Joseph’s nodule: a clinical and histological study. J Am Acad Dermatol1984; 10: 610-.-15. 12 Schwartz IS. Sister Mary Joseph‘s nodule. N Engl J M e d 1987; 316 1348. 13 Vlahoussis AP, Kaplanis CN, Zis JS, Papadimitriou GC. A rare case of umbilical metastasis from primary ovarian carcinoma. Ini Surg 1982; 61: 535-6.

Fine needle aspiration of Sister Mary Joseph's nodule.

A case of Sister Mary Joseph's nodule (umbilical metastasis) is described from a primary adenocarcinoma of the transverse colon. Needle aspiration cyt...
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