Int J Gynaecol Obstet 17: 229-230, 1979
Umbilical Mass as a Presenting Symptom of Endometrial Adenocarcinoma I. Bukovsky,1 Y. Lifshitz, 1 R. Langer, 1 R. Reif 2 and E. Caspi 1 Departments of Obstetrics and Gynecology and Pathology, Assaf Harofeh Government Hospital, Zerifin, Israel
ABSTRACT Bukovsky I, Lifshitz Y, Langer R, ReifR, Caspi E (Depts of Obstetrics and Gynecology and Pathology, Assaf Harofeh Government Hospital, Zerifin, Israel). Umbilical mass as a presenting symptom of endometrial adenocarcinoma. Int J Gynaecol Obstet 17: 229-230, 1979 A case of an umbilical mass as a primary presenting symptom of otherwise asymptomatic endometrial adenocarcinoma is reported. The pertinent literature is reviewed with regard to the relation of the umbilical mass to metastatic carcinoma.
INTRODUCTION Umbilical metastasis is infrequently the primary presenting finding in cases of metastatic adenocarcinoma, especially that of endometrial adenocarcinoma. The following is a case report of umbilical metastatic adenocarcinoma originating from an asymptomatic endometrial adenocarcinoma. CASE REPORT A 52-year-old gravida 2, para 2 was referred and admitted to the surgical department of our hospital for surgical repair of an umbilical hernia. At the time of operation, a 4 X 4-cm mass was noted within the subcutaneous tissue. A biopsy from this mass revealed adenocarcinoma of unknown origin. O n e and one-half years previously, the patient experienced an episode of menorrhagia. A dilation and curettage (D&C) performed at that time revealed a small amount of normal proliferative endometrial tissue. Following the D&C, the patient had three regular menstrual periods, then became menopausal. When the result of the biopsy from the umbilical mass was known, the patient was reevaluated. Intravenous pyelography, radiographic examination of
the upper and lower gastrointestinal tract, and liver and lung scan were all normal. O n gynecologic examination, a nontender, immovable mass measuring 3 X 3 cm was found in the pouch of Douglas. T h e uterus and ovaries were of normal size a n d shape. At exploratory laparotomy, a diffuse carcinomatosis of omentum and peritoneum was found. This extended over the diaphragmatic surface a n d several small metastatic areas were found in the liver. A small amount of ascites was also present. Areas of carcinoma were distributed on the surface of both ovaries in a shell-like configuration. Some paraortic nodes were enlarged. No tumor was found on the uterine serosa and both tubes were normal. A total abdominal hysterectomy a n d bilateral salpingo-oophorectomy and omentectomy were performed. At a wide retroperitoneal exploration, biopsies were taken from some nodes; they showed no malignant changes. Examination of the uterus, which measured 9 X 7 X 6 cm, revealed a poorly differentiated diffuse endometrial adenocarcinoma extending to the endocervix and penetrating deeply into the myometrium. Histologic findings from peritoneal and omental metastasis revealed a diffuse endometrial adenocarcinoma of low-grade malignancy. T h e postoperative course was uneventful.
DISCUSSION T h e usual presenting symptom of uterine adenocarcinoma is vaginal bleeding, which is found in nearly 90% of cases. Late symptoms of tumor extension are pelvic pain and odorous vaginal discharge. Cullen (2) collected from the literature 22 cases of carcinomata presenting with an umbilical mass. In most cases, the primary tumor was in the gastrointestinal tract; less frequently was it ovarian or endometrial in origin. Steck and Helwig (5) reported 112 cases of umbilical tumors; of these, 64 were benign and 48 were malignant. O f the latter, eight were primary umbilical tumors a n d 40 were meta-
IntJ Gynaecol Obstet 17
230
Bukovsky et al
static. Of the 40 metastatic tumors, the primary origin was found in 31 cases of which 25 were from the gastrointestinal tract, especially the stomach and pancreas. Three cases originated from the ovaries, two cases from the penis a n d cervix and one was of endometrial origin. T h e umbilical mass itself was the presenting symptom in 18 of the 40 cases, and histologic findings in this group determined a primary focus in 29 cases. O'Leary and O'Leary (4) summarized two new cases with an umbilical mass. O n e case was primary squamous cell carcinoma of the umbilicus and one was secondary to endometrial carcinoma. T h e general presenting complaint in most cases is that of a nontender, painless solitary mass. Discoloration of the umbilicus varies with the tumor vascularization and extension. T u m o r extension to the umbilicus might be direct, hematogenous or lymphatic along the falciforme ligament or the urachus. T h e prognosis in such cases is poor. Clements (1) claims that the discovery of a mass in the umbilical area is usually a clue to inoperable carcinoma. O'Leary and O'Leary (4), in contrast, stated that surgical exploration is mandatory when such a mass is discovered since it may represent a solitary metastatic or even a second primary. In the case reported here, the primary presenting symptom of endometrial adenocarcinoma was a painless umbilical mass that was misdiagnosed as
IntJ Gynaecol Obstet 17
an umbilical hernia. It must be kept in mind that what appears to be acquired umbilical hernia in an otherwise asymptomatic patient should raise the suspicion of intra-abdominal malignancy (3). T o the best of our knowledge, no case of asymptomatic metastatic adenocarcinoma has been reported in the literature during the last decade.
REFERENCES 1. Clements AB: Metastatic carcinoma of the umbilicus. J A M A 150:556, 1952. 2. Cullen T S : Embryology, a n a t o m y and diseases of the umbilicus. Saunders C o m p a n y , Philadelphia, 1916. 3. Millar R C , Geelhoed G W , Ketcham AS: O v a r i a n cancer presenting as umbilical hernia. J Surg Oncol 7.493, 1975. 4. O'Leary J L , O'Leary J A : Carcinoma of the umbilicus. A m J Obstet Gynecol 89:136, 1964. 5. Steck W D , Helwig EB: T u m o r s of the umbilicus. Cancer /
Umbilical Mass as a Presenting Symptom of Endometrial Adenocarcinoma I. Bukovsky,1 Y. Lifshitz, 1 R. Langer, 1 R. Reif 2 and E. Caspi 1 Departments of Obstetrics and Gynecology and Pathology, Assaf Harofeh Government Hospital, Zerifin, Israel
ABSTRACT Bukovsky I, Lifshitz Y, Langer R, ReifR, Caspi E (Depts of Obstetrics and Gynecology and Pathology, Assaf Harofeh Government Hospital, Zerifin, Israel). Umbilical mass as a presenting symptom of endometrial adenocarcinoma. Int J Gynaecol Obstet 17: 229-230, 1979 A case of an umbilical mass as a primary presenting symptom of otherwise asymptomatic endometrial adenocarcinoma is reported. The pertinent literature is reviewed with regard to the relation of the umbilical mass to metastatic carcinoma.
INTRODUCTION Umbilical metastasis is infrequently the primary presenting finding in cases of metastatic adenocarcinoma, especially that of endometrial adenocarcinoma. The following is a case report of umbilical metastatic adenocarcinoma originating from an asymptomatic endometrial adenocarcinoma. CASE REPORT A 52-year-old gravida 2, para 2 was referred and admitted to the surgical department of our hospital for surgical repair of an umbilical hernia. At the time of operation, a 4 X 4-cm mass was noted within the subcutaneous tissue. A biopsy from this mass revealed adenocarcinoma of unknown origin. O n e and one-half years previously, the patient experienced an episode of menorrhagia. A dilation and curettage (D&C) performed at that time revealed a small amount of normal proliferative endometrial tissue. Following the D&C, the patient had three regular menstrual periods, then became menopausal. When the result of the biopsy from the umbilical mass was known, the patient was reevaluated. Intravenous pyelography, radiographic examination of
the upper and lower gastrointestinal tract, and liver and lung scan were all normal. O n gynecologic examination, a nontender, immovable mass measuring 3 X 3 cm was found in the pouch of Douglas. T h e uterus and ovaries were of normal size a n d shape. At exploratory laparotomy, a diffuse carcinomatosis of omentum and peritoneum was found. This extended over the diaphragmatic surface a n d several small metastatic areas were found in the liver. A small amount of ascites was also present. Areas of carcinoma were distributed on the surface of both ovaries in a shell-like configuration. Some paraortic nodes were enlarged. No tumor was found on the uterine serosa and both tubes were normal. A total abdominal hysterectomy a n d bilateral salpingo-oophorectomy and omentectomy were performed. At a wide retroperitoneal exploration, biopsies were taken from some nodes; they showed no malignant changes. Examination of the uterus, which measured 9 X 7 X 6 cm, revealed a poorly differentiated diffuse endometrial adenocarcinoma extending to the endocervix and penetrating deeply into the myometrium. Histologic findings from peritoneal and omental metastasis revealed a diffuse endometrial adenocarcinoma of low-grade malignancy. T h e postoperative course was uneventful.
DISCUSSION T h e usual presenting symptom of uterine adenocarcinoma is vaginal bleeding, which is found in nearly 90% of cases. Late symptoms of tumor extension are pelvic pain and odorous vaginal discharge. Cullen (2) collected from the literature 22 cases of carcinomata presenting with an umbilical mass. In most cases, the primary tumor was in the gastrointestinal tract; less frequently was it ovarian or endometrial in origin. Steck and Helwig (5) reported 112 cases of umbilical tumors; of these, 64 were benign and 48 were malignant. O f the latter, eight were primary umbilical tumors a n d 40 were meta-
IntJ Gynaecol Obstet 17
230
Bukovsky et al
static. Of the 40 metastatic tumors, the primary origin was found in 31 cases of which 25 were from the gastrointestinal tract, especially the stomach and pancreas. Three cases originated from the ovaries, two cases from the penis a n d cervix and one was of endometrial origin. T h e umbilical mass itself was the presenting symptom in 18 of the 40 cases, and histologic findings in this group determined a primary focus in 29 cases. O'Leary and O'Leary (4) summarized two new cases with an umbilical mass. O n e case was primary squamous cell carcinoma of the umbilicus and one was secondary to endometrial carcinoma. T h e general presenting complaint in most cases is that of a nontender, painless solitary mass. Discoloration of the umbilicus varies with the tumor vascularization and extension. T u m o r extension to the umbilicus might be direct, hematogenous or lymphatic along the falciforme ligament or the urachus. T h e prognosis in such cases is poor. Clements (1) claims that the discovery of a mass in the umbilical area is usually a clue to inoperable carcinoma. O'Leary and O'Leary (4), in contrast, stated that surgical exploration is mandatory when such a mass is discovered since it may represent a solitary metastatic or even a second primary. In the case reported here, the primary presenting symptom of endometrial adenocarcinoma was a painless umbilical mass that was misdiagnosed as
IntJ Gynaecol Obstet 17
an umbilical hernia. It must be kept in mind that what appears to be acquired umbilical hernia in an otherwise asymptomatic patient should raise the suspicion of intra-abdominal malignancy (3). T o the best of our knowledge, no case of asymptomatic metastatic adenocarcinoma has been reported in the literature during the last decade.
REFERENCES 1. Clements AB: Metastatic carcinoma of the umbilicus. J A M A 150:556, 1952. 2. Cullen T S : Embryology, a n a t o m y and diseases of the umbilicus. Saunders C o m p a n y , Philadelphia, 1916. 3. Millar R C , Geelhoed G W , Ketcham AS: O v a r i a n cancer presenting as umbilical hernia. J Surg Oncol 7.493, 1975. 4. O'Leary J L , O'Leary J A : Carcinoma of the umbilicus. A m J Obstet Gynecol 89:136, 1964. 5. Steck W D , Helwig EB: T u m o r s of the umbilicus. Cancer /
