a 75 year old woman presented to the emergency room with a seven months history of increased fatigability , loss of appetite , weight loss and progressive abdominal distension . on examination the patient was markedly pale , asthenic , dehydrated and febrile and had altered mental status . her general physical examination revealed anemia and pedal edema without any lymphadenopathy . on inspection abdomen was distended , without any visible vessel , scar or sinus . a periumblical bluish violet swelling 5 cm in diameter was also noted ( figure 1 ) . on palpation a firm liver edge 4 cm below the right costal margin with a hard periumblical swelling was also found . the cardiovascular system was normal except for a systolic flow murmur at the apex and base . investigations revealed a low hemoglobin of 3% , microcytic hypochromic type with a reticulocyte count of 5% and no abnormal cells on peripheral blood smear . kidney function tests , electrolytes , blood sugar , urine examination and septic screen ( blood , urine and asitic fluid cultures ) were normal . ascites and pleural taps revealed a lymphocytic exudate without malignant cells and adenosine deaminase in a suspect range . ultrasound of the abdomen revealed ascites with an enlarged liver , normal pancreas , gall bladder , adnexae and no para - aortic lymphadenopathy . fine needle aspiration cytology ( fnac ) of the umbilical nodule done showed metastatic deposits of well - differentiated adenocarcinoma ( figure 2 ) . the patient succumbed to massive rectal bleeding and despite all measures could not be resuscitated . a visible periumblical bluish violet swelling suggestive of a sister mary joseph nodule metastatic deposits of a well differentiated adenocarcinoma documented by fnac umbilical tumors are relatively rare and can be classified as benign or malignant.1 malignant tumors can be primary or metastatic tumors . sister mary joseph nodule  is used to describe a malignant umbilical tumor usually associated with advanced metastasizing intra - abdominal cancer and generally indicating a poor prognosis . this sign was first identified by sister mary joseph ( 1856 - 1939 ) who as a surgical assistant to dr william james mayo drew attention to the presence of a hard umbilical nodule in a patient being prepared for surgery in 1928 . sister mary joseph nodule  in the 11 edition of his textbook  demonstrations of physical signs in clinical surgery  in 1949 . the nodule usually presents as a firm , indurate often vascular swelling which may be fissured or ulcerated and may have serous , mucinous , purulent or bloody discharge . the nodule has been described as white , bluish violet and brownish red and is occasionally pruritic . it is usually irregular in shape , generally painless when palpated except if the overlying skin has ulcerated . it is typically less than 5 cm in diameter but occasionally enlarges enough to form a protruding tumor . patients with sister mary joseph nodule present with a number of clinical symptoms consistent with intra - abdominal cancer including epigastric pain , abdominal distension , weight loss , nausea , ascites and bleeding per rectum.2 the sign of sister mary joseph nodule has been extensively described in literature . the evaluation of an umbilical mass should be directed by suspicion of its being a metastatic deposit keeping in mind its potential to be either a primary malignant umbilical lesion or a benign disease . in a patient with a known malignancy an umbilical mass represents a spread or seeding of the primary tumor and thus can influence therapeutic decision making.3 the most common origins of sister mary joseph nodule are gastrointestinal ( 52% ) , gynecologic ( 28% ) , stomach ( 23% ) and ovarian ( 16% ) carcinomas . about 15 - 29% of all cases have an unknown origin ( as depicted by the presented case ) and 3% originate from the thoracic cavity . primary tumors in many other sites like gall bladder , uterus , liver , endometrium , small intestine , fallopian tube , appendix , cervix , penis , prostrate , urinary bladder , breast , lung and kidneys have also been reported to cause sister mary joseph nodules . histology of the metastatic umbilical tumor usually reveals adenocarcinoma but rare reports of umbilical metastasis from sarcomas , mesotheliomas and melanomas have also been seen.24 ct scan ( abdomen and chest ) and fine needle aspiration cytology ( fnac ) of the tumor are invaluable in the diagnosis of sister mary joseph nodule and help to exclude a primary benign umbilical neoplasm . in 14 - 33% of cases , umbilical metastases lead to the diagnosis of previously occult neoplasms.5 in 40% of patients with a known neoplasm the nodule was an early sign of relapse.6 spread of metastatic carcinoma to the umbilical region has been hypothesized to occur by either contiguous spread of peritoneal cancer , hematogenous spread through arterial and venous systems or lymphatic spread ( mainly pancreatic carcinoma ) with extension along ligaments of embryonic origin ( round ligament of liver , urachus , vitello intestinal duct reminant and the obliterated vitelline artery).67 the presence of a sister mary joseph nodule verified histological signifies advanced metastatic carcinoma and a poor prognosis with a survival time of 10 months ( range 2 - 17 months ) and inoperability . treatment of established sister mary joseph nodule is palliative as wide excision , surgery and radiotherapy have all proved ineffective . nevertheless a sister mary joseph nodule is a time tested , honored clinical sign emphasizing the importance of a careful physical examination of the abdomen . ihd examined , planned the work up , executed the investigative profile and wrote the manuscript .