Hematogenous umbilical metastasis from colon cancer treated by palliative single-incision laparoscopic surgery

Figure 1 Findings of diagnostic nodule and colonorectal enema. A: A 5.0- × 4.5-cm hard, ulcerated, caulescent tumor was observed in the umbilicus. Two swollen right inguinal lymph nodes were palpable (circle); B: Colonorectal enema showed an apple core sign at the transverse colon near the hepatic flexure, red arrow: the length of narrowed lumen.

Figure 2 Computer tomography showed tumors of the transverse colon (A, circle), umbilicus (B, circle), right inguinal lymph nodes (C, arrow) and left lung (D, circle). The lung tumor was accompanied by a typical spicula. Vessels along the round ligament of the liver did not develop to and from the umbilical tumor.

Figure 3 Findings of dynamic computer tomography and fluorodeoxyglucose-positron emission tomography. A: Dynamic computer tomography revealed feeding arteries and drainage veins for the umbilical tumor were the inferior epigastric vessels; B: Fluorodeoxyglucose-positron emission tomography showed uptake in the transverse colon, umbilicus, right inguinal lymph nodes, and left lung (arrows).

Figure 4 Intraoperative findings and surgical procedures. A: The umbilicus and caulescent tumor were resected en bloc with establishment of a surgical margin and ligation of vessels; B: Single-site laparoscopic surgery involving right hemicolectomy with paracolic lymph node dissection was subsequently performed. C: Indocyanine green was injected into the paraumbilical portion beforehand, allowing for detection of the drainage lymph nodes in the abdomen (arrow). SMNJ: Sister Mary Joseph’s nodule.

Figure 5 Histopathological findings of the primary colon cancer and Sister Mary Joseph’s nodule are shown (hematoxylin and eosin staining). A: In the primary colon cancer, severe invasion and tumor thrombosis were observed in the vessels (circle), and nontortuous arteries and multiple A-V shunts were also present (arrows); B: The umbilical tumor was consistent with a moderately differentiated adenocarcinoma of colonic origin. The peritoneum of the umbilicus revealed normal findings.

Figure 6 Actual intensities of the normal colon, primary colon tumor, and Sister Mary Joseph’s nodule in western blotting gelatin zymography, and real-time polymerase chain reaction (telomerase) are shown. CDK2: Cyclin-dependent kinase 2; EGFR: Epidermal growth factor receptor; MAPK: Mitogen-activated protein kinase; TUNEL: Terminal deoxynucleotidyl transferase dUTP nick end labeling; VEGF: Vascular endothelial growth factor; MMP: Matrix metalloproteinase; TIMP: Tissue inhibitor of metalloproteinase; TM: Thrombomodulin; SMNJ: Sister Mary Joseph’s nodule.