Metastatic Pancreatic Adenocarcinoma Presenting With Rapidly Progressing Cutaneous Sister Mary Joseph Nodules

CASE REPORT A 65-year-old man with diabetes and obesity noticed small periumbilical and suprapubic nodules before elective laparoscopic hernia repair. Postoperatively, the nodules rapidly enlarged, coalesced, ulcerated, and became painful. Computer tomography of the abdomen revealed a 3.4-cm pancreatic tail mass with anterior abdominal wall implants and lytic vertebral lesions (Figures 1 and 2). Biopsy confirmed metastatic adenocarcinoma with KRAS G12C, MTAP, CDKN2A/B loss, and TP53 mutation.Figure 1.: Computed tomography of the abdomen showing pancreatic tail mass (red arrow).Figure 2.: Abdominal computed tomography showing periumbilical metastasis (A) and anterior abdominal wall metastasis (B) originating from pancreatic adenocarcinoma (red arrows).Cutaneous metastases occur in <3% of pancreatic ductal adenocarcinoma cases, most often at the umbilicus as Sister Mary Joseph Nodules.1–3 They may be the initial manifestation and often present variably as nodules, plaques, or ulcerations, making diagnosis challenging.2–4 Our patient developed extensive, friable, periumbilical and suprapubic lesions (Figures 3 and 4), as well as port-site metastases, a complication previously described with laparoscopic procedures.4Figure 3.: Sister Mary Joseph Nodules; periumbilical metastasis of pancreatic adenocarcinoma.Figure 4.: Suprapubic skin metastasis in pancreatic adenocarcinoma.He was diagnosed with stage IV pancreatic ductal adenocarcinoma and treated with gemcitabine/nab-paclitaxel and then FOLFIRINOX, but the disease progressed despite therapy.5 This case highlights the importance of considering cutaneous metastases in the differential diagnosis of unexplained abdominal skin lesions, particularly before elective surgery, as early recognition may guide timely treatment and avoid exacerbating tumor spread. DISCLOSURES Author contributions: P. Aijaz contributed to the conception, data collection, drafting, and critical revision of the manuscript and is the article guarantor. PH Seaberg contributed to the clinical care, data interpretation, and critical revision of the manuscript. All authors reviewed and approved the final version of the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.