Patient Report

Yonago Acta medica 2016;59:183–187

Melanoma of the Umbilicus: A Patient Report, Precaution in Operative Strategy,
and the First Histopathological Review of Published Cases
Shuji Suzuki,* Yuichi Yoshida,* Tatsushi Shiomi,† Shigeto Yanagihara,* Ryoko Kimura* and Osamu Yamamoto**Division of Dermatology, Department of Medicine of Sensory and Motor Organs, School of Medicine, Tottori University Faculty of
Medicine, Yonago 683-8503, Japan and †Division of Organ Pathology, Department of Pathology, School of Medicine, Tottori University
Faculty of Medicine, Yonago 683-8503, Japan

ABSTRACT
Umbilical melanoma is extremely rare. Among the past
English reports on umbilical melanoma, there are only 8reports in which histopathology was described in detail,and there has been no report with a review of the histopathology of previously reported cases.
We experienced a case of umbilical melanoma andreviewed previously reported cases including our case.
Because of the anatomical location, it is difficult tobecome aware of the umbilical melanoma unless there
are some concomitant symptoms such as discharge or
swelling. Even with these symptoms, patients tend topostpone a hospital visit for unknown reasons, resulting
in increased risk of tumor growth and metastasis. Whenperforming resection of umbilical melanoma, a portionof the peritoneum should also be removed. Sentinel
lymph nodes can be axilla or inguinal lymph nodes.
There is a possibility of metastasis to the preoperative
abdominal cavity or to nearby skin through hematogenous spread. Preoperative evaluation of tumor spreadand postoperative observation are important for umbilical melanoma in order to detect recurrence or metastasis
because of its unique anatomical location.

umbilical melanoma with histopathology, locations ofsentinel lymph nodes, metastasis, and operative treatment.
PATIENT REPORTAn 83-year-old woman presented to our hospital with anumbilical skin tumor. She first noticed it with exudates
and pruritus 2 weeks earlier, saw a local physician, andwas referred to us. She had a past medical history of agastric cancer operation 26 years ago. There was a 12
× 6 mm black nodule arising in the umbilicus without
an ulcer on the surface (Figs. 1a and b). No lymph nodeswelling was palpable on either side of the inguinal andaxillary areas.
Biopsy of the nodule revealed a solid proliferation of
atypical melanocytes of epithelioid and spindle shapeswith tumor thickness exceeding 2 mm. Numerous mitoses were seen and there was no maturation towards
the deeper side. Immunostainings against S-100 protein,
HMB-45, and Melan-A were all positive. Computed
tomography (CT) revealed no metastasis or lymph nodeswelling. At that time, we diagnosed the nodule as melanoma, T3a (or 4a) N0M0, stage IIA (or IIB). Lymphoscintigraphy with intradermic injections of 99mTc near
the nodule showed accumulation of gamma-emitting
lymph nodes on both sides of the inguinal areas (Fig.
1c).
Excision with a 2.0 cm margin and sentinel lymph
node biopsy of both sides of the inguinal areas were
performed after injecting blue dye. The excision line included part of the previous operation scar (Fig. 1d). The
peritoneum under the navel was also included within theexcision (Fig. 1e). The fascia of each layer and the skin
was sutured without obvious tension that might cause
the sutures to break at this point.
On the next day after surgery, there was a noticeable
swelling of the abdominal wall, and CT of the abdomen
revealed an abdominal hernia arising from the umbilicalarea (Fig. 1f). An emergent radical operation for the hernia using a silicon mesh sheet was performed.
Histopathology of the tumor showed atypical melanocytic proliferation in the dermis invading into thesubcutaneous fat layer without maturation (Fig. 1g).

Key words

abdominal hernia; peritoneum; prognosis;
sentinel lymph node; umbilical melanoma

Primary melanoma arising in the umbilicus is extremely
rare. Its anatomical location makes it difficult for the patients to realize the abnormality and challenges surgeonsin the treatment strategy. Since Cullen reported thefirst 3 cases in 1916, 24 cases have been reported in the
English literature; however, only 8 cases were reportedwith sufficient histopathological description.1–13 There
has been no review of the histopathology of reported
cases.
We present a case of melanoma that arose in the umbilicus. We also discuss 7 reports of 8 cases of primary
Corresponding author: Shuji Suzuki, MD, PhD
drshuji@yahoo.co.jp
Received 2016 March 8
Accepted 2016 April 6
Abbreviation: CT, computed tomography

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S. Suzuki et al.

Fig. 1. Clinical and operative view, image study, and histopathology.
a: A pigmented nodule of 2 × 1 cm in the umbilicus. b: The umbilicus was filled with the nodule. c: Lymphoscintigraphy with intradermic
injections of 99mTc near the nodule. Accumulation of gamma-emitting lymph nodes on both sides of the inguinal area was visible, being
more prominent on the right side. d: Incision line included the lower part of the previous operation scar of gastrectomy. e: A portion of theperitoneum was removed and a part of the jejunum is exposed (red arrow). f: Computed tomography on the first day after tumor resection.
A part of the jejunum herniated under the skin (red ellipse). g: Atypical melanocyte proliferation in the dermis close to the subcutaneous
fat layer (hematoxylin and eosin). Bar = 1 mm. h: Some of these cells were in mitosis and no maturation was observed. (hematoxylin andeosin). Bar = 20 μm.

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Table 1. Umbilical melanomas
Age(years old) Sex

Time
between
onset/first Size
visit

Breslow
Clark’slevel tumor
thickness

Colonna
19994

58

f

Not
4 cm
described

V

Colonna
19994

30

m

18 mo.

> 10 cmV(size of fist)

Not
Death,
described 7 months Not
Not(> 4mm, after
described examinedapparently) initial visit

Meine
20035

69

f

2 mo.

1.4 × 2.4
cm

III

1 mm

Alive 3 y

Superficial Not
spreading examined––/+(Secondsurgery)

CamposMunoz
20076

34

f

3 mo.

1.2 cmIII

1.06 mmAlive 18
mo

Left axilla
Superficial without
spreadingmetastasis–+

Mangas
20087

63

m

Unknown Not
time
described III

0.8 mmAlive
6 mo

Superficial Not
spreading examined–Notmentioned

Cecchi
20098

72

f

4y

1.5 × 3.0cm

IV

4.3 mmAlive
1y

Superficial Bothspreading inguinal
without+ nodular metastasis–+

Zaccagna
60
20109

f

Not
1.8 × 2.3
described cm

IV

2.8 mm

Alive
86 mo

Left axilla
Not
described without
metastasis

–

+

Song
20131362m

4y

2 × 1 cm

IV

3 mm

Alive
36 mo

Not
Not
described examined–+

Present
case

83

f

14 days

1.2 × 0.6
cm

IV

11 mm

Alive
15 mo

NodularBoth uinal
without
metastasis–+

Death/
Alive

Melanoma Location
subtypeof SLN

Not
Death,
described 10 months
Nodular(> 4mm, after
apparently) resection

PeritoMetastasis neumexcision

2 satellite
Notskinexamined lesions+

Multiple
abdominal (Surgery
and pelvic refused)metastases

CT, computed tomography; f, female; m, male; mo, month(s); MRI, magnetic resonance imaging; PET, positron emission tomography;
SLN, sentinel lymph node; US, ultrasonography; y, year(s).

DISCUSSION
Clark et al. described the histopathological level of cutaneous melanoma cell invasion and prognosis in 1969.14
A review of the histopathology of umbilical melanoma
in relation to prognosis was not done until Colonna et al.
reported 2 cases of umbilical melanoma in 1999.4 Manycase reports of umbilical melanoma lack histopatho-

Frequent mitoses were observed. Clark’s level andBreslow’s tumor thickness were IV and 11 mm, respectively (Figs. 1g and h). No melanoma cells were seen insentinel lymph nodes. The case was diagnosed as melanoma, pT3aN0M0, stage IIA. There have been no signsof recurrence or metastasis of the tumor or of abdominal
hernia for 15 months after surgery.
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S. Suzuki et al.

logically sufficient evaluation, making it questionable
whether the lesions were melanoma or primary lesions.
Taking these factors into account, 9 cases including thepresent case are considered to be histopathologicallydetermined primary umbilical melanoma (Table 1). The
age of those patients ranged from 30 to 83 years with anaverage age of 59 years. The patients included 2 Caucasians, 2 Asians, and 5 patients without ethnical description. Six patients were female.
The present case had the largest described tumor
thickness of 11 mm among the 9 cases, but the patient
became aware of the tumor only 14 days before the initial visit to a local physician, suggesting that the tumor
had existed for a considerably long time. Her abdominal
skin sagged and the umbilicus area was not easily visible. She went to hot spas with her daughter about once amonth for many years but she first noticed the umbilicalnodule when she experienced itching and bleeding after
the scratching. There was also a delay in medical care inmany of the previously reported cases. Among 5 cases
for which there was description about the time between
the patient’s realization of the lesion and the first medical visit, there were delays of 18 months or more in 3
cases and 2 to 3 months in 2 cases (Table 1). There was atendency not to visit a physician at an early stage if there
were no concomitant symptoms such as discharge or
swelling. Sagging skin caused by obesity or aging might
be the main reason for not being aware of umbilical lesions. Other patients were aware of the nodules, but they
did not seek medical care for a long time for unknown
reasons, and the delay resulted in growth and possible
metastasis of the tumor.
The long-term prognosis of umbilical melanoma is
not clear. Among the histopathologically determinedcases, only 2 cases had a follow-up period of 3 years or
longer, and the size and thickness of the tumor seem tobe important in evaluation of prognosis. Two patients
reported died within one year (10 months after resectionof the tumor and 7 months after refusing treatment).
Both patients had tumors of 4 cm or larger, and, although not specifically described, probably had Breslow
tumor thickness far larger than 4 mm judging from theclinical pictures showing large nodules.4 Breslow tumor
thickness of our case was also very large (11 mm) andthere has been no sign of recurrence or metastasis for 15
months after the surgery. It is important to continue tofollow up this patient. Four cases were described withhistopathological subtypes, superficial spreading in 2
cases, nodular in one case, and both components mixed
in the same lesion in one case, and the present case is
the second reported case of nodular subtype (Table 1).
The most unique feature of umbilical melanoma is

its anatomical location. Being the embryological remnant of the conduit between the embryo and the placenta, primary melanoma in the umbilicus may metastasize
to the abdominal cavity through ligaments derived fromthe umbilical vein, umbilical arteries, the omphalomesenteric duct, or remnants of the urachus if present.9 The
tumor may metastasize directly to the adjacent skinthrough lymphatic or hematogenous spread or to thesentinel lymph nodes. Two cases actually showed metastases: one case had metastasis to adjacent skin andthe other case had metastases to multiple abdominal andpelvic organs and to internal thoracic and external iliac
lymph nodes.4 Among cases in which sentinel lymph
nodes were examined, it was found in axillary nodes in
2 cases and in inguinal nodes in 2 cases including thepresent case.6, 8, 9 Because of the possibility of metastases through remnant ligaments, 6 of 7 previous reports
supported resection of a part of the peritoneum below
the umbilicus.4–6, 8, 9, 13 In fact, one case first underwent
resection of the fascia level, but remnant melanoma waslater found and a second operation was performed one
year later to remove the remnant tumor and a portion of
the peritoneum.5
Regarding the operative treatment approach, alloperated cases followed the WHO Melanoma trial forthe resection margin, but only one report described augmentation of the abdominal cavity with pre-peritoneal
synthetic mesh.4, 15 We first performed resection of apart of the peritoneum and closed the abdominal cavity, which resulted in postoperative abdominal hernia.
Her rectus abdominis may have been brittle due to theprevious gastric cancer surgery and her advanced age.
Her abdominal cavity should have been reinforced withpre-peritoneal synthetic mesh at the time of resection.
Even without pre-surgical fragility of the abdominal
wall, resection of the umbilical melanoma with a portionof the peritoneum should be considered with synthetic
mesh augmentation.
Umbilical melanoma has a greater chance of tumor
growth than does skin melanoma of other areas at thetime of the first presentation. Pre-surgical evaluation oftumor spread is necessary, and the resection should be
deep enough to include a portion of the peritoneum beneath the lesion.
The authors declare no conflict of interest.

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