Purpose: “Sister Mary Joseph Nodule” (SMJN), a term coined by Sir Hamilton Bailey in 1949, refers to a periumbilical metastatic tumor from advanced abdominal malignancies. We report an extremely rare case of multiple SMJN from primary gastric adenocarcinoma diagnosed 2 years after presentation. A 56-year-old cachectic female with a diagnosis of intra-abdominal malignancy of unknown primary presented with intractable nausea and vomiting. Two previous EGDs and a colonoscopy were negative. Diagnosis was made following multiple laparotomies, and a peritoneal wall biopsy revealed poorly differentiated adenocarcinoma of signet ring type. Pathology reported it was likely from a stomach, pancreas, biliary, or endocervical primary. However, extensive workup was negative at that time. Abdominal exam showed an ileostomy bag, a cecostomy tube, and a skin graft with scar tissue. Around the graft were more than 15 nodules ranging in diameter from 2 to 15 mm. A repeat EGD this admission showed multiple nodules in the antrum, body, and fundus of the stomach, with severe stenosis of the antrum from intrinsic compression by the nodules seen. Biopsies showed poorly differentiated adenocarcinoma with signet rings. Excisional biopsies of the abdominal wall nodules showed poorly differentiated adenocarcinoma, positive for tumor markers CK7, CEA and negative for p63 and CK5/6. Patient was not a candidate for salvage chemotherapy and was discharged to home hospice. SMJN is an uncommon, yet classic sign indicating advanced intra-abdominal malignancy. The presence of multiple nodules is extremely rare with only one case previously reported. The nodules are an indicator of dismal prognosis with an average survival of less than 1 year. Several hypotheses are postulated regarding the origin of these nodules, including contiguous spread from the peritoneum, hematogenous or lymphatic spread, iatrogenic implantation, or via embryologic remnants. In this case, two previous EGDs on presentation detected no lesions, reflecting the subtle nature of this cancer. Despite delayed diagnosis, primary gastric adenocarcinoma remains one of the classic tumors associated with SMJN.Figure: Multiple SMJNs.