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The umbilical lesion above was noted in an 82 year old man who presented with weight loss and abdominal pain. The lesion is known as a Sister Joseph's nodule. Sister Joseph, surgical assistant and later nursing superintendent at St Mary's Hospital, Rochester, Minnesota, drew the sign to the attention of Dr W J Mayo who published an article on the sign in 1928, referring to it as “pants button umbilicus”. The lesion had been recognised previously and reported in publications from the mid-19th century. The lesion is usually due to a secondary deposit from gastric carcinoma but lesions from primary colonic, ovarian, pancreatic, and uterine tumours are reported. The sign is usually, but not invariably, associated with a poor prognosis. In this particular case, fine needle aspiration of the lesion revealed metastatic adenocarcinoma and ultrasound of the liver revealed multiple metastases. The patient died and postmortem examination was not performed.