Case Report
HJOG 2024, 23 (4), 281-286| doi: 10.33574/hjog.0577
Chrysi Xylouri1,Damaskini Polychroni1, Athanasios Maurogiorgis2
1Obstetrics/Gynecology department of General Hospital of Mytilini “Vostaneio”, Mytilini, Greece
2Pathological Anatomy department of General Hospital of Mytilini “Vostaneio”, Mytilini, Greece
Correspondence: Xylouri Chrysi, Obstetrics/Gynecology department of General Hospital of Mytilini “Vostaneio”, 81132, Mytilini, Greece, e-mail: chrysa096@gmail.com
Abstract
Fibroepithelial polyps are one of the most common benign masses of the vulva and are characterized by relatively small size, vague symptomatology, and morphological diversity. These lesions mainly affect women of reproductive age and are hormone dependent. They are usually found around the urogenital area. A biopsy and histological examination are necessary to exclude the possibility of malignant neoplasm. The pathophysiology of the disease appears to be associated with the coexistence of diabetes mellitus, chronic inflammation and chronic friction. Below we will describe the case of a 17-year-old Somali patient who had undergone female genital mutilation type IIb tyand who presented to the regular clinic with a reported unspecified vulvar mass with coexisting chronic lower limb lymphedema.
Key words: Fibroepithelial polyp, vulva, histology, lymphedema
Introduction
Fibroepithelial polyps belong to the category of mesenchymal tumors and are among the most common benign skin lesions in women of reproductive age1. They are usually detected incidentally during routine gynaecological examination at regular appointments. They are usually no larger than 5 cm in size and appear as small, soft, fleshy growths attached to the skin by a narrow stalk.2They are mainly located in the vulvovaginal area and less frequently in the perineum and extragenital areas. They are also referred to as mesodermal stromal polyps, cellular pseudosarcomatous fibroepithelial polyps, pseudosarcomatous botryoids or acrochordons. Depending on their size, fibroepithelial polyps are classified as skin tags if they are up to a few millimetres in diameter, fibroepithelial polyps if they are larger (usually less than 5 cm) and giant fibroepithelial polyps if they are larger than 5 cm.3 It has been observed that their incidence increases with age.1 Basically, these polyps are painless, but occasionally they may become irritated or inflamed due to friction or trauma, causing symptoms such as bleeding, vaginal discharge and general discomfort in the vaginal area. Another factor that exacerbates the patients’ subjective symptoms is the cosmetic- aesthetic aspect. Due to the need for differential diagnosis and exclusion of malignancy, a biopsy and histological examination is often required. Reported cases of large fibroepithelial polyps of the vulva are few in the literature. Below we present the case of a 17-year-old patient who referred a large mass occupying the entire vulva, and which has been present since the age of 7 years old when she underwent FGM.
Case presentation
A 17-year-old patient of Somali origin, presented to the regular gynaecological clinic by appointment, and complained about a painful lump on the external genitalia. The patient reported that her history goes back several years, following a female genital mutilation (FGM type IIb) she underwent in childhood, specifically at the age of 7. The symptoms worsened after menarche, as the mass became larger and more painful, causing the patient discomfort and difficulties in daily life, such as difficulty walking. The patient also reportthat she has never had sexual intercourse. In addition, lymphedema was observed on the patient’s right lower limb, and for which she reported receiving conservative treatment. A possible diagnosis of the lymphedema was chronic filariasis following an assessment by a vascular surgeon. Clinical examination of the patient revealed a large hypertrophic papilloma-type protrusion of vulvar labia with HPV-like papillomatous lesion characters. The cutaneous lesion did not extend to the labia minora and inside the vagina, nor did it obstruct the urethral opening. No abnormal vaginal discharge or lesions in the anal area were observed. The mole was slightly solid in texture and covered by normal skin, as illustrated below.
Figure 1. Vulvar papillomatous lesion
Figure 2. Clinical examination of vulvar papillomatous lesion
Figure 3. Lymphedema of the right lower limb
Her medical record revealed that she was not taking any medication or treatment other than antithrombotic stockings, had never had surgery, did not smoke and reported no known allergies. The patient reported oligomenorrhea with a cycle duration of approximately 2 days.
The patients’ vital signs were normal. Laboratory testing was performed and the following findings were shown.
WBC: 3.7, CRP (-), Vaginal culture: (+) for Candida non albicans From a previous laboratory test we observed the following:
CEA-AFP-Ca 15.3- Ca 19.9- Ca 125 (-)
Abdominal U/S: uterus detected normal size 4*3*7cm with normal ultrasound findings. Normal endometrial thickness 10mm. Right ovary normal echomorphology. Left ovary normal echomorphology. Douglas’ space free of fluid.
Afterwards, under local anaesthesia, one of the lumps was ligated and biopsy samples were taken for histological examination which revealed the following:
Histological report findings: polypoidal nodule with a pigmented surface with a maximum diameter of 1cm.
Microscopic examination: fibroepithelial polyp type lesion. There is hyperplasia of the covering epithelium, hyperplasia of the basal layer and development of melanophages in the dermis. Lymphatic vessel dilatation.
Figure 4. Pathology analysis
Results
The histological report found that the excised mass was characterized as a polypoidal nodule with a pigmented surface with a maximum diameter of 1cm, while the microscopic examination revealed a fibroepithelial polyp type lesion. There is hyperplasia of the covering epithelium, hyperplasia of the basal layer and development of melanophages in the dermis. There was also lymphatic vessel dilatation noted. The histological findings were consistent with her medical history, as the patient was not sexually active, so the possibility of HPV-induced lesion was excluded and the possibility of a benign tumor was confirmed. Since the patient was living in a temporary accommodation shelter for unaccompanied minor refugees, a recommendation was made to seek specialist surgical/plastic surgical reconstruction at a tertiary hospital after the cancellation of the patient’s geographical restriction. A recommendation was also made for conservative treatment with moisturizing creams until she receives specialized care.
Discussion
Fibroepithelial polyps are a common benign lesion found mainly in women of reproductive age. The exact cause of fibroepithelial polyps is not fully understood. It is believed to arise from the proliferation of fibrous connective tissue and epidermal components. Genetic factors, hormonal changes, obesity, type II diabetes mellitus, lymphoestasis, chronic inflammation and chronic site friction are considered as possible contributing factors.4 In literature, an association with lymphatic dysfunction has also been observed, a fact that is also confirmed by our histological examina-tion.5 Their development shows a hormone- dependent character and because of that they are more frequently observed in women of reproductive age. In pregnant women, spontaneous cure is observed after delivery.2 The lesions mentioned above do not cause specific symptoms, but cause disturbances such as discomfort, cosmetic disturbance and less frequently local bleeding. Depending on the social and psychological profile of the patients, the timing of the diagnosis varies. Due to the limited literature on this condition, it is often misinterpreted by clinicians as a wart-type lesion and mistakenly treated as an HPV-related lesion. For this reason, the diagnostic gold-standard is to obtain a biopsy and histological examination before making a treatment decision. In our patient, the main factor affecting her quality of life was the social extensions of her health problem as, due to age sensitiveness and the special nature of the lesion area, she reported -not unreasonable- excessive concerns regarding the severity of the condition and the difficulty of treatment. Finally, there are reports that, despite the rarity of the event, fibroepithelial polyps may recur, especially if removal is not thorough and total.3 Therefore, it is recommended that all patients with previous surgical removal and repair of a fibroepithelial polyp be followed long-term and treated individually.
Conclusion
Fibroepithelial polyps are common benign skin tumors that can cause discomfort and aesthetic concerns. An understanding of their clinical features, underlying mechanisms and management strategies is essential for clinicians to provide appropriate care and guidance to patients seeking relief from these growths. Priority should be given to correct microscopic differential diagnosis from any malignant lesions. Individualized treatment planning can help improve patient satisfaction and well-being.
Consent
The patient gave written informed consent for the publication of this case report. A copy of the written consent is available for review by an authorized specialist.
References
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- Orosz Z, Lehoczky O, Szőke J, Pulay T. Recurrent giant fibroepithelial stromal polyp of the vulva associated with congenital lymphedema. Gynecologic Oncology. 2005;98(1):168- 171. doi:10. 1016/j.ygyno.2005.01.020