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Introduction

Fibro epithelial stromal polyps are a type of benign mesenchymal hormone sensitive lesions most commonly seen in pregnant women. Skin, oral cavity, urinary tract, breast and genital area are common areas of presentation of which genital presentation is much more common and has a greater predilection for vulvovaginal region and rarely the cervix [1]. However, they can also be seen in premenopausal females who are on hormone replacement therapy. They always pose diagnostic problems because of their resemblance to various other mesenchymal lesions. Cases of fibro epithelial polyp in vulva have been reported and usually they do not grow larger than 5 cm in diameter. Because of their smaller size they are usually identified on routine gynecological examination only. However, the largest size reported ever was 28x27x12 cm in a 16 year old women [2]. The case report presented is a rarest of its kind as regards to its size and weight because the polyp in this patient measured 35x23x11 cm and weighing 10 kg which becomes the largest polyp reported ever.
 
Case Report

A 56 year old female reported to our hospital with the complaint of difficulty during walking because of a growing mass between her thighs. History revealed that the mass initially started as a small growth 40 years back and it had been growing since then. The growth grew rapidly in size for the past six years. No significant medical or surgical history was present. The patient had not taken consultation since so many years because of personal reasons being the site of its presentation. She attained menopause six years back and no significant gynecological history was present. She was a non-smoker and denied alcohol or drug use. Physical examination revealed a large, non-tender, skin colored, pumpkin sized broad based pedunculated mass extending from the right labium majus [Fig.1]. Transvaginal ultrasound showed atrophic uterus and ovaries but also described a broad-based encapsulated soft tissue mass from the right labium at the level of the clitoris. Surgery being the only treatment option, surgical removal of the mass was planned after obtaining consent from the patient and explaining the procedure in detail. The tumor arising from labia majora was excised completely [Fig.2] and primary closure of wound was carried out. Consent of the patient was obtained for publishing this as a case report.


Discussion

In the present case report, a mass in a 56 year old female has been described. The mass was diagnosed to be a giant fibro epithelial stromal polyp which is the largest ever reported measuring 35x23x11 cm and weighing 10 kg. The fibro epithelial stromal polyp, also called “cellular pseudoangiomatous fibroepithelial stromal polyps” was described originally by Norris and Taylor in 1966 like a benign injury [3]. These polypoid exophytic tumor growth arises from proliferation of mesenchymal cells within the hormone sensitive sub epithelial stromal layer of the lower genital tract in females of reproductive age [4,5]. Symptoms include bleeding, discharge and discomfort. Usually the margins are unidentifiable as they merge with the normal tissue. Histologically, they contain conspicuous fibrovascular core and a hypocellular stroma. However, this bizarre stromal cytomorphology, atypical mitosis and hypercellularity often lead to misdiagnosis [6]. Malignancy must be excluded in every diagnosis of fibro epithelial stromal polyp. Various other lesions like leiomyomas, superficial angiomyxoma, perineureomas and neurofibromas mimic fibro epithelial polyps [7]. For this reason final diagnosis is always based on microscopic findings. Microscopically, the most characteristic feature of a fibro epithelial stromal polyp is the presence of stellate and multinucleate stromal cells identified near the epithelial-stromal interface [8]. Microscopic evaluation of the lesion in this case revealed loose fibrocollagenous and fibrofatty tissue lined by unremarkable stratified squamous epithelium. The stroma was traversed by small blood vessels and chronic inflammatory cells. Cases of reoccurrence of fibro epithelial polyps raise concern about complete surgical excision [9]. As a result, all patients with this diagnosis should be followed up on long term and managed appropriately after initial treatment.

Conclusion

Fibro epithelial stromal polyps are benign, mesenchymal lesions that typically occur in women of child-bearing age. These polyps have a predilection for the vulval region and although they typically are small in size; they sometimes can grow as large as 10 kilograms and 35 cm in diameter as seen in our presenting case. Although benign, the polyp mimics some more serious and malignant growths in appearance and as a result, microscopic evaluation of the polyp is critical in the exclusion of malignancy.
 
References

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