A HUGE FIBRO EPITHELIAL POLYP OF THE VULVA WITH MYXOID STROMA IN TUNISIAN NULLIPAROUS WOMAN

Introduction: Fibroepithelial polyps are a type of mesenchymal lesion that typically occurs in women of reproductive age. These lesions can be polypoid or pedunculated and are usually solitary. They are typically asymptomatic and do not grow larger than 5 cm in diameter. However, there are few reported cases of giant fibroepithelial polyps of the vulva. In these cases, tumors cause usually symptoms including bleeding, discharge and general discomfort (with sensation of a mass). Case Report: Here we report a painful giant fibro epithelial polyp on the left labia majora in a 47-year-old Tunisian nulliparous woman. The mass was pedunculated, firm, 10cm in diameter. It was excised and the histological examination confirmed the diagnosis of fibro epithelial polyp with myxoid stroma and abcesses. Conclusion: The current case is characterized by huge fibro epithelial polyp of the vulva, rare disorder which may cause symptoms resulting from its size. Abcesses can be added to the main complications of these tumors such as bleeding, discharge and superficial ulceration.


Introduction
Different types of tumors of the vulva are reported [1].Fibromas are the most common benign tumours of the vulva [1].fibromas are connective-tissue benign tumors that have multiple synonyms (naevus molluscum, acrochordon, templeton skin tag, and fibroepithelial polyp) [2].Fibro epithelial polyps are a type of mesenchymal lesion that typically occurs in women of reproductive age [3].These polyps are site-specific and have a predilection for the vulvovaginal region.They are most frequently found in the vagina.Infrequently they occur on the vulva and cervix and rarely are found in extra-genital sites.These polyps are hormone sensitive and most commonly occur in pregnancy.Here we report a case of a FEP on the left labia majora with myxoid stroma and complicated by multiple abcesses.

Case Report
A 47-year-old woman, with no particular medical history, was referred to our department for a painful giant polyp on the left labia majora that was progressively increasing in size over three years.Physical examination revealed a 10x8 cm pedunculated, globular, and firm mass.The proximal edge was connected to the left labia majora by 3x1.5 cm pedicle (Fig. 1).No lymph nodes were palpable in the vulvar and inguinal regions.The mass was excised at the base of the pedicle.The surgical specimen consisted of a pedunculated spherical mass, 10 cm in diameter (Fig. 2).It was well circumscribed but had no definite capsule.Cut surface was homogenous, tanwhite, gelatinous, and with abcesses (Fig. 3).On microscopic examination, the mass was entirely coverd by an epidermis.It was hypocellular with abundant loose connective tissue stroma and focal myxoid area (Fig. 4).No mitosis or cytologic atypia was noted.Areas of dense inflammatory infiltrate of neutrophils forming abcesses were showed (Fig. 5).These findings are consistent with the diagnosis of vulvar fibroepithelial polyp with myxoid stroma and abcesses.One year later, the patient showed no evidence of recurrent disease.

Discussion
Vulvovaginal polyps are very rare lesions of the female genital tract [4].It was first reported originally by Norris and Taylor in 1966 as a benign injury [5].Vulvar FEP is a benign tumour that is predominantly found in women of reproductive age group [3].However, they have been also reported in infants and in post menopausal women [2,3].The tumor may arise from either the deep connective tissue of introitus, labia majora, perineal body or round ligament [6].Usually, these tumors are small [4], but they, rarely, can have an extremely large size [1][2][3][4] as the case of our patient.The largest FEP was reported by Chan et al in 201, the tumor weighed 1.112 kg and measured 20.5 x 17 x 5 cm [1].FEP are usually asymptomatic in the beginning, however they develop symptoms resulting from their size and from their main complication, the superficial ulceration [2].Symptoms usually include bleeding, discharge and general discomfort with sensation of a mass.They may also cause extreme emotional upheaval, psychological disturbances and social withdrawal [6].Macroscopically, the polyps can be sessile or pedunculated [2,3].Differential diagnosis may be lipoma, inguinal hernia, vulvovaginal cyst, vulval elephantiasis and other benign tumors of the vulva [2,6].Histologically, vulvar fibroepithelial polyps are hypocellular with abundant loose connective tissue stroma and focal myxoid areas [4].The stromal cells may be reactive with desmin, vimentin, actin, and S-100 [4].The surgical excision, which was the treatment proposed to our patient, is the first line treatment according to the literature [1][2][3][4].Only 2 recurrences were reported within two years following initial surgical treatment [3,4].The pathogenesis of FSP is not yet well understood [1].Some authors suggest a reactive hyperplastic process involving the distinctive subepithelial mesenchyma of the lower female genital tract [7].Moreover, the potential role of hormonal influence is raised by the fact that FSP rarely occurs before puberty and multiple FSPs are often associated with pregnancy [8].On the other hand, some diseases associated with FEP have been previously reported such as psoriasis [9] and congenital lymphoedema [10].In summary, we report a new case of a giant FEP in Tunisian women complicated by abcesses.Further report cases of these rare tumors may allow a more detailed understanding of their morphological and epidemiological characteristics.

Figure 3 .
Figure 3. Cut surface of the tumor mass demonstrating a homogenous firm and gelatinous features with abscesses.

Figure 4 .Figure 1 .
Figure 4.The mass covered by an epidermis and formed by a hypocellular connective tissue with myxoid area.(HEX100)