A clinical case of large fibroepithelial polyp of breast nipple

Introduction: Polyp of breast nipple is a rare benign tumor which is pedunculated. The typical polypoid appearance makes the clinical diagnosis apparent. The breast nipple polyp in woman are generally small in size. Giant size fibroepithelial polyp are very rare. Case Report: This is case report of a large size fibroepithelial polyp arising from nipple of left breast in 40-year-old woman. This polyp was more than 10 cm size in length having a long pedicle. This polyp with its pedicle was excised from nipple. The histopathological diagnosis was consistent with fibroepithelial polyp. Conclusion: The large size fibroepithelial polyp of nipple breast is very rare.


INTRODUCTION
Fibroepithelial polyp is an uncommon benign tumour arising from skin commonly of the vulva-vaginal area [1].These fibroepithelial polyp are also known to occur in mucosa of oral cavity and urinary tract [2].The fibroepithelial polyp can be sessile or pedunculated.A long pedicle of a fibroepithelial polyp is not unusual.The fibroepithelial polyp breast nipple is a rare lesion; the clinical presentation of such lesion has been described in one case report [3].The peculiar shape and surface of polyp of the breast nipple generally gives a clear clinical diagnosis, however, these polyps pose a diagnostic problem for the pathologist [3].Also, only a few case reports of histopathology description of breast nipple are available in medical literature [4].These case reports pertain to fibroepithelial polyps of breast nipple generally small sized.The fibroepithelial polyp of size more than 10 cm are described as large size or giant size have been described in vulva region [5].One case of large fibroepithelial polyp of the breast nipple with size > 10 cm is presented here for its exceptional large size with clinical description.

CASE REPORT
A 40-year-old woman presented with a mass hanging from the tip of nipple of left breast for last 3 years (Figure 1).This lesion started as a small lesion of sub centimetric size.The lesion was painless and did not caused any symptoms.So, the patient ignored this lesion for long time.The lesion kept on growing slowly and silently to reach the present size.There was no history of lump in the breast and no discharge from nipple.She had three grown up children.The last pregnancy was 16 years back.Menstrual cycles were normal of 3-4 days/28 days.There was no history of any breast lesion in the family.On clinical examination, the mass shows a well circumscribed oval shape lesion of size 12x7 cm.The lesion was pedunculated and was having a long pedicle connected to nipple of left breast.The surface of this lesion was covered by thin skin all around which was glossy at www.ijcasereportsandimages.com Arora BK 2 certain places due to stretching.The surface of this lesion was uneven like cauliflower.There were no ulcers on its surface.This swelling was firm in consistency (Figure 2).The nipple areola complex and breast were normal.There was no axillary lymphadenopathy.The clinical diagnosis was of a benign polyp.
The ultrasound of the bilateral pectoral breasts was normal.The mammography of both pectoral breasts was normal except showing a soft tissue mass with macro calcification outside the line of left pectoral breast (Figure 3).
The patient was operated under local anesthesia.About 2 ml of 2% lignocaine was infiltrated under the skin of left nipple.An elliptical incision was given on the tip of nipple.The incision was deepened by 3mm and this wedge was excised along with long pedicle.There was a small feeder vessel which coagulated.The small elliptical wound was closed with 4-0 polypropylene suture.The patient was discharged after two hours on the same day as it was a day surgery procedure.There were no postoperative complications.The wound healed well and stitches were removed on 7th postoperative day.The excised specimen was sent for histopathological examination.
The gross appearance of the excised specimen showed a 12x7 cm size, grey brown polypoidal mass with a long pedicle of about 5 cm (Figure 4).The cut section of specimen revealed white coloured, uniform smooth and whirly appearance.This polypoidal mass was covered with skin.It showed grey white areas infiltrating normal parenchyma (Figure 5).
The microsection H&E stain 100 X showed lining of stratified epithelium with underlying subepithelial composed of loose collagenous tissue (Figure 6).Histopathological examination revealed it a fibroepithelial polyp as final diagnosis.The patient was followed at three months, the scar has healed well and no recurrence was observed.

DISCUSSION
The fibroepithelial polyp is very common benign tumour of skin.The fibroepithelial tumours are basically skin tags which enlarge in size.They are also known as acrochordon.These fibroepithelial polyps or skin tags are pedunculated.They commonly occur on neck, axilla, perineum and thighs.These fibroepithelial polyps do occur on female external genitalia like vulva and male external genitalia like penis and urethra.Also, these fibroepithelial polyps have been reported on nipple of breast [6].
In this case report, a 40-year-old woman presents with a large size polyp hanging down from the nipple of left breast.The incidence of the fibroepithelial polyps increases with increasing age [7].The breast nipple is an unusual site for origin of a fibroepithelial polyp [8].Second unusual thing about this lesion was its macroscopic clinical appearance.It begins as filiform or bag like protrusion [9].The third unusual thing was its large size 12x7 cm, fibroepithelial polyp of breast nipple of such a large size has been rarely reported in medical literature.Most of these polyps are smaller than 5 cm in size [10].The fibroepithelial polyp of vulva having more than 10 cm size has been defined as the giant fibroepithelial polyp [11].A case giant fibroepithelial polyp in perineum area having size of 18 cm has been reported in literature [12].
In this case report, the size of polyp was more than 10 cm, so this extraordinary large size polyp has been reported in this case.This large fibroepithelial polyp was having a long pedicle.She never wears brassier for breast support and never felt uncomfortable.Neither she developed ulceration or bleeding.The continuous hanging in loose clothing, this lesion developed a long pedicle due to gravity.The fourth unusual thing was its benign appearance clinically.It is quite unusual for such large size polyp to have benign appearance.Clinically, the possibility of leiomyoma or dermatofibroma was considered in differential diagnosis [13].The fifth unusual thing was histological appearance which described it as fibroepithelial polyp which are common in vulva and thighs.The fibroepithelial polyps is commonly a mesenchymal tumour.In this case, histopathology shows stratified epithelium lining with underlying subepithelial composed of loose collagenous tissue.However, histopathology in polyps gives a clear diagnosis [14].

CONCLUSION
A giant size of 12 cm fibroepithelial polyp of nipple breast is an uncommon benign lesion, amenable for surgical excision with curative intent.