Giant soft fibroma located in the vulva: a case report

Received on: 12 February 2012
Approved on: 9 May 2012
This study was carried out at the Universidade
Federal do Piauí (UFPI) – Teresina (PI), Brazil.
Conflict of interest: None
Financial support: None

Abstract

This article describes the case of a soft fibroma of unusual size and development located in the vulva of a post-menopausal woman.

Keywords: FIBROMA, NEOPLASMS, FIBROUS TISSUE, VULVAR DISEASES, VULVAR NEOPLASMS

INTRODUCTION

A wide variety of tumors, many of them malignant, occur in the vulva. 1 Soft fibromas are connective-tissue benign tumors that have multiple synonyms (naevus molluscum, acrochordon, Templeton skin tag, and fibroepithelial polyp). They occur more frequently in the eyelids, neck, axillae, submammary regions, and inguino-crural folds, and are unusual in the vulva. 2 In rare cases they are malignant, with varying growth rates (from slow and steady over the years to fast). Malignant fibromas rarely reach large dimensions, with an estimated occurrence frequency between 1/9,000 and 1/23,000 in gynecological patients, when malignancy generation is always considered. 3

Soft fibromas are described as pedunculated tumors due to an elongation in their conjunctive tissue, especially in superficial tumors. When located in the vulva, they occur more often in the labia majora and less frequently in the labia minora, clitoris, vestibule, and posterior commissure. In tumors of long clinical duration, ulcerations with superficial bleeding, often due to repeated trauma, are often observed. 3

The case of a vulvar soft fibroma on the left labium majus, with a development of more than 20 years and uncommon dimensions, is described in this case report.

CASE REPORT

A 73-year-old mulatto female patient, who is married, reported a tumor that had been progressively developing for 20 years. Initially asymptomatic, it had progressed with discomfort in previous months, causing difficulty in walking due to the weight of the tumor. There were also areas of ulceration and bleeding. During the gynecological examination, a massive tumor with a long pedicle, torus-like contours, and an elastic consistency was revealed. The pedicle had great dimensions and was located in the upper left labium majus, extending down to the knee in its distal portion (Figure 1). The internal genitalia did not present abnormalities. The patient underwent the extirpation of the lesion (Figures 2A,B and C). At the macroscopic examination, the tumor presented as polypoid and had a grayish-brown color, with a firm consistency. It was 28 cm long and measured 13 cm x 10 cm in its distal portion, and weighed 985 g. The hematoxylin-eosin based histology revealed a benign neoplasia comprised of a proliferation of loose connective tissue covered by keratinized squamous epithelium, without atypias – which was consistent with a soft fibroma diagnosis (Figure 3). The reassessment after one week showed complete healing without complications.

DISCUSSION

Soft fibromas of the vulva develop from mesenchymal tissue – most frequently in the external genitalia''''''''s dermal connective tissue. They may also originate in the conjunctive tissue of the extraperitoneal portion of the round ligament or in the pelvis'''''''' subperitoneal ligament.4 The rarity of these tumors prevents a more detailed understanding of their morphological and epidemiological characteristics, with only short descriptive texts and citations in the literature regarding their gynecology or pathology. 4, 5, 6 This type of tumor has a peak incidence at 20-40 years old and is rare in children, breastfeeding and pregnant women, and elderly patients. While it is uncommon for such tumors to exceed 8 cm in length, this case refers to a 73-yearold woman affected by a 13 cm-long soft fibroma. 7 Its long course (20 years) is quite unusual compared to other cases found in the literature, which describe 2-7 years of development; cases of ulceration are even rarer. 8

A tumor begins as a small sessile nodule and becomes pediculated during the course of its growth. Pediculated cases are most commonly seen in tumors that originate from the connective tissue around the vulva, often from the labia majora. Conversely, when originating from the round ligament''''''''s inguinal portion, they tend to grow towards the abdominal wall, while those originating in the pelvis'''''''' subperitoneal ligament are usually multiple, despite having pedicles originating in the same point. 9

Fibromas are usually asymptomatic in the beginning, however they develop symptoms resulting from their size (when they reach great dimensions) and from their main complication – the superficial ulceration. Differential diagnose is carried out against lipoma, inguinal hernia, vulvovaginal cyst, and other benign tumors of the vulva. 9, 10

According to the histological variants, fibromas of the vulva can be classified as either pure or mixed. The pure form may be hard or soft. The pure - hard variant presents fibrous and hard conjunctive tissue, with a white or pink hue, and a lobulated and well-differentiated appearance. Disorganized conjunctive bundles, entangled in all directions, can be observed under a microscope. The microscopic view of the pure variant also presents a soft and loose consistency, with conjunctive fibers intertwining with a seromucous substance. In the mixed variant, the conjunctive tissue is combined with other tissues, such as fat and muscle; they primarily originate in the extraperitoneal portion of the round ligament. 4

Giant soft fibromas of the vulva are benign tumors that in some cases, due to their macroscopic appearance, can lead to a mistaken diagnosis of malignancy.

References

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9 . Lima Filho OA. Fibroma of the vulva: molluscum pendulum. Rev Gynecol Obstet. 1952;46(4):287-96.

10 . Rodrigues JB. Sobre dois casos de fibroma de vulva (molluscum pendulum). Rev Ginecol Obstet. 1964;114:105-8.