An intriguing case of an unusually large nipple mass

INTRODUCTION

Fibroepithelial polyps, also known as acrochordons, are a common dermatosis that typically affects the axillae, groin, and gluteal regions. However, the involvement of the nipple areola complex by this disease is an uncommon finding. We are presenting this case to highlight an unusual manifestation of a very common dermatosis.

CASE REPORT

A 25-year-old unmarried female presented to the dermatology outpatient department with chief complaints of a gradually progressive dark brown pendulous mass arising from the right nipple for 5 years. It was asymptomatic and not associated with pain or discharge from the nipple areola complex or adjacent area of the breast.

On examination, an approximately 5 × 4 cm brown–black, soft, non-tender, lobulated mass was attached to the right nipple through a peduncle [Figure 1]. The contralateral breast was unremarkable.

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Figure 1:

A pedunculated, brown-black, lobulated mass attached to the right nipple. A pedunculated 5*4 cm brown-black, lobulated mass attached to the right nipple

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The lesion was completely excised and sent for histopathological analysis, which revealed epidermal papillomatosis and variable mild acanthosis surrounding a core of fibrovascular tissue with dense collagen fibers. There was no evidence of an exaggerated level of mitoses in cells or an increased nuclear cytoplasmic ratio [Figure 2]. Based on these findings, a diagnosis of fibroepithelial polyp was made.

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Figure 2:

Epidermis is papillomatous with variable mild acanthosis as shown by black arrows. Dermis shows loose fibro collagenous stroma with variably dilated blood vessels as shown by circle. Hematoxylin and eosin, 20x.

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DISCUSSION

Fibroepithelial stromal polyps are benign tumors of mesodermal origin. They are usually located in the axillae, groin, and gluteal region and occasionally on the oral mucosa, penis, urethra, and vulva.^[1-3] Rarely, they can be present on the nipple (incidence <2%).^[3] Fibroepithelial polyps, also known as acrochordons, are benign lesions that present as skin-colored or hyperpigmented, often pedunculated lesions with a cauliflower-like surface. Histologically, such lesions are typically polypoid with a prominent fibrovascular core. Although their clinical appearance is characteristic, their varying sizes and shapes can lead to diagnostic uncertainty. A giant fibroepithelial polyp over an unusual location like the nipple is rare, with very few cases reported in the literature. Conditions such as pedunculated seborrheic keratosis, leiomyomas, superficial angiomyxoma, perineuromas, neurofibromas, and nodular exophytic (polypoid) melanoma can cause further dilemmas in making a diagnosis; hence, the need for biopsy of these lesions is necessary.^[4] Neurofibromas are peripheral nerve sheath tumors presenting as soft, non-tender, sessile or pedunculated fleshy masses with a buttonhole sign on examination. On histopathology, it consists of low-to-moderate cellularity of bland-looking spindle-shaped cells with scant cytoplasm and oval, elongated, and regular nuclei without nucleoli, haphazardly embedded in a variably fibromyxoid stroma, often containing coarse collagen bundles. Seborrheic keratosis presents as tan to brown to black, hyperkeratotic, adherent papules, giving a “stuck-on” appearance with multiple plugged follicular orifices. Histopathologically, it shows hyperkeratosis, acanthosis, papillomatosis, horn cysts, and variable melanin deposition. Leiomyomas present as multiple red to red brown firm papules associated with pain of variable intensity. Histopathologically, it is characterized by interlacing bundles of smooth muscle cells in the upper dermis.

CONCLUSION

Fibroepithelial polyps are common dermatoses seen in clinical parlance but its presence on unusual locations like nipple can create a diagnostic dilemma, it is important to keep a high index of suspicion in such cases.