Bizarre Leiomyoma of the Uterus: Therapeutic Mapping

Leiomyomas represent the most common type of benign tumors of the female genital tract. Assiduous preoperative imaging findings reflect proper therapeutic mapping. In cases of female patients of reproductive age, the ultimate goal remains the fertility preservation and the quality of life of the patient. According to recent bibliography, bizarre leiomyomas remain a controversial issue regarding the preoperative and postoperative therapeutic mapping. Giant cells with pleomorphic nuclei and little or no mitotic activity compose the microscopic analysis of such lesions. Multidisciplinary approach is mandatory in order to establish ultimate diagnosis and treatment. Bizarre leiomyomas still represent a gray scale among the whole scientific community.


Introduction
The incidence of uterine fibroid tumors increases as women grow older, and they may occur in more than 30% of women 40-60 years of age (Figure 1). Risk factors include null parity, obesity, family history, black race, and hypertension.
Many tumors are asymptomatic and may be diagnosed incidentally. Many studies have indicated the proper therapeutic mapping in cases of nulliparous young patients.
Therapeutic strategy is strongly accompanied with age and fertility capacity of the patient. In cases of degenerated uterine fibroids in nulliparous patients, laparoscopic approach represents the gold standard of surgical confrontation.
In reproductive age women, 15-30% of these tumors are responsible for menstrual disorders, anemia due to perfuse uterine bleeding, pelvic pain, pregnancy loss, rarely preterm birth, and percentage of infertility [1].
In order to establish a proper diagnosis and treatment, especially in women of reproductive age, there is a classification of uterine fibroids [2].
Many factors affect the therapeutic mapping of uterine myomas. Age of the patient, gynecologic or obstetrical history, previous surgical procedures and fertility preservation.
Uterine fibroids consist of smooth muscular tissue with always the possibility of malignant transformation. Tumor size and anatomic location are strongly accompanied with assiduous therapeutic strategy.    Transvaginal ultrasonography reflects the first preoperative procedure, depending on the physician's experience and technical sufficiency of the ultrasound machine.
In such cases, abdominal MRI can, without a doubt, guide the preoperative management [4] (Figure 2).
In order to avoid diffuse menorrhagia and procedures of diffuse intravascular coagulation, an appropriate solution consists of uterine fibroid embolization [5]. With the use of colloid substances, we can lead to fibroid necrosis and cell apoptosis (Figure 3).
There are cases after fibroid surgical dissection and abdominal or vaginal hysterectomy where the histopathologic evaluation confirms bizarre myomas. The dilemma is controversial especially in cases of female patients of reproductive age. The ultimate goal remains fertility preservation of such patients.

Discussion
All mentioned scientific guidelines reflect the pathway from general depictions of uterine anatomy and physiology to specific fibroid pathology.
Many authors complete their monograph concerning uterine fibroids. They described several tumors with similar macroscopic view as uterine fibroid, but microscopically they include large multinucleated tumor cells.
After WHO (World Health Organization) classification bizarre leiomyomas presented as fibroids with giant cells with pleomorphic nuclei and little or no mitotic activity [6].
In many cases they represent a histologic gray zone concerning the therapeutic mapping in female patients of reproductive age.
Before final diagnosis is established, assiduous examination of the specimen is mandatory focusing on terms of atypia or necrosis (simple, moderate, or severe).
Along with genetic predisposition and ovarian hormone stimulation, many growth factors are identified.
Besides genetic predisposition and ovarian hormones that play a major role in tumor expansion, a large number of growth factors have also been identified which favor expansion.
These are insulin-like growth factor (IGF), epidermal growth factor (EGF) and platelet-derived growth factor (PDGF), transforming growth factor beta (TGF beta), and basic fibroblast growth factor (BFGF) [7]. These may have a role to play in tumor expansion.
The major differential dilemma remains the establishment of bizarre uterine myomas versus endometrial stromal sarcoma (ESS) (Figure 4).
The main characteristics of ESS consist of infiltrative myometrium growth and vascular invasion, presence of necrotic areas, and mitotic activity [8].
Due to infiltration of the myometrial basal membrane, surgical dissection after staging of the lesion represents the gold standard. Multidisciplinary approach is mandatory in order to establish proper postoperative treatment.
In cases of metastatic ESS, neoadjuvant therapy or series of radiotherapy will understage the tumor expansion and make the tumor staging surgically feasible.
On the other hand, patients with positive progesterone or estrogen receptors (ER+, PR+), can be treated postoperatively with hormonal agents such as progestogens [9]. DOI: http://dx.doi.org /10.5772/intechopen.89963 Ki-67 as exceptional biomarker is strongly accompanied with proliferative activity and presence of necrotic areas. Many conducted studies have adjusted Ki-6 and successful postoperative management.
In primary stages of the lesion, fertility preservation in female patients of reproductive age remains a controversial dilemma [10].
The impact of bizarre leiomyoma on fertility is not well known. Bizarre leiomyoma consists of a rare entity composing pleomorphic or symplastic cells which require assiduous histopathologic evaluation.
If fertility preservation is not required, the standard surgical intervention for bizarre leiomyoma that shows a benign clinical course is a simple hysterectomy [11,12].
Due to rare incidence of bizarre myomas, in cases of female patients of reproductive age with ultimate scope the fertility preservation, simple myomectomy as the gold standard remains a controversial issue.
Etiology concerning this issue depends on the identification difficulty during myomectomy between specimen surgical borders and myometrium. After histopathologic evaluation and not clear surgical margins, there is an increased incidence of tumor recurrence [13].
On the other hand, surgical treatment with dissection part of the associated myometrium, can lead in a future pregnancy, to spontaneously membrane rupture and episodes of preterm birth.
Precise scientific evaluation of current bibliography, focusing on optimal treatment in patients of reproductive age, reveals a lack of scientific guidelines.

Author details
Chrisostomos Sofoudis Department of Obstetrics and Gynecology, Konstandopoulio General Hospital, Athens, Greece *Address all correspondence to: chrisostomos.sofoudis@gmail.com The ultimate scope of the above presentation reflects the stimulus of completion and composition new conducted studies, which will guide assiduously and clear all controversial issues.
Bizarre uterine myomas, as rare entity, still represent a gray area among the whole scientific society.

Conclusion
Bizarre uterine fibroids represent a controversial scientific zone in the current bibliography. More studies must be conducted in order to establish proper diagnosis and treatment.
Multidisciplinary approach is mandatory in cases of patients of reproductive age. The ultimate goal remains in such cases, always fertility preservation.