Classification of uterine fibroids. Women’s Health 2014. Future Medicine Ltd.
\r\n\tThe book will present up to date knowledge on mentioned ADHD topics in order to be implemented in every day clinical practice.
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Risk factors include null parity, obesity, family history, black race, and hypertension.
\nUterine fibroids. newsnetwork.mayoklinic.org.
Many tumors are asymptomatic and may be diagnosed incidentally. Many studies have indicated the proper therapeutic mapping in cases of nulliparous young patients.
\nTherapeutic 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.
\nIn 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].
\nIn order to establish a proper diagnosis and treatment, especially in women of reproductive age, there is a classification of uterine fibroids [2].
\nMajor categories consist of submucosal, intramural, subserosal, and others (cervical, parasitic) (Table 1).
\nClassification of uterine fibroids. Women’s Health 2014. Future Medicine Ltd.
Many factors affect the therapeutic mapping of uterine myomas. Age of the patient, gynecologic or obstetrical history, previous surgical procedures and fertility preservation.
\nUterine 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.
\nTransvaginal ultrasonography reflects the first preoperative procedure, depending on the physician’s experience and technical sufficiency of the ultrasound machine.
\nImaging findings as areas of cystic degeneration, enlarged and asymmetric vascularization, papillary protrusions, and possibly increased tumor markers as Ca-125/Ca 15-3/Ca 19-9 reveal preoperative procedures of malignant metaplasia [3].
\nIn such cases, abdominal MRI can, without a doubt, guide the preoperative management [4] (Figure 2).
\nAbdominal MRI with enlarged uterine fibroid depiction. Researchgate.net.
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).
\nUterine fibroid embolization. Interventionalnews.com.
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.
\nAll mentioned scientific guidelines reflect the pathway from general depictions of uterine anatomy and physiology to specific fibroid pathology.
\nMany 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.
\nAfter WHO (World Health Organization) classification bizarre leiomyomas presented as fibroids with giant cells with pleomorphic nuclei and little or no mitotic activity [6].
\nIn many cases they represent a histologic gray zone concerning the therapeutic mapping in female patients of reproductive age.
\nBefore final diagnosis is established, assiduous examination of the specimen is mandatory focusing on terms of atypia or necrosis (simple, moderate, or severe).
\nAlong with genetic predisposition and ovarian hormone stimulation, many growth factors are identified.
\nBesides 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.
\nThese 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.
\nThe major differential dilemma remains the establishment of bizarre uterine myomas versus endometrial stromal sarcoma (ESS) (Figure 4).
\nEndometrial stromal sarcoma. H&E stain. Wikipedia.
The main characteristics of ESS consist of infiltrative myometrium growth and vascular invasion, presence of necrotic areas, and mitotic activity [8].
\nDue 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.
\nIn cases of metastatic ESS, neoadjuvant therapy or series of radiotherapy will understage the tumor expansion and make the tumor staging surgically feasible.
\nOn the other hand, patients with positive progesterone or estrogen receptors (ER+, PR+), can be treated postoperatively with hormonal agents such as progestogens [9].
\nKi-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.
\nIn primary stages of the lesion, fertility preservation in female patients of reproductive age remains a controversial dilemma [10].
\nThe 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.
\nIf fertility preservation is not required, the standard surgical intervention for bizarre leiomyoma that shows a benign clinical course is a simple hysterectomy [11, 12].
\nDue 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.
\nEtiology 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].
\nOn 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.
\nPrecise scientific evaluation of current bibliography, focusing on optimal treatment in patients of reproductive age, reveals a lack of scientific guidelines.
\nThe 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.
\nBizarre uterine myomas, as rare entity, still represent a gray area among the whole scientific society.
\nBizarre uterine fibroids represent a controversial scientific zone in the current bibliography. More studies must be conducted in order to establish proper diagnosis and treatment.
\nMultidisciplinary approach is mandatory in cases of patients of reproductive age. The ultimate goal remains in such cases, always fertility preservation.
\nSignificant role to the completion of this book chapter, exploration and searching throughout medical data bases such as PubMed and Cochrane database.
\nThe author declares no financial procedure with respect to this manuscript.
\n"I work with IntechOpen for a number of reasons: their professionalism, their mission in support of Open Access publishing, and the quality of their peer-reviewed publications, but also because they believe in equality. Throughout the world, we are seeing progress in attracting, retaining, and promoting women in STEMM. IntechOpen are certainly supporting this work globally by empowering all scientists and ensuring that women are encouraged and enabled to publish and take leading roles within the scientific community." Dr. Catrin Rutland, University of Nottingham, UK
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