Difference between revisions of "Endometrial hyperplasia"
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==Simple endometrial hyperplasia with atypia== | ==Simple endometrial hyperplasia with atypia== | ||
===General=== | ===General=== | ||
* | *Very uncommon. | ||
===Microscopic=== | ===Microscopic=== |
Revision as of 04:42, 13 January 2012
- See Endometrium for dating and benign pathologies.
Endometrial hyperplasia, abbreviated EH, is a precursor to endometrial carcinoma.
Overview
The most widely used system is from the World Health Organization (WHO).
WHO classification - overview
The WHO system is based on determining:
- Gland density (normal = simple hyperplasia, high density = complex hyperplasia).
- Presence/absence of nuclear atypia.
Alternate classifications - overview
Two alternative grading systems exist, that are (currently) not widely used:[1]
- European group of experts (1999).
- Endometrial collaborative group/Harvard (2000).
Both consist of two categories, as opposed to four found in the WHO classification.
European group of experts classification
- Endometrial hyperplasia.
- Endometrioid neoplasia.
Endometrial collaborative group/Harvard classification
- Endometrial hyperplasia.
- Endometrial intraepithelial neoplasia (EIN).
WHO classification
Management of endometrial hyperplasia
- Endometrial hyperplasia with atypia is usually treated with hysterectomy.[2]
- In women who want to maintain fertility it may be treated with progestin + short interval re-biopsies (q3 months).[3]
- Endometrial hyperplasia without atypia is treated by:
- Progestins + close follow-up OR hysterectomy.
Risk of progression to carcinoma
Approximate risk of progression to carcinoma:[4]
Simple | Complex | |
Without atypia | 1% | 3% |
With atypia | 9% | 27% |
WHO system
Almost all hyperplasia is seen in the context of proliferative-type glands. Hyperplasia in the secretory phase is extremely rare and something diagnosed by or in consultation with an expert in gynecologic pathology.
Simple endometrial hyperplasia
General
- More common than simple endometrial hyperplasia with atypia.
Microscopic
Features:[5]
- Irregular dilated glands (with large lumens) - key feature.
- Glands described as "animal shapes".
- Variation of gland size.
- No nuclear atypia.
- Uniform columnar nuclei.
- Normal gland density (gland area in plane of section/total area ~= 1/3).
DDx:
Images:
Simple endometrial hyperplasia with atypia
General
- Very uncommon.
Microscopic
Features:[5]
- Irregular dilated glands (with large lumens) - important feature.
- Glands described as "animal shapes".
- Variation of gland size.
- No nuclear atypia.
- Uniform columnar nuclei.
- Normal gland density (gland area in plane of section/total area ~= 1/3).
- Nuclear atypia:[6]
- Loss of basal nuclear stratification.
- Nuclear size variation.
- Nuclear rounding.
- Nuclei lacking atypical = uniform columnar nuclei.
- Nucleoli.
- Hyperchromasia or vesicular nuclei.
Notes:
- There are no clear criteria for atypia. Different sources list different features.
- VL criteria for atypia (all should be present):
- Increased NC ratio.
- Atypical: ~ 1:2
- Not atypical: ~1:3.
- Oval nuclei with small major axis to minor axis ratio.
- Atypical: major axis:minor axis = <=2:1.
- Not atypical: major axis:minor axis = >=3:1
- NB: round nuclei: major axis:minor axis = 1:1.
- Small nucleoli (~1/5 the size of the nucleus).
- Increased NC ratio.
Complex endometrial hyperplasia
Microscopic
Features:
- Increase in size & number of glands + irregular shape.
- Cell stratification.
- Nuclear enlargement.
- Mitoses common.
- No nuclear atypia.
Notes:
- Normal "gland-to-stroma ratio" is 1:3.
- Two "touching" glands may be one gland in section.
DDx:
- Complex endometrial hyperplasia with atypia.
- Endometrioid endometrial carcinoma - see endometrial carcinoma versus complex endometrial hyperplasia.
Image:
Endometrial carcinoma versus complex endometrial hyperplasia
Complex endometrial hyperplasia:
- Non-confluent - glands distinct from one another.
Classic criteria for endometrial carcinoma
This is pimping material that shows up on exams.
Endometrial carcinoma has one of the following:[7][8][9]
- Desmoplastic stromal response.
- Confluent cribriform growth. †
- Extensive papillary growth. †
- Severe cytologic atypia. †
Note:
- † There is a size cut-off for criteria 2, 3 and 4: > 2.1 mm.[8]
How to remember ABCDE:
- Atypia Bad.
- Confluent cribriform growth.
- Desmoplasia.
- Extensive papillary growth.
Complex endometrial hyperplasia with atypia
General
- High risk of transformation to endometrial carcinoma.
Microscopic
Features:
- Increase in size & number of glands + irreg. shape.
- Need cribriform architecture.
- Two "touching" glands are likely one gland in section.
- Cell stratification.
- Nuclear enlargement.
- Mitoses common.
- Nuclear atypia present.
DDx:
- Complex endometrial hyperplasia.
- Endometrioid endometrial carcinoma - see endometrial carcinoma versus complex endometrial hyperplasia.
Image:
See also
References
- ↑ Dietel, M. (Nov 2001). "The histological diagnosis of endometrial hyperplasia. Is there a need to simplify?". Virchows Arch 439 (5): 604-8. PMID 11764378.
- ↑ URL: http://www.aafp.org/afp/990600ap/3069.html.
- ↑ URL: http://www.aafp.org/afp/20060801/practice.html.
- ↑ LAE Jan 2009.
- ↑ 5.0 5.1 Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 236. ISBN 978-0443069208.
- ↑ Silverberg, SG. (Mar 2000). "Problems in the differential diagnosis of endometrial hyperplasia and carcinoma.". Mod Pathol 13 (3): 309-27. doi:10.1038/modpathol.3880053. PMID 10757341.
- ↑ Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 239. ISBN 978-0443069208.
- ↑ 8.0 8.1 Kurman, RJ.; Norris, HJ. (Jun 1982). "Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma.". Cancer 49 (12): 2547-59. PMID 7074572.
- ↑ URL: http://www.cap.org/apps/docs/committees/cancer/cancer_protocols/2011/Endometrium_11protocol.pdf. Accessed on: 12 January 2012.