Proliferative phase endometrium

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Proliferative phase endometrium
Diagnosis in short

LM round spaced pseudostratified glands, mitoses (stroma and glands), normal gland-to-stroma ratio, no glandular dilation
LM DDx disordered proliferative phase, simple endometrial hyperplasia, complex endometrial hyperplasia, early secretory phase endometrium
Site endometrium

Prevalence common - normal finding

Proliferative phase endometrium, abbreviated PPE, is a very common diagnosis in endometrial specimens.

General

  • Day 1-13 in the protypical menstrual cycle of 28 days.
    • May be day 5-13 - if the menstruation is not included.
    • "Exodus" pattern is a term used to describe exfoliation of endometrial cells during the proliferative phase.
      • On pap tests this is associated with the classic double contoured balls of endometrial epithelium and stroma.

Note:

  • Proliferative phase = follicular phase.
    • Gynecologists prefer the ovarian descriptor, i.e. follicular phase; pathologists go by what they see, i.e. proliferative endometrium.
  • When the patient is >40 years, some advocate the use of the term proliferative type endometrium (instead of the term proliferative endometrium).[1]

Gross

  • Thickened endometrium.

Microscopic

Features:[2]

  • Glands:
    • Straight, tubular, composed of tall pseudostratified columnar cells - key feature.
    • Mitotic figures - key feature. †
  • Stroma:
    • Cellular stroma (spindle cells).
    • Mitoses.
      • Usually harder to find than in the glands.

Notes:

  • † McCluggage says one shouldn't call PPE without mitoses, as some pseudostratification can be seen in atrophic endometrium.[2]
    • There is no guidance on how hard one should look. VL suggests searching ~ 10 mm^2 with the 20x objective. This represents approximately ~ 10 fields of view with a microscope that has a 22 mm eye piece.
  • Significant negatives:
    • No vacuolation.
    • No mucus secretion.
  • Inflammation (neutrophils, rare plasma cell) & stromal breakdown common early in the proliferative phase.[3]

DDx:

Images:

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ENDOMETRIUM, BIOPSY: 
- PROLIFERATIVE PHASE ENDOMETRIUM.
ENDOMETRIUM, ASPIRATION: 
- PROLIFERATIVE PHASE ENDOMETRIUM.
ENDOMETRIUM, BIOPSY: 
- PROLIFERATIVE PHASE ENDOMETRIUM.
- ENDOCERVICAL MUCOSA AND STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS. 
ENDOMETRIUM, BIOPSY:
- PROLIFERATIVE ENDOMETRIUM, FOCALLY WITH A FIBROTIC STROMA.
- BENIGN STRIPPED ENDOCERVICAL EPITHELIUM.
- NEGATIVE FOR HYPERPLASIA AND NEGATIVE FOR MALIGNANCY.
ENDOMETRIUM, ASPIRATION:
- EARLY PROLIFERATIVE PHASE ENDOMETRIUM WITH SOME SHEDDING (APOPTOTIC CELLS,
  INFILTRATING NEUTROPHILS, BALLS OF CONDENSED ENDOMETRIAL STROMA).
- SCANT STRIPPED ENDOCERVICAL EPITHELIUM WITHIN NORMAL LIMITS.
- NEGATIVE FOR HYPERPLASIA.

Not quite normal

ENDOMETRIUM, BIOPSY:
- EARLY SECRETORY PHASE ENDOMETRIUM.
- FOCUS OF CROWDED PROLIFERATIVE GLANDS, SEE COMMENT.

COMMENT:  
There is a small focus of crowded and irregular proliferative glands
without cytologic atypia.  The possibility of a polyp is considered but the vessels and
polyp-type stroma are lacking.  Suggest clincal follow up with a consideration of a repeat
biopsy in 3 to 6 months to rule out a hyperplastic lesion.

Post-menopausal

ENDOMETRIUM, BIOPSY:
- PROLIFERATIVE TYPE ENDOMETRIUM.
-- NEGATIVE FOR HYPERPLASIA.
-- NEGATIVE FOR MALIGNANCY.

Micro

The sections show endometrium with proliferative glands without significant dilation or irregularity of shape. The gland-to-stroma ratio is within normal limits. Mitotic activity is mild. No nuclear atypia is apparent.

See also

References

  1. Gardiner G. January 2009.
  2. Jump up to: 2.0 2.1 McCluggage, WG. (Aug 2006). "My approach to the interpretation of endometrial biopsies and curettings.". J Clin Pathol 59 (8): 801-12. doi:10.1136/jcp.2005.029702. PMC 1860448. PMID 16873562. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860448/.
  3. Nucci, Marisa R.; Oliva, Esther (2009). Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 197. ISBN 978-0443069208.
  4. Mazur, Michael T.; Kurman, Robert J. (2005). Diagnosis of Endometrial Biopsies and Curettings: A Practical Approach (2nd ed.). Springer. pp. 14. ISBN 978-0387986159.
  5. URL: http://www.cytochemistry.net/microanatomy/medical_lectures/oviduct_and_uterus.htm. Accessed on: 23 October 2012.