Endometrial hyperplasia
- 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
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
- 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.
Image:
Endometrial carcinoma vs. complex endometrial hyperplasia:
- Complex endometrial hyperplasia: non-confluent (glands distinct from one another).
- Endometrial carcinoma - one of the following:[7]
- Cribriform architecture.
- Desmoplastic stromal response.
- Extensive papillary pattern.
- Stroma replaced by squamous epithelium.
Complex endometrial hyperplasia with atypia
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.
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.