12019/4/ Endometrial hyperplasia - Libre Pathology

Endometrial hyperplasia
From Libre Pathology

See Endometrium for an introduction to the topic.

Endometrial hyperplasia, abbreviated EH, is a precursor to endometrial carcinoma.

Contents
1 Overview
1.1 WHO endometrial hyperplasia classification of 2014
1.2 WHO endometrial hyperplasia classification of 1994
1.3 Alternate classifications - overview
1.3.1 European group of experts classification
1.3.2 Endometrial collaborative group/Harvard classification
1.4 WHO classification of 1994
1.4.1 Management of endometrial hyperplasia
1.4.2 Risk of progression to carcinoma as per 1994 system
1.4.3 Ki-67
1.5 WHO system of 1994 - detail articles
1.5.1 Simple endometrial hyperplasia
1.5.2 Simple endometrial hyperplasia with atypia
1.5.3 Complex endometrial hyperplasia
1.5.4 Complex endometrial hyperplasia with atypia
2 Other
2.1 Endometrial hyperplasia with secretory changes
2.1.1 General
2.1.2 Microscopic
3 See also
4 References

Overview
WHO endometrial hyperplasia classification of 2014

The 2014 WHO system has two categories:[1]

Hyperplasia without atypia.

Atypical hyperplasia/endometrioid intraepithelial neoplasia.

WHO endometrial hyperplasia classification of 1994

The 1994 WHO system is based on determining:[1]

1. Gland density (normal/low = simple hyperplasia, high density = complex hyperplasia).

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2. Presence/absence of nuclear atypia.

It consists of four categories:

Simple endometrial hyperplasia.

Simple endometrial hyperplasia with atypia.
Complex endometrial hyperplasia.
Complex endometrial hyperplasia with atypia.

Alternate classifications - overview

Two alternative grading systems exist, that are (currently) not widely used:[2]

1. European group of experts (1999).

2. Endometrial collaborative group/Harvard (2000).

Both consist of two categories, as opposed to four found in the WHO classification.

European group of experts classification

1. Endometrial hyperplasia.
2. Endometrioid neoplasia.

Endometrial collaborative group/Harvard classification

1. Endometrial hyperplasia.
2. Endometrial intraepithelial neoplasia (EIN).

WHO classification of 1994

Management of endometrial hyperplasia

Endometrial hyperplasia with atypia is usually treated with hysterectomy.[3]

In women who want to maintain fertility it may be treated with progestin + short interval re-biopsies
(q3 months).[4]
Endometrial hyperplasia without atypia is treated by:
Progestins + close follow-up OR hysterectomy.

Risk of progression to carcinoma as per 1994 system

Approximate risk of progression to endometrial carcinoma - Latta rule of 3s:[5]

Simple Complex
Without atypia 1% 3%
With atypia 9% † 27% ‡

Notes:

† 8% is the true number.[6]

‡ 29% is the true number.[6]
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Ki-67

There is one paper that looks at Ki-67:[7]

Diagnosis Percent positive

Secretory phase endometrium 15%
Proliferative phase endometrium 42%
Simple hyperplasia 26%
Simple hyperplasia with atypia 23%
Complex hyperplasia 16%
Complex hyperplasia with atypia 42%

WHO system of 1994 - detail articles

Almost all hyperplasia is seen in the context of proliferative-type endometrium. Hyperplasia in the secretory-type
endometrium is extremely rare and something diagnosed by or in consultation with an expert in gynecologic
pathology.

Simple endometrial hyperplasia

AKA simple hyperplasia.

Main article: Simple endometrial hyperplasia

Simple endometrial hyperplasia with atypia

Main article: Simple endometrial hyperplasia

Complex endometrial hyperplasia

Abbreviated CEH.

Main article: Complex endometrial hyperplasia

Complex endometrial hyperplasia with atypia

AKA complex atypical hyperplasia.

Main article: Complex endometrial hyperplasia

Other
Endometrial hyperplasia with secretory changes
General

Rare.
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Secretory changes seen in 1-2% of endometrial hyperplasias/endometrial carcinomas.[8]

Microscopic

Features:[9]

Secretory changes - includes at least one of three following:[10]

1. Stromal decidualization.
2. Cytoplasmic vacuolization.
3. Intraluminal secretions.
Proliferative-type epithelium. †
Mitoses.
Nuclear atypia.
Pseudostratified epithelium.

Notes:

† This is not precisely defined. I suppose it is some of the things Bell and Ostrezega[11] mention (mitoses,
nuclear atypia, pseudostratified epithelium).
Bell and Ostrezega[11] give a laundry list for differentiating benign secretory endometrium from
hyperplasia with secretory changes: focal architectural abnormalities, metaplastic ciliated & "clear"
cells, sharp luminal border, epithelial pseudopalisading, nuclear atypia, vesicular nuclei, mitoses.

DDx:

Secretory phase endometrium.

Endometrium with hormonal changes.

Images:

Endometrial hyperplasia with secretory changes (cap.org) (http://www.cap.org/apps/docs/cap_today/0612/06

12a_qa.pdf).

See also
Endometrium.
Endometrial carcinoma.
Gynecologic pathology.

References
1. Emons, G.; Beckmann, MW.; Schmidt, D.; Mallmann,
P. (Feb 2015). "New WHO Classification of
Endometrial Hyperplasias.". Geburtshilfe Frauenheilkd
75 (2): 135-136. doi:10.1055/s-0034-1396256 (http://d
x.doi.org/10.1055%2Fs-0034-1396256).
PMID 25797956 (http://www.ncbi.nlm.nih.gov/pubme
d/25797956).
2. Dietel, M. (Nov 2001). "The histological diagnosis of
endometrial hyperplasia. Is there a need to simplify?".
Virchows Arch 439 (5): 604-8. PMID 11764378 (http://
www.ncbi.nlm.nih.gov/pubmed/11764378).
3. URL: http://www.aafp.org/afp/990600ap/3069.html.
4. URL: http://www.aafp.org/afp/20060801/practice.html.
5. Latta, E. January 2009.
6. Kurman, RJ.; Kaminski, PF.; Norris, HJ. (Jul 1985).
"The behavior of endometrial hyperplasia. A long-term
study of untreated hyperplasia in 170 patients.". Cancer
56 (2): 403-12. PMID 4005805 (http://www.ncbi.nlm.n
ih.gov/pubmed/4005805).

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7. Abike, F.; Tapisiz, OL.; Zergeroglu, S.; Dunder, I.; wrPtlt&cntvwrPtlt%7BactionForm.contentReference%

Temizkan, O.; Temizkan, I.; Payasli, A. (2011). "PCNA
and Ki-67 in endometrial hyperplasias and evaluation
of the potential of malignancy.". Eur J Gynaecol Oncol
32 (1): 77-80. PMID 21446331 (http://www.ncbi.nlm.n
ih.gov/pubmed/21446331).
8. Simon RA, Hansen K, Xiong JJ, et al. PTEN status and
frequency of endometrial carcinoma and its precursors
arising in functional secretory endometrium; an
immunohistochemical study of 29 cases (http://www.ab
stracts2view.com/uscap12/view.php?nu=USCAP12L_1
248). Mod Pathol. 2012;25(Suppl 2): 1248A.
9. Simon RA. CAP Today (http://www.cap.org/apps/cap.p
ortal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fport
lets%2FcontentViewer%2Fshow&_windowLabel=cntv
7D=cap_today%2F0612%2F0612_qa.html). June
2012. Accessed on: 24 April 2013.
10. Tresserra, F.; Lopez-Yarto, M.; Grases, PJ.; Ubeda, A.;
Pascual, MA.; Labastida, R. (Mar 2003). "Endometrial
hyperplasia with secretory changes.". Gynecol Oncol
88 (3): 386-93. PMID 12648591 (http://www.ncbi.nlm.
nih.gov/pubmed/12648591).
11. Bell, CD.; Ostrezega, E. (Aug 1987). "The significance
of secretory features and coincident hyperplastic
changes in endometrial biopsy specimens.". Hum
Pathol 18 (8): 830-8. PMID 3610133 (http://www.ncbi.
nlm.nih.gov/pubmed/3610133).

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