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{{Endometrial hyperplasia}}
{{Endometrial hyperplasia}}
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==Overview==
==Overview==  
Endometrial hyperplasia is further classified based on [[histology]] into simple and complex types. Endometrial hyperplasia can also be classified based on the presence or absence of cellular [[atypia]]; hyperplasia with cellular [[atypia]] and hyperplasia without cellular atypia.


==Classification==
==Classification==
Like other [[hyperplasia|hyperplastic]] disorders, endometrial hyperplasia initially represents a [[physiology|physiological]] response of endometrial tissue to the growth-promoting actions of [[estrogen]]. However, the gland-forming cells of a hyperplastic endometrium may also undergo changes over time which predispose them to [[cancer]]ous transformation. Several [[microscopic|histopathology]] subtypes of endometrial hyperplasia are recognisable to the [[pathology|pathologist]], with different therapeutic and [[prognosis|prognostic]] implications.<ref name="Weidner's">{{cite book |author=Richard Cote, Saul Suster, Lawrence Weiss, Noel Weidner (Editor) |title=Modern Surgical Pathology (2 Volume Set) |publisher=W B Saunders |location=London |year= |pages= |isbn=0-7216-7253-1 |oclc= |doi=}}</ref>
===The [[World Health Organization]] (WHO) Classification System===
====The [[WHO]] Classification (1994)====
*[[Endometrial]] [[hyperplasia]] may be [[Classification|classified]] based on [[glandular]] complexity and [[nuclear]] atypicality into the following types:<ref name="qq">Scully RE. Histological typing of female genital tract tumours. Springer; 1994.</ref><ref name="wp">Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.</ref><ref name="pmid12130438">{{cite journal| author=Jorizzo JR, Chen MY, Martin D, Dyer RB, Weber TM| title=Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography. | journal=AJR Am J Roentgenol | year= 2002 | volume= 179 | issue= 2 | pages= 385-9 | pmid=12130438 | doi=10.2214/ajr.179.2.1790385 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12130438  }} </ref>


*Endometrial hyperplasia (simple or complex) - Irregularity and cystic expansion of glands (simple) or crowding and budding of glands (complex) without worrisome changes in the appearance of individual gland cells. In one study, 1.6% of patients diagnosed with these abnormalities eventually developed endometrial cancer.<ref name="Kurman">{{cite journal |author=Kurman RJ, Kaminski PF, Norris HJ |title=The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients |journal=Cancer |volume=56 |issue=2 |pages=403-12 |year=1985 |pmid=4005805 |doi=}}</ref>
{{familytree/start |summary=Endometrial hyperplasia classification}}
{{familytree |boxstyle=background: #DCDCDC; | | | | | | | | | | A01 |A01=<div style="width: 12em; padding:0.2em;">'''Endometrial hyperplasia'''</div>}}
{{familytree |boxstyle=background: #DCDCDC; | | | | | | |,|-|-|-|^|-|-|-|.| }}
{{familytree |boxstyle=background: #DCDCDC; | | | | | | B01 | | | | | | B02 |B01=<div style="width: 9em; padding:0.2em;">'''Simple'''
</div>|B02=<div style="width: 9em; padding:0.2em;">'''Complex'''</div>}}
{{familytree |boxstyle=background: #DCDCDC; | | | | |,|-|^|-|.| | | |,|-|^|-|.|}}
{{familytree |boxstyle=background: #DCDCDC; | | | | C01 | | C02 | | C03 | | C04|C01=<div style="width: 9em; padding:0.2em;">'''Simple hyperplasia with cellular atypia '''
</div>|C02=<div style="width: 9em; padding:0.2em;">'''Simple hyperplasia without cellular atypia'''</div>|C03=<div style="width: 9em; padding:0.2em;">'''Complex hyperplasia with cellular atypia '''
</div>|C04=<div style="width: 9em; padding:0.2em;">'''Complex hyperplasia without cellular atypia '''
</div>|}}
{{familytree/end}}


*Atypical endometrial hyperplasia (simple or complex) - Simple or complex architectural changes, with worrisome (''atypical'') changes in gland cells, including cell stratification, tufting, loss of nuclear polarity, enlarged nuclei, and an increase in [[mitosis|mitotic activity]]. These changes are similar to those seen in true cancer cells, but atypical hyperplasia does not show invasion into the connective tissues, the defining characteristic of cancer. The previously mentioned study found that 22% of patients with atypical hyperplasia eventually developed cancer.<ref name="Kurman">{{cite journal |author=Kurman RJ, Kaminski PF, Norris HJ |title=The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients |journal=Cancer |volume=56 |issue=2 |pages=403-12 |year=1985 |pmid=4005805 |doi=}}</ref>
====The New WHO Classification (2014)====
*The updated [[WHO]] [[classification]] has been proposed to simplify [[clinical]] [[Decision making|decision]] [[Decision making|making]], particularly when making treatment choices.<ref name="pmid25797956">{{cite journal| author=Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO)| title=New WHO Classification of Endometrial Hyperplasias. | journal=Geburtshilfe Frauenheilkd | year= 2015 | volume= 75 | issue= 2 | pages= 135-136 | pmid=25797956 | doi=10.1055/s-0034-1396256 | pmc=PMC4361167 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25797956  }} </ref>
**Simple [[hyperplasia]] without [[atypia]]
**Simple [[hyperplasia]] is characterized by:
***[[Dense|Densely]] packed, [[Cystic|cystically]] [[Dilate|dilated]], [[variable]] sized [[glands]] separated by [[normal]] intervening [[stroma]] ( Figure 10 ). Although
***3:1 gland-to-stroma ratio.
***Ciliated cells  
***Squamous morular metaplasia
**Complex hyperplasia without atypia
**Complex hyperplasia without atypia is defined as:
***Glands with abnormal, irregular architecture set in a background of scant intervening stroma
***Some stroma must be present,  
***Basement membrane lining individual glands and a rim of intervening endometrial-type stroma between them. In addition to back-to-back and cribriform-like arrangements, other glandular architectural abnormalities warranting designation of complex hyperplasia include
***Outpouchings,  
***Infoldings, and budding
***Squamous or morular metaplasia
***Eosinophilic and ciliated cell changes 
**Simple hyperplasia with atypia
**Complex hyperplasia with atypia
***Increased gland-to-stroma ratio (≥3:1)
***Gland complexity—caused by:
****Branching
****Outward budding
****Internal papillary infoldings
****Internal bridge
**Hyperplasia without [[atypia]]
**Atypical hyperplasia/endometrioid intraepithelial neoplasia
 
===The Endometrial Intraepithelial Neoplasia (EIN) Classification===
Endometrial changes may be classified according to the International Endometrial Collaborative Group into two types:<ref name="pmid10684697">{{cite journal| author=Mutter GL| title=Endometrial intraepithelial neoplasia (EIN): will it bring order to chaos? The Endometrial Collaborative Group. | journal=Gynecol Oncol | year= 2000 | volume= 76 | issue= 3 | pages= 287-90 | pmid=10684697 | doi=10.1006/gyno.1999.5580 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10684697  }} </ref><ref name="pmid15623473">{{cite journal| author=Baak JP, Mutter GL| title=EIN and WHO94. | journal=J Clin Pathol | year= 2005 | volume= 58 | issue= 1 | pages= 1-6 | pmid=15623473 | doi=10.1136/jcp.2004.021071 | pmc=PMC1770545 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15623473  }} </ref>
* [[Benign]] hyperplasia (a hormone dependent diffuse lesion, which is polyclonal)
** Benign endometrial hyperplasia is mostly observed with anovulation or after prolonged exposure to estrogen.  
** The morphology of endometrial hyperplasia varies from proliferative endometrium with a few cysts  to heavier endometria with many dilated and contorted glands that are designated as "cystic glandular hyperplasia," "mild hyperplasia," or "simple hyperplasia."
 
* Endometrial intraepithelial neoplasia
** Endometrial precancers
** Epithelial crowding depicts less stromal volume which is approximately half of total tissue volume in non secretory endometrium
** Typically cells appear morphologically clonal and distinct from the surrounding endometrium.
** With advanced stage, it may become a more diffuse lesion
** In the beginning a localized clonal proliferation, which is [[monoclonal]] and [[neoplastic]] (EIN)
* The D-score is an integral part of the EIN classification :
** It is a measure of stromal volume as a proportion of total tissue volume (stroma + epithelium + gland lumen)
 
* The D-score is assigned based on evaluation with computerized morphometry
**  Using this method, specimens are classified as:
*** Benign (D >1)
*** Indeterminate (0< D <1)
*** EIN (D <0).<ref name="pmid11420465">{{cite journal |vauthors=Baak JP, Ørbo A, van Diest PJ, Jiwa M, de Bruin P, Broeckaert M, Snijders W, Boodt PJ, Fons G, Burger C, Verheijen RH, Houben PW, The HS, Kenemans P |title=Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias |journal=Am. J. Surg. Pathol. |volume=25 |issue=7 |pages=930–5 |date=July 2001 |pmid=11420465 |doi= |url=}}</ref>


==References==
==References==
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Latest revision as of 16:00, 3 May 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Swathi Venkatesan, M.B.B.S.[2]

Overview

Endometrial hyperplasia is further classified based on histology into simple and complex types. Endometrial hyperplasia can also be classified based on the presence or absence of cellular atypia; hyperplasia with cellular atypia and hyperplasia without cellular atypia.

Classification

The World Health Organization (WHO) Classification System

The WHO Classification (1994)

 
 
 
 
 
 
 
 
 
Endometrial hyperplasia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Simple
 
 
 
 
 
Complex
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Simple hyperplasia with cellular atypia
 
Simple hyperplasia without cellular atypia
 
Complex hyperplasia with cellular atypia
 
Complex hyperplasia without cellular atypia

The New WHO Classification (2014)

  • The updated WHO classification has been proposed to simplify clinical decision making, particularly when making treatment choices.[4]
    • Simple hyperplasia without atypia
    • Simple hyperplasia is characterized by:
    • Complex hyperplasia without atypia
    • Complex hyperplasia without atypia is defined as:
      • Glands with abnormal, irregular architecture set in a background of scant intervening stroma
      • Some stroma must be present,
      • Basement membrane lining individual glands and a rim of intervening endometrial-type stroma between them. In addition to back-to-back and cribriform-like arrangements, other glandular architectural abnormalities warranting designation of complex hyperplasia include
      • Outpouchings,
      • Infoldings, and budding
      • Squamous or morular metaplasia
      • Eosinophilic and ciliated cell changes
    • Simple hyperplasia with atypia
    • Complex hyperplasia with atypia
      • Increased gland-to-stroma ratio (≥3:1)
      • Gland complexity—caused by:
        • Branching
        • Outward budding
        • Internal papillary infoldings
        • Internal bridge
    • Hyperplasia without atypia
    • Atypical hyperplasia/endometrioid intraepithelial neoplasia

The Endometrial Intraepithelial Neoplasia (EIN) Classification

Endometrial changes may be classified according to the International Endometrial Collaborative Group into two types:[5][6]

  • Benign hyperplasia (a hormone dependent diffuse lesion, which is polyclonal)
    • Benign endometrial hyperplasia is mostly observed with anovulation or after prolonged exposure to estrogen.
    • The morphology of endometrial hyperplasia varies from proliferative endometrium with a few cysts to heavier endometria with many dilated and contorted glands that are designated as "cystic glandular hyperplasia," "mild hyperplasia," or "simple hyperplasia."
  • Endometrial intraepithelial neoplasia
    • Endometrial precancers
    • Epithelial crowding depicts less stromal volume which is approximately half of total tissue volume in non secretory endometrium
    • Typically cells appear morphologically clonal and distinct from the surrounding endometrium.
    • With advanced stage, it may become a more diffuse lesion
    • In the beginning a localized clonal proliferation, which is monoclonal and neoplastic (EIN)
  • The D-score is an integral part of the EIN classification :
    • It is a measure of stromal volume as a proportion of total tissue volume (stroma + epithelium + gland lumen)
  • The D-score is assigned based on evaluation with computerized morphometry
    • Using this method, specimens are classified as:
      • Benign (D >1)
      • Indeterminate (0< D <1)
      • EIN (D <0).[7]

References

  1. ↑ Scully RE. Histological typing of female genital tract tumours. Springer; 1994.
  2. ↑ Endometrial hyperplasia. Radiopedia. http://radiopaedia.org/articles/endometrial-hyperplasia-1 Accessed on March 3, 2016.
  3. ↑ Jorizzo JR, Chen MY, Martin D, Dyer RB, Weber TM (2002). "Spectrum of endometrial hyperplasia and its mimics on saline hysterosonography". AJR Am J Roentgenol. 179 (2): 385–9. doi:10.2214/ajr.179.2.1790385. PMID 12130438.
  4. ↑ Emons G, Beckmann MW, Schmidt D, Mallmann P, Uterus commission of the Gynecological Oncology Working Group (AGO) (2015). "New WHO Classification of Endometrial Hyperplasias". Geburtshilfe Frauenheilkd. 75 (2): 135–136. doi:10.1055/s-0034-1396256. PMC 4361167. PMID 25797956.
  5. ↑ Mutter GL (2000). "Endometrial intraepithelial neoplasia (EIN): will it bring order to chaos? The Endometrial Collaborative Group". Gynecol Oncol. 76 (3): 287–90. doi:10.1006/gyno.1999.5580. PMID 10684697.
  6. ↑ Baak JP, Mutter GL (2005). "EIN and WHO94". J Clin Pathol. 58 (1): 1–6. doi:10.1136/jcp.2004.021071. PMC 1770545. PMID 15623473.
  7. ↑ Baak JP, Ørbo A, van Diest PJ, Jiwa M, de Bruin P, Broeckaert M, Snijders W, Boodt PJ, Fons G, Burger C, Verheijen RH, Houben PW, The HS, Kenemans P (July 2001). "Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias". Am. J. Surg. Pathol. 25 (7): 930–5. PMID 11420465.

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