*Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota (A.M.T.) †Department of Pathology, Tel Aviv Medical Center, Tel Aviv (B.L.-M) ‡Patho-Lab Diagnostics Ltd., (B.C.) Ness-Ziona, Israel.
Int J Gynecol Pathol. 2014 Mar;33(2):107-13. doi: 10.1097/PGP.0b013e3182a2945d.
The diagnosis of endometrial hyperplasia or carcinoma in a background of secretory endometrium can be difficult. We attempt to establish the diagnostic criteria to be used in such cases. We examined 80 cases of endometrial hyperplasia, carcinoma, and other conditions with glandular crowding arising in secretory endometrium, analyzed their morphologic features, assessed the volume percentage stroma in each case and performed Ki67 immunostaining on 27 cases. Thirteen cases each of secretory and gestational endometrium served as controls. The mean age of the patients was 45 yr. The non-neoplastic diseases included simple hyperplasia without atypia (56%), endometrial polyps (12.5%), and chronic endometritis with glandular crowding (3%). The proportion of cases with complex hyperplasia without atypia was 10%. Neoplastic diseases included atypical complex hyperplasia (12.5%) and endometrioid carcinoma (6%). The secretory changes were usually less advanced in the hyperplastic glands than in the background endometrium. The morphologic features that best distinguished hyperplasia or carcinoma from secretory endometrium included glandular crowding that stood out from the background; architectural disorder (the long axes of the glands pointing in different directions or parallel to the endometrial surface); dilated, irregularly shaped glands, including budding or branching glands and staghorn-shaped glands; stroma of a polyp; cribriform or confluent glands in cases of carcinoma; nuclear atypia in cases of atypical hyperplasia and carcinoma; and crowded nonsecretory glands. The volume percentage stroma of neoplastic lesions was less than that of non-neoplastic ones (34% vs. 61%, P=0.000001) and that of secretory endometrium (34% vs. 68%, P=0.000038). Non-neoplastic lesions did not have significantly more crowded glands than secretory endometrium (61% vs. 68%, P=0.11). Gestational endometrium had more crowded glands than non-neoplastic lesions (39% vs. 61%, P=0.000004), an approximately equal volume percentage stroma with complex hyperplasia without atypia (39% vs. 43%, P=0.51), and less crowded glands than neoplastic lesions (39% vs. 34%, P=0.03). The Ki67 index of the neoplastic lesions was higher than that of the controls, including secretory and gestational endometria (positive nuclei per 100 epithelial cells, 44.8 vs. 4.6, P=0.0004), of the non-neoplastic lesions (44.8 vs. 5.4, P=0.002) and of complex hyperplasia without atypia (44.8 vs. 9.3, P=0.007). Hyperplasia and carcinoma in secretory endometrium can be diagnosed on the basis of increased glandular crowding, architectural irregularity, nuclear atypia, and increased Ki67 index.
在分泌期子宫内膜中诊断子宫内膜增生或癌可能具有挑战性。我们试图建立适用于此类病例的诊断标准。我们检查了 80 例子宫内膜增生、癌和其他在分泌期子宫内膜中出现腺体拥挤的情况，分析了它们的形态特征，评估了每例病例中基质的体积百分比，并对 27 例病例进行了 Ki67 免疫染色。每个分泌期和妊娠子宫内膜各有 13 例作为对照。患者的平均年龄为 45 岁。非肿瘤性疾病包括单纯性增生无不典型性（56%）、子宫内膜息肉（12.5%）和伴有腺体拥挤的慢性子宫内膜炎（3%）。单纯性增生无不典型性的比例为 10%。肿瘤性疾病包括不典型复杂增生（12.5%）和子宫内膜样癌（6%）。增生腺体的分泌变化通常比背景子宫内膜的分泌变化落后。能够最好地区分增生或癌与分泌期子宫内膜的形态特征包括：突出于背景的腺体拥挤；结构紊乱（腺体的长轴指向不同方向或平行于子宫内膜表面）；扩张、不规则形状的腺体，包括芽状或分支状腺体和鹿角状腺体；息肉样基质；癌病例中的筛状或融合状腺体；不典型增生和癌病例中的核异型性；以及拥挤的非分泌性腺体。肿瘤性病变的基质体积百分比小于非肿瘤性病变（34%比 61%，P=0.000001）和分泌期子宫内膜（34%比 68%，P=0.000038）。非肿瘤性病变的腺体拥挤程度并不明显高于分泌期子宫内膜（61%比 68%，P=0.11）。妊娠子宫内膜的腺体拥挤程度高于非肿瘤性病变（39%比 61%，P=0.000004），与单纯性增生无不典型性的基质体积百分比大致相等（39%比 43%，P=0.51），且腺体拥挤程度低于肿瘤性病变（39%比 34%，P=0.03）。肿瘤性病变的 Ki67 指数高于对照组，包括分泌期和妊娠子宫内膜（每 100 个上皮细胞中的阳性核，44.8 比 4.6，P=0.0004）、非肿瘤性病变（44.8 比 5.4，P=0.002）和单纯性增生无不典型性（44.8 比 9.3，P=0.007）。在分泌期子宫内膜中，通过增加腺体拥挤程度、结构不规则、核异型性和增加 Ki67 指数，可以诊断增生和癌。
