Evaluation of Criteria for Distinguishing A typical Endometrial Hyperplasia from Well-Differentia fed Carcinoma

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ROBERT J. KURMAN, MD,’ AND HENRY J. NORRIS, MDt

Abstract: 

Endometrial curettings from 204 patients containing severe forms of atypical hyperplasia, carcinoma in situ, and well-differentiated carcinoma were compared with subsequent hysterectomy specimens to evaluate and identify the most useful histologic criteria for predicting the presence of invasive carcinoma. Endometrial stromal invasion, increased degrees of nuclear atypism, mitotic activity, cellular stratification, and epithelial necrosis in curettings were associated with a greater likelihood of carcinoma in the uterus. Of these, stromal invasion was the most significant feature. When stromal invasion was absent, carcinoma was present in the uterus in only 17%, and the carcinomas were well differentiated and confined to the endometrium or only superficially invasive. When stromal invasion was present in curettings, residual carcinoma was present in the uterus in half, and of these, one third were moderately or poorly differentiated and a quarter invaded deeply into the myometrium. The criteria for invasion are 1) an irregular infiltration of glands associated with an altered fibroblastic stroma or desmoplastic response; 2) a confluent glandular pattern in which individual glands are uninterrupted by stroma and merge to form a cribriform pattern of stromal replacement; 3) an extensive papillary pattern; and 4) replacement of stroma by masses of squamous epithelium. To qualify as invasion, items 2, 3, and 4 must occupy at least one half (2.1 mm) a low power field 4.2 mm in diameter. Because of the important role of stromal invasion in predicting prognosis, future classifications of endometrial neoplasia should utilize this feature in distinguishing atypical hyperplasia from well differentiated adenocarcinoma.

Cancer 49:2547-2559. 1982.

摘要：204名患者的子宫内膜诊刮标本，其中均含有重度非典型增生、原位癌和高分化癌。与后续切除子宫相比较，以确定最有用的组织学标准来预测是否存在浸润性癌。子宫内膜间质浸润，核异型程度增加，核分裂象活性，细胞复层化，诊刮标本中上皮性坏死，很可能并存子宫内的癌。上述指标中，间质浸润是最有意义的特征。无间质浸润时，子宫中存在癌的可能性仅有17%，并且为局限于子宫内膜的高分化癌或仅有浅表浸润。诊刮中存在间质浸润时，子宫内残存癌的可能性为50%，其中1/3为中或低分化癌，1/4浸润深肌层。

浸润的标准：

1）不规则浸润的腺体伴改变的纤维母细胞性间质或促结缔组织增生性间质反应；

2）融合的腺体结构，其中的单个腺体无间质分隔并融合成取代间质的筛状结构；

3）广泛的乳头状结构；

4）大片鳞状上皮取代间质。

为了量化浸润，第2、3、4条标准必需至少2.1mm（4.2mm直径低倍视野的一半）。由于浸润浸润对预测预后具有重要作用，将来的子宫内膜肿瘤分类应当利用这一特征，以区分非典型增生或高分化癌。

曹登峰教授和赵澄泉教授点评：

• 本文是1982年发表的，其中的标准至今还在用，这就是伟大的文章

• 第4条标准后来取消了（不再强调鳞化），现在用的是前3条标准

• 量化不是绝对的；量化只是针对2、3、4这三个指标，并没有限制第1个指标

• 乳头指的是是外生性乳头，不是腺腔内的

• 原文中的术语后来也有不少更新，原位癌的概念废除了，非典型增生不分轻中重

致谢：感谢赵澄泉（Chengquan Zhao）教授提供全文及点评；感谢曹登峰教授点评；感谢薛德彬（abin）老师翻译摘要。

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