Atypical endometrial hyperplasia: A tough call

Abstract

Most gynecologists determine therapy based on current World Health Organization (WHO) classification of endometrial hyperplasia. Endometrioid neoplastic lesions of the endometrium are thought to follow a continuum of histologically distinguishable lesions ranging from endometrial hyperplasia without atypia, to endometrial hyperplasia with atypia (AEH), to well-differentiated carcinoma. Because it is thought to be a precursor lesion to invasive carcinoma, one accepted treatment option for AEH is hysterectomy with bilateral salpingoophorectomy. However, many clinicians and patients have attempted conservative hormonal management, either to preserve fertility in younger women, or to avoid hysterectomy in women with serious comorbidities, or simply to avoid surgery among women who did not wish to undergo surgery if at all possible. GOG167A was a prospective cohort study including 306 women with a community diagnosis of atypical endometrial hyperplasia, 302 of which had evaluable specimens. Its initial purpose was to estimate the rate of concurrent carcinoma in women with a tissue diagnosis of AEH. Study patients underwent hysterectomy within 12 weeks of entry onto protocol, without interval treatment. Diagnostic biopsy slides and subsequent hysterectomy material were reviewed by a panel of GOG pathologists. Reproducibility of the community diagnosis of AEH was poor (38%). Both under diagnosis and over diagnosis were common. The rate of concurrent carcinomas in the hysterectomy specimens was 43%. Better criteria and better sampling are needed to improve the reproducibility of this diagnosis. A new classification system which is biologically meaningful, predictive of the lesion in the endometrium, and highly reproducible within the general community of diagnostic pathologists is needed but may not be achievable based on morphologic characteristics alone. For now, when considering management strategies for a biopsy diagnosis of AEH, clinicians and patients should take into account the considerable rate of concurrent carcinoma.