Diagnosis of
Endometrial Biopsies and Curettings
Second Edition
Michael T. Mazur, MD
Clinical Professor of Pathology, State University of New York, Upstate Medical University, Syracuse, New York, and ClearPath Diagnostics, Syracuse, New York
Robert J. Kurman, MD
Richard W. TeLinde Distinguished Professor, Departments of Gynecology, Obstetrics and Pathology, The Johns Hopkins Hospital, and The Johns Hopkins University School of Medicine, Baltimore, Maryland
Diagnosis of
Endometrial Biopsies and Curettings
A Practical Approach
Second Edition
With 230 Illustrations, 77 in Full Color
Michael T. Mazur, MD Clinical Professor of Pathology State University of New York Upstate Medical University Syracuse, NY 13210 and
ClearPath Diagnostics Syracuse, NY 13202 USA
Robert J. Kurman, MD
Richard W. TeLinde Distinguished Professor
Departments of Gynecology, Obstetrics and Pathology The Johns Hopkins Hospital and
The Johns Hopkins University School of Medicine
Baltimore, MD 21231 USA
Library of Congress Cataloging-in-Publication Data Mazur, Michael T.
Diagnosis of endometrial biopsies and curettings : a practical approach / Michael Mazur, Robert J. Kurman.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-387-98615-4 (h/c : alk. paper)
1. Endometrium—Biopsy. 2. Endometrium—Diseases—Cytodiagnosis. 3.
Endometrium—Cytopathology. I. Kurman, Robert J. II. Title.
[DNLM: 1. Uterine Diseases—diagnosis. 2. Biopsy—methods. 3. Dilatation and Curettage—methods. 4. Endometrium—pathology. 5. Pregnancy
Complications—diagnosis. WP 440 M476d 2004]
RG316.M39 2004
618.1¢42—dc22 2004046866
ISBN 0-387-98615-4 Printed on acid-free paper.
© 1995, 2005 Springer Science+Business Media, Inc.
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v
Preface to the Second Edition
This second edition of Diagnosis of Endometrial Biopsies and Curettings:
A Practical Approach follows a number of favorable comments we received about the first edition. As before, this book is designed to offer a practical reference for the everyday interpretation of endometrial biopsies. This edition has been extensively updated to reflect the advances in our understanding of the pathology and pathophysiology of the endometrium over the past few years. In addition, a large number of color illustrations have been added to help the reader understand the morphologic changes described in the text.
Although the entire book has been revised, several areas received par- ticular attention. Our knowledge of the utility of immunohistochemistry in the interpretation of these specimens, especially trophoblastic disease and endometrial neoplasia, has expanded considerably since the first edition. Accordingly, in this edition the problems, pitfalls, and utility of this valuable diagnostic adjunct have received greater attention.
While immunohistochemistry is discussed in all the chapters, it is also summarized in the final chapter, which addresses methods of endome- trial evaluation.
Expanded knowledge of newer entities, such as the epithelioid tro- phoblastic tumor, endometrial intraepithelial carcinoma, and the effects of tamoxifen on the endometrium have received increased emphasis in this edition. Because hydatidiform mole is now commonly recognized at an earlier stage of gestation, the features of these “early moles” are dis- cussed in greater detail. The chapter on polyps was revised to further clarify the terminology of these common lesions, as they demonstrate a wide spectrum of morphologic features. Information about the distinc- tion of endometrial carcinoma from endocervical adenocarcinoma also was significantly revised.
Most importantly, however, the text continues its focus on those
aspects of endometrial biopsy interpretation that can be especially
vexing, such as the diagnosis of atypical hyperplasia, grading of endome-
trial carcinoma, and the myriad of benign changes and artifacts that can
be confusing to the pathologist. In addition, a clear understanding of the
terminology that the pathologist uses to communicate diagnostic infor-
mation to the clinician is critically important. A diagnosis of carcinoma
is straightforward, but a clear and precise diagnosis of the various benign, yet abnormal pattens of endometrial development and bleeding can be a challenge.
Finally, we have tried to not only provide a reference for evaluating the morphologic details of a wide variety of lesions but also to convey to the reader the manner by which we approach the evaluation of the endometrial biopsy. It is not possible to cover every aspect of endome- trial pathology in a single text of this size, but we believe that the book is a reasonable foundation and starting point for the diagnosis of these specimens. We hope it will be useful to pathologists and gynecologists.
Michael T. Mazur, MD Robert J. Kurman, MD
vi Preface to the Second Edition
vii
Preface to the First Edition
The incentive for writing this book came from a short course, “Endome- trial Biopsy Interpretation,” that we presented for five years at the United States and Canadian Academy of Pathology. The enthusiastic response we received from this endeavor prompted us to consider writing a practical text on the histologic interpretation of these speci- mens, which are commonly encountered in the surgical pathology labo- ratory but are given short shrift in standard texts. Several gynecologic pathology textbooks, such as Blaustein’s Pathology of the Female Genital Tract, 4th ed. (1994), describe the morphologic features and classification of benign and malignant endometrial lesions, but little attention is given to the subtle differences between physiologic changes and pathologic conditions and the artifacts of biopsy and processing. In addition, micro- scopic findings that can be safely ignored because they have no clinical bearing are generally not discussed in standard texts. It is our impression that it is precisely these areas that present most of the difficulties in daily practice, more so, in fact, that the diagnosis of a malignant tumor.
This text is not a reference or atlas that describes pathologic curiosi- ties that one might never encounter in a lifetime of practice. Instead, we attempt to provide a logical approach to formulating a pathologic diag- nosis from the diverse array of fragmented, often scant pieces of tissue and blood received in the laboratory. As such, the material is presented in a less traditional fashion. Conventional histopathologic classifications remain an integral part of the text, but the various chapters focus on a clinically oriented approach to the microscopic diagnosis of common problems. For example, the individual chapters address the clinical ques- tions and specifics of reporting the findings, aspects that vary according to the patient’s age and the clinical circumstances.
One important subject is that of changes in the endometrium induced by breakdown and bleeding, independently of the underlying pathology.
These alterations are highly prevalent in endometrial biopsies and are
often misinterpreted, so they are described in detail. The updated World
Health Organization classification of endometrial hyperplasia is based
on the distinction of atypical and non-atypical hyperplasia. This topic is
especially important, since cytologic atypia is the critical prognostic
feature in their behavior, yet the characteristics of what constitutes
atypia are not well appreciated. Metaplasia and other benign changes can mimic hyperplasia and carcinoma, so the text focuses on these lesions in detail. Clinical management of endometrial carcinoma is greatly influ- enced by the histologic evaluation of the curettings. Accordingly, the dis- cussion of endometrial carcinoma considers not only the differential diagnosis, but also the grading of carcinoma and the distinction of endometrial from endocervical primary tumors.
Trophoblast presents unique problems in diagnosis. This is largely because the pathologist lacks experience with the diverse morphologic array of trophoblastic changes in benign and malignant lesions. Gesta- tional trophoblastic disease is rare in routine practice. Furthermore, tro- phoblast of abortion specimens, including the trophoblast of the implantation site, usually receives little scrutiny. Two chapters have been included to cover this complex subject, one devoted to physiologic and one to neoplastic conditons.
Almost all the illustrations used in this text are from biopsies, and some show artifact and distortion, as occurs in routine specimens. We intentionally use this less-than-perfect material, since it better illustrates the problems that the pathologist faces in the interpretation of these specimens.
Since this monograph is not a reference text or atlas, we suggest reading it in its entirety in order to appreciate the clinically oriented problem-solving approach that we advocate. We hope that the reader finds this approach informative, useful, and enjoyable.
Michael T. Mazur, MD Robert J. Kurman, MD
viii Preface to the First Edition
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