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Uterus
Non tumor
Endometrial metaplasia
Reviewer: Nat Pernick, M.D. (see Reviewers page)
Revised: 5 March 2012, last major update March 2012
Copyright: (c) 2002-2012, PathologyOutlines.com, Inc.
Subtypes: clear cell, eosinophilic (oxyphilic), intestinal, mucinous, papillary, squamous, stromal, syncytial, tubal
General
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● Often due to hormonal or irritative stimuli (J Clin Pathol 2011;64:97, Am J Surg Pathol 1980;4:525) Clear cell metaplasia
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● Tall cells, apical nuclei and clear cytoplasm; no atypia
Eosinophilic (oxyphilic) metaplasia
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● Also called eosinophilic cell change
Intestinal metaplasia
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● Rare Micro images
Positive stains
● CK20, CDX2, chromogranin, villin (Int J Gynecol Pathol 2011;30:492) Mucinous metaplasia
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● Resembles endocervical mucosa (Int J Gynecol Pathol 1983;1:383); benign features Micro images
Papillary proliferation / papillary change
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● Rare, usually post-menopausal women Gross description
● 0.7 cm to 3.0 cm in size, 2/3 occur in endometrial polyps Micro description
● Focal areas of fibrovascular cores without atypia, usually near endometrial surface Micro images
Cytology description
● Endometrial glandular and stromal breakdown with papillary metaplasia may resemble well differentiated adenocarcinoma due to similar nuclear size (Diagn Cytopathol 2009;37:487); may have metaplastic clumps with irregular protrusions (Diagn Cytopathol 2006;34:665) Differential diagnosis
● Well differentiated / low grade papillary adenocarcinoma Squamous metaplasia
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● Occurs in normal or hyperplastic endometrium, polyps and leiomyomas; also as part of malignant processes Micro images
Differential diagnosis
● Well-differentiated endometrial adenocarcinoma with squamous metaplasia Stromal metaplasia
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● Formation of smooth muscle, cartilage and bone Micro images
Differential diagnosis
● Retained fetal parts Syncytial change
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● Also known as papillary syncytial change, surface syncytial change Micro description
● Denuded endometrial surface produced by breakdown or breakthrough bleeding covered by sheet-like plaque of regenerating epithelial cells, often eosinophilic, without discrete cell boundaries (Mod Pathol 2000;13:309) Micro images
Surface papillary syncytial change Positive stains
● p16(INK4A) (J Clin Pathol 2011;64:97) Tubal (ciliated cell) metaplasia
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● Markedly increased ciliated cells (non-metaplastic endometrium have some ciliated cells), resembles fallopian tube; often seen with endometrial hyperplasia and other hyperestrogenic states Micro images
Complex stellate; complex, cribriform glands; mosaic p16 positivity Positive stains
● p16 (Cell Oncol 2007;29:37), MUC5AC (52%, Mod Pathol 2005;18:1243)
End of Uterus > Non tumor > Endometrial metaplasia
● Must evaluate metaplasia separately from hyperplasia
● Tends to be associated with adenocarcinoma and is more common in women at high risk for endometrial carcinoma
● Clear cell change by itself is nonspecific
● Case reports: with atypical endometrial hyperplasia (Ann Diagn Pathol 2003;7:381)
● DD: clear cell adenocarcinoma
Atypical endometrial hyperplasia with clear cell change
● Estrogen-induced, resembles atypical hyperplasia except there is no atypia
● Nonspecific and very common; associated with mucinous metaplasia and ciliated (tubal) change (Mod Pathol 2005;18:1243)
● MUC5AC+
Eosinophilic cell change and MUC5AC+ in normal proliferative endometrium
Eosinophilic change associated with simple hyperplasia without atypia
Eosinophilic cell change in endometrioid adenocarcinoma
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Intestinal metaplasia
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● Associated with hyperestrogen states, endometrial polyps
● Multifocal lesions associated with lobular endocervical glandular hyperplasia /pyloric gland metaplasia (Histopathology 2009;54:184)
● May produce mucometra if cervical stenosis present
● Mucin pools are associated with neutrophils
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Associated with complex hyperplasia with atypia, HE stain
Left: simple mucinous metaplasia in the basalis of an atrophic endometrium
Middle: Complex papillary mucinous metaplasia in curettings
Right: Complex endometrioid hyperplasia with a glandular space lined by micropapillary mucinous metaplasia (arrow)
Mucinous metaplasia in adenocarcinoma
● May be similar to papillary syncytial change
● Usually benign behavior
● Polypectomy or curettage appears to be adequate treatment (Am J Surg Pathol 2001;25:1347)
● More aggressive treatment may be needed for extensive complex papillary proliferations
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● Either simple or complex papillary patterns
● Often metaplastic epithelial changes
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Papillae are limited to the surface epithelium, and composed of bland uniform lining cells
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● Usually diffuse (adenoacanthosis) or in morules (rounded aggregates of bland cells with indistinct cytoplasmic borders)
● Usually in pre-menopausal women with exogenous hormones (Arch Pathol Lab Med 1995;119:458) or with polycystic ovary disease; also associated with foreign-body reactions, chemical irritants and endometritis
● Note: central necrosis of morules is common and not specific for malignancy
● Ichthyosis uteri: complete replacement of endometrium by squamous epithelium; may be associated with malignancy (Diagn Pathol 2006 May 19;1:8)
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Squamous metaplasia
Squamous and mucinous metaplasia post-tamoxifen therapy
Left: with adenosarcoma; middle: with squamous cell carcinoma; right: with endometrioid carcinoma
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● May be it difficult to assess myometrial invasion in carcinoma (Int J Gynecol Pathol 2007;26:115)
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Endometrial stromal nodule with smooth muscle metaplasia
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● Finding in endometrial biopsies and curettings from patients with uterine bleeding
● Associated with anovulatory dysfunctional bleeding, endometrial hyperplasia, estrogen usage or other hormonal treatment
● Appears to be degenerative, not reparative (Int J Gynecol Pathol 2008;27:534)
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● Nuclear debris, neutrophils and rounded clumps of endometrial stromal cells usually present
● Usually no papillae with fibrovascular cores
● May resemble microglandular hyperplasia due to small glandular lumina or pseudolumina
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Surface syncytial change
p16+
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● Presence of atypia does not affect prognosis (Mod Pathol 2011;24:1254)
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Hyperplastic endometrium with ciliary change (tubal metaplasia)
Tubal-type ciliated epithelium
Tubal metaplasia
Ciliated (tubal) metaplasia
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