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Sternberg’s pattern approach to diagnosis

Reviewer: Nat Pernick, M.D. (see Reviewers page)
Revised: 2 October 2011, last major update October 2011
Copyright: (c) 2002-2011, PathologyOutlines.com, Inc.


● See Mills, SE: Sternberg's Diagnostic Surgical Pathology (4th Ed); Lippincott Williams & Wilkins, 2004 - note: 5th edition is available by clicking here
● Based on low power microscopic appearance

Pattern 1: proliferations composed of glands and supportive nonneoplastic endometrial stroma; must evaluate gland to stroma ratio, glandular and stromal features, appearance of vessels and pattern uniformity

Gland to stroma ratio:
● 1:1 associated with normal cycling endometrium, dysfunctional uterine bleeding and infertility
● Glands > stroma associated with menstruation, late secretory phase, hyperplasia and carcinoma
● Glands < stroma associated with normal decidua, atrophy and monophasic stromal proliferations

Glandular features:
● Must evaluate cytologic features and architecture of glands to determine if atrophy, weakly proliferative endometrium, proliferative endometrium, presence of cytologic atypia, secretory endometrium (early, mid-, late), Arias-Stella reaction, disintegrating glands / shedding and budding or branching of glands

Stromal features:
● Usual stroma in proliferative phase has minimal cytoplasm and spindled or oval nuclei; in secretory phase or pregnancy, has decidual changes of abundant eosinophilic or clear cytoplasm, large round/oval nucleus

● In proliferative phase, vessels are delicate branching network throughout stroma
● Secretory phase vessels have thicker walls, are coiled (aka spiral arteries)
● Thick walled vessels in fibrotic stroma are characteristic of endometrial polyps

Pattern uniformity:
● Cycling endometrium has uniform pattern throughout, except for lower uterine segment / isthmus (spindled stromal cells separated by collagen, hybrid endocervical-endometrial glands) and stratum basalis layer (unresponsive to hormones, appears weakly proliferative throughout menstrual cycle)

Pattern 2: biphasic proliferations of glands and abundant (possibly neoplastic) stroma
● Includes endometrial polyps, atypical polypoid adenomyoma, MMMT, adenosarcoma, sarcoma, endometrial stromal neoplasms and adenomatoid tumor

Pattern 3: predominantly monophasic spindle cell proliferations
● Includes smooth muscle neoplasms, endometrial stromal tumors, spindled epithelial neoplasms, pure heterologous uterine sarcomas and undifferentiated sarcoma
● Epithelial neoplasms typically express CD10, EMA, keratin
● Smooth muscle neoplasms express smooth muscle actin, desmin and h-caldesmon

Pattern 4: sheetlike proliferations of large, round undifferentiated cells
● Includes undifferentiated malignancies such as high grade adenocarcinoma, MMMT, undifferentiated sarcomas, extension of cervical primary, metastatic carcinoma, melanoma, leukemia and lymphoma
● Lobular carcinoma of breast looks deceptively bland

Pattern 5: extensive necrosis, inflammation and disintegration
● Necrosis suggests malignancy; also cervical stenosis, pyometra and xanthomatous endometritis
● Inflammatory cells common in post-partum endometrium; also bacterial infection
● Disintegration associated with menstruation, hyperplasia; may mimic carcinoma due to stromal collapse

Pattern 6: scanty samples that raise question of sampling adequacy
● May be due to atrophy or obstructing lesion that shields endometrium from sampling

End of Uterus > Non tumor > Sternberg’s pattern approach to diagnosis

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