Endometrial Hyperplasia 子宫内膜增生（是否伴有非典型增生的困惑）

在子宫内膜病理板块中，经常看到一些内膜活检的病理诊断分歧很大：比如有些认为有非典型增生，有些认为没有！还有的对不典型增生进行分级！带着这些问题去找诊断标准和诊断思路，首先理清概念和把握标准：

1. World Health Organization classification of endometrial hyperplasia.

    Hyperplasia (without atypia)
                Simple              简单型增生
               Complex            复杂型增生
          Atypical hyperplasia
                Simple            简单型增生伴不典型增生
                Complex         复杂型增生伴不典型增生

2.  Atypical Hyperplasia

The diagnosis of atypical hyperplasia is based on the presence of nuclear atypia. Architecturally, atypical hyperplasia can have simple or complex patterns.

非典型增生的诊断是基于细胞核非典型性的存在。在结构上可以是简单型增生，也可以是复杂型增生。

The specific nuclear features of atypical hyperplasia include stratification, nuclear enlargement with altered chromatin, and nucleoli. The nuclei characteristically show true stratification ranging from two to four layers, with loss of polarity in relation to the basement membrane, giving an appearance of disarray to the nuclei that contrasts with the pseudostratification in nonatypical hyperplasia.The nuclei are enlarged and rounded rather than oval and may have irregular nuclear membranes. The chromatin is centrally dispersed and forms clumps along the nuclear membrane, resulting in a distinctive vesicular appearance that is highly characteristic of endometrial atypia. Nucleoli may be prominent.

非典型增生细胞核的特征包括：核的分层，核增大伴染色质的改变和核仁明显。细胞核出现2-4层的真正的复层，相对于基底膜的极向消失，相对于无非典型增生的假复层而言，细胞核排列混乱。细胞核增大变圆而不是卵圆形，核膜可以不规则。染色质成块状沿核膜分布，导致明显的空泡状核的表现，这是非典型增生的一个重要特征。核仁明显。

3.  下面一段话对是否伴有非典型增生提供了一些思路上的帮助，不典型增生是不分级的，因为可重复性的原因！

Atypical hyperplasia can be focally present in tissue along with nonatypical hyperplasia.The minimal criteria for the diagnosis of focal atypia have not been defined. Nonetheless, for focal atypia to be a significant finding, it should be readily discernible in a background of clearly hyperplastic glands. In equivocal cases where there is a question of focal atypia in a background of simple or complex hyperplasia, there often are atypical nuclei focally distributed in many glands. In other cases the apparent atypia is confined to only a few glands. In either case a diagnosis of atypical hyperplasia is best limited to those cases in which clearly atypical nuclei are readily identified without diligent searching. In equivocal cases, we recommend that atypia not be diagnosed unless clearly atypical nuclei involve most of the epithelium, lining several well-visualized glands in cross section. Surface epithelium should be avoided in assessing the presence of atypia. Atypia cannot be reproducibly subdivided or graded into categories such as mild, moderate, and severe.

非典型增生改变可以局灶存在于无非典型增生的组织中。局灶非典型增生的最低诊断标准没有被明确。然而，因为局灶非典型增生是一个有意义的表现，所以应该把它从增生的腺体背景中辨认出来。在模棱两可的病例，单纯性增生和复杂性增生中局灶非典型增生是否存在的争论，有非典型性核散在于许多腺体中。另一些病例，明显非典型的核仅局限于很少的腺体中。在这些病例中，诊断非典型增生最好限于那些很容易找到核非典型的病例。在模棱两可的病例中，我们建议除非在整个切片中，衬覆于几个完好的腺体的绝大多数腺上皮的核具有明显的非典型性，否则不能诊断非典型增生。在评估非典型增生存在与否，表面上皮不应包括在内。非典型增生程度的分级如轻度、中度和重度，不具有可重复性。