DOI: 10.1097/AOG.0000000000001071
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PMID: 26393443
Issn Print: 0029-7844
Publication Date: 2015/10/01
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Excerpt
The authors assert that “the preferred terminology is endometrial intraepithelial neoplasia (rather than atypical endometrial hyperplasia)” and support this assertion by comparing the World Health Organization (WHO) 1994 schema with the endometrial intraepithelial neoplasia system. However, the authors seem to disregard a publication that is effectively the new diagnostic standard for pathologists—WHO 2014.2 The WHO 2014 schema is a two-tier system like the endometrial intraepithelial neoplasia schema. It divides endometrial hyperplasia into benign hyperplasia, a lesion that arises secondary to exposure to unopposed estrogen, and atypical hyperplasia, this being equivalent to endometrial intraepithelial neoplasia.2 WHO 2014 equates atypical hyperplasia with endometrial intraepithelial neoplasia, implying that either terminology can be used; parenthetically, WHO 2014 uses the term endometrioid rather than endometrial in endometrial intraepithelial neoplasia to reflect this being a precursor of endometrioid neoplasia. Thus, the WHO 2014 system clearly accomplishes the primary goal of separating clinicopathologic entities that should be managed differently, which the authors' state is one of the primary reasons for recommending the endometrial intraepithelial neoplasia classification.
Although the formal criteria for the diagnosis of endometrial intraepithelial neoplasia differed originally from those of atypical hyperplasia, recognition of the strengths of the endometrial intraepithelial neoplasia system has led many pathologists to embrace the diagnostic criteria for endometrial intraepithelial neoplasia while at the same time labeling it as atypical hyperplasia. This is reflected in more recent studies that investigate interobserver variability among pathologists comparing the two-tier WHO system with the endometrial intraepithelial neoplasia system3; these show comparable kappa statistics between the two systems. However, outside of a few major centers in the United States, the endometrial intraepithelial neoplasia system is rarely used in our experience, and it is unclear why the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncology specifically endorsed the endometrial intraepithelial neoplasia terminology over the atypical hyperplasia terminology.
A change of terminology that replaces years of use and familiarity should not occur without a concerted effort in education of clinicians and pathologists; many are not familiar with the term endometrial intraepithelial neoplasia, and the rapid adoption of this terminology has the potential to result in confusion. As such, we advocate retention of the WHO 2014 system. It is our hope that international organizations of gynecologic oncologists, gynecologists, and gynecologic pathologists will work together if any terminology changes are advocated.
