In the United States,
endometrial cancer is the most commonly diagnosed
cancer of the female reproductive system. Strategies to sensitively and accurately diagnose premalignant endometrial lesions are sorely needed. We reviewed studies pertaining to the diagnostic challenges of endometrial precancers, their predictive value, and evidence to support management strategies. Currently, two diagnostic schemas are in use: the four-class 1994 World Health Organization
hyperplasia system, based on morphologic features of architectural complexity and nuclear atypia and, more recently, the two-class endometrial intraepithelial
neoplasia system, which is quantitative. Diagnosis should use criteria and terminology that distinguish between clinicopathologic entities that can be managed differently. In some instances, such as for women with
hereditary nonpolyposis colon cancer,
biomarkers may aid in diagnosis, but the clinical utility of
biomarkers has yet to be determined. Total
hysterectomy is curative for
atypical endometrial hyperplasia or endometrial intraepithelial
neoplasia, and provides a definitive standard for assessment of a concurrent
carcinoma, when clinically appropriate. If
hysterectomy is performed for
atypical endometrial hyperplasia or endometrial intraepithelial
neoplasia, then intraoperative assessment of the uterine specimen for occult
carcinoma is desirable, but optional. Nonsurgical management may be appropriate for patients who wish to preserve fertility or those for whom surgery is not a viable option. Treatment with
progestin therapy may provide a safe alternative to
hysterectomy; however, clinical trials of hormonal
therapies for
atypical endometrial hyperplasia or endometrial intraepithelial
neoplasia have not yet established a standard regimen. Future studies will need to determine the optimal nonsurgical management of
atypical endometrial hyperplasia or endometrial intraepithelial
neoplasia, standardizing agent, dose, schedule, clinical outcomes, and appropriate follow-up.