患者，39岁，阴道出血一月余。妇检：宫颈内口赘生物，切除局部组织活检。07年5月因阴道流血曾行子宫内膜诊刮并活检，清宫后止血，现又出现阴道流血……去年切片图像与现在相仿（去年切片借片后遗失……）。

今日电话联系了负责取材的妇产科医生，据描述：“送检物取自子宫颈管，但肿物并非与宫颈管相连，而似由宫腔内长出突出于宫颈管，肿物质脆，极易出血（用棉签轻触即出血）”。患者是在门诊做的检查，因门诊部器械不足，妇科医生怕引起大出血，因而只用竹签挑取了少量肿物送检。另外去年的清宫组织物切片正在追回中，望近日能将图片上传。

去年借片的图片发布在本帖第2页的第28楼、29楼。近日诊刮图片在44楼。

My diagnosis will be: "Complex hyperplasia without nulcear atypia, confined within a benign endometrial polyp with chronic endometritis （复合型子宫内膜上皮增生和鳞状化生， 不伴核间变，局限于一良性内膜息肉内。 伴慢性子宫内膜炎）。

此例关键要看，非息肉宫内膜部分是否也有“复合型子宫内膜上皮增生和鳞状化生”。如果没有，建议临床抗生素治疗慢性子宫内膜炎。如果内膜息肉完全去除，病人随访即可； 如果非息肉宫内膜部分也有复合型子宫内膜上皮增生和鳞状化生，建议临床使用孕激素治疗子宫内膜上皮增生。

I conceptually agree with Dr. Yu's analysis. My only concern is that squamous metaplasia is not usually seen in benign endometrial polyp, without hyperplasia. In a situation we see squamous metaplasia in an endometrial polyp, there are two differential diagnoses we should entertain: 1) atypical polypoid adenomyoma (APA), 2) complex hyperplasia within the polyp. In the former, hyperplasia is similar to atypical complex hyperplasia with nuclear atypia. I did not see smooth muscle bundles in the picture provided. Therefore, I speculate this is enough to call "complex hyperplasia without nuclear atypia".  I agree with Dr. Yu that we usually tolerate some complexity and irregularity of glands within an endometrial polyp. Without squamous metaplasia, I may let it go as "Benign endometrial polyp with Chronic endometritis". However, given the infrequence to see squamous metaplasia in a usual polyp, and given the complex glandular archtecture in the focus which is so different from surrounding polypoid tissue, I think it is appropriate to render the diagnosis of "complex hyperplasia" in this case.  It is soly academic exercise here. Clinically, it did not change much regarding exogenous progestin therapy, unless there is complex hyperplasia present in non-polypoid endometrium. The latter will be the key evaluation in this case.

 谢谢mingfuyu和杨斌老师精彩的点评，小结如下，供学习：

mingfuyu
诊断：子宫内膜息肉伴子宫内膜炎。上皮反应性改变（胞核变大，核仁明显），并不萎缩，也不够非典型增生。间质较多，纤维化不明显。
处理意见：取宫腔内子宫内膜做细菌培养，然后抗生素治疗。内膜息肉本身并不可怕，刮掉就好。病人需随访。
杨斌
诊断：复合型子宫内膜上皮增生和鳞状化生， 不伴核间变，局限于一良性内膜息肉内。 伴慢性子宫内膜炎）。
处理意见：此例关键要看，非息肉宫内膜部分是否也有“复合型子宫内膜上皮增生和鳞状化生”。如果没有，建议临床抗生素治疗慢性子宫内膜炎。如果内膜息肉完全去除，病人随访即可； 如果非息肉宫内膜部分也有复合型子宫内膜上皮增生和鳞状化生，建议临床使用孕激素治疗子宫内膜上皮增生。

 Dear Dr. Yang,

So nice to have professional discussion here with you.  We have met in USCAP 2006 in Atlanta and i believe we both had the previlege to be trained at BJC/Wash U under superb pathologists like Dr. Huttner and Dr. Dehner.  thank you for your comment.  I did not pay much attention to the squamous metaplasia in this case because i feel i see squamous met in benign endometrium sometimes, sometimes mimicking epithelioid granulomas.  I have seen squamous metaplasia associated with chronic endometritis numerous times.  I remember in my early cases, I always do AFB GMS, as our attendings have emphasized for years (but they are almost always negative, only one positive case in my career so far).  Then i learned that those are squamous met associated with -itis.  Then i did find some literatures or books talking about squamous met as reactive changes.

I like this website very much. Now i feel i work as a pathologist day and night,  as to show how much i like it!  Ha Ha1

同时归还的有蜡块和切片，因原切片有些许退色，再重切了一下（楼上的是原片，本楼是今天重切的），可惜的是蜡块内的组织所剩无几了……

对比之下，去年的片子里腺体增生更为明显、复杂，内膜间质里的浆细胞数量相对少很多。可能与最近一次取材范围过于局限所致。

Dear bobol, 

Thank you for providing more slides and pictures. From additional photos, it clearly demonstrates that the complex hyperplasia present in non-polypoid endometrium, evidenced on Figure 6-9 with loose stroma surrounding the hyperplastic areas. If you are careful enough, you can also spot foamy macrophages/histiocytes in the stroma. Whenever you encounter foamy histiocytes in endometrial stroma, you must entertain the diagnosis of a complex hyperplasia or beyond.

For treatment, I strongly recommend she is treated with exogenous progestin. Most complex hyperplasia should response to such a treatment regimen. She should also be closed followed clinically.

 谢谢杨斌老师和mingfuyu老师的回帖，学习到了非常有用的知识。关于这个病例，我想我会建议她在完善相关影像学（如B超）检查后做一次全面的诊刮，然后再做进一步的治疗（如孕激素方面的治疗或手术），尤其是当前患者在准备手术全宫切除的前提下。再次感谢。

此外还要向abin学习，我的英文阅读能力太弱了……

杨斌老师和mingfuyu老师的要点翻译如下：

杨斌：
非息肉区存在复杂性增生，间质出现泡沫细胞（巨噬细胞/组织细胞）提示至少为复杂性增生。
处理：外源性孕激素治疗（绝大多数复杂性增生有效）。密切随访。
mingfuyu：
同意上述，腺体更拥挤，至少为简单性增生。无法判断细胞学非典型性。我会建议刮宫以排除更严重病变。一些腺体背靠背，令人担忧。

我的观点：

切子宫确诊。

因为国内情况特殊，很多时候无法遵循正规的诊治程序，降低医患双方的风险是第一位的。

 感谢两位版主对病例详细的点评，也感谢杨斌老师对我们的鼓励，感谢abin的翻译。

本例建议先了解宫腔的情况，治疗随访一段时间后仍然没有改善的情况下可以考虑切除子宫，当然这都必须先与病人及其家属沟通。

Abin, 悠着点，手下留情，刀下留宫！