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Reproducibility determination of WHO classification of endometrial hyperplasia/well differentiated adenocarcinoma and comparison with computerized morphometric data in curettage specimens in Iran

Narges Izadi-Mood1*, Maryam Yarmohammadi1, Seyed Ali Ahmadi2, Guity Irvanloo3, Hayedeh Haeri3, Ali Pasha Meysamie4 and Mahmood Khaniki3

Author Affiliations

1 Department of pathology, Mirza Koochak Khan Hospital, Tehran University of Medical sciences, Tehran, Iran

2 Department of pathology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

3 Department of pathology, Imam Khomeini Hospital, Tehran University of Medical sciences, Tehran, Iran

4 Department of Community and Preventive Medicine, Medical school, Tehran University of Medical sciences, Tehran, Iran

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Diagnostic Pathology 2009, 4:10  doi:10.1186/1746-1596-4-10

Published: 25 March 2009



Management of endometrial precancerous lesions has been of much debate due to inconsistencies in their classification, natural history and histologic diagnosis. Endometrial hyperplasia constitutes a wide range of histomorphologic features associated with high intra and interobserver diagnostic variability.

Although traditional microscopic diagnosis is by far the most applicable method and the gold standard for histomorphologic diagnosis, digitized image analysis has been used as a powerful adjunct to maximize the histologic data retrieval and to add some detailed objective criteria for correct diagnosis in difficult cases.


A series of 100 endometrial curettage specimens with diagnosis of endometrial hyperplasia or well differentiated adenocarcinoma were blindly reviewed by 5 pathologists; their intra and interobserver reproducibility determined and further compared to the objective morphometric data i.e. D-score and volume percent of stroma (VPS).


The results were assessed using the weighted kappa statistics. Mean intraobserver kappa value was 0.8690 (99.44% agreement). Mean interobserver kappa values by diagnostic category were: simple hyperplasia without atypia: 0.7441; complex hyperplasia without atypia: 0.3379; atypical hyperplasia: 0.3473, and well-differentiated endometrioid carcinoma: 0.6428; with a kappa value of 0.5372 for all cases combined.

Interobserver agreement was in substantial rate for simple hyperplasia (SH) and well differentiated adenocarcinoma (WDA) but was in fair limit for complex hyperplasia (CH) and atypical hyperplasia (AH). Intraobserver agreement was almost perfect. The specimens were divided in two groups according to the computerized morphometric analysis: Endometrial Hyperplasia (EH) ( D Score ≥ 1 or VPS ≥ 55%) and Endometrial Intraepithelial Neoplasia (EIN) (D-Score < 1 or VPS < 55%). Morphometric findings were closely compatible with routine WHO classification made by one expert pathologist; however; diagnosis of (CH) and (AH) made by other pathologists were not concordant with morphometric data.


It may be necessary to make some revisions in WHO classification for endometrial hyperplasia and precancerous lesions.