Mod Pathol. 2023 May 10. pii: S0893-3952(23)00118-7. [Epub ahead of print] 100213
Gestational endometrium can demonstrate a spectrum of atypical but benign changes. One such lesion is Localized Endometrial Proliferation of Pregnancy (LEPP), first described in a series of 11 cases. To understand its biologic and clinical importance, we explore the pathologic, immunophenotypic and molecular features of this entity. Nine cases of LEPP identified in a 15-year period were retrieved from departmental archives and reviewed. Immunohistochemistry and next generation sequencing using a comprehensive 446-gene panel were performed when material was available. Eight cases were identified in curettage specimens performed after first-trimester pregnancy loss, and one in the basal plate of a mature placenta. Mean patient age was 35 (range 27-41) years. Mean lesion size was 6.3 (range 2-12) mm. Architectural patterns, often coexisting in the same case, included cribriform (n=7), solid (n=5), villoglandular (n=2), papillary (n=2) and micropapillary (n=1). Cytologic atypia was mild in 7 cases and moderate in two. Mitotic activity was low (up to 3 per 2.4 mm2). All lesions were associated with neutrophils. Background Arias-Stella phenomenon was present in 4 cases. Immunohistochemistry was performed in 7 LEPP, all of which demonstrated wildtype p53, retained MSH6 and PMS2, membranous beta-catenin, and positive ER (mean 71%) and PR (mean 74%). All were negative for p40 except one case (focal weak positivity). PTEN was markedly reduced in background secretory glands in all cases; in 5/7, LEPP foci showed complete absence of PTEN expression. PIK3CA pathogenic variants were identified in 4/4 cases sequenced; 3/4 had inactivating PTEN mutations. Follow-up, available in 8 patients (mean length = 51 months, range 7-161), was conservative with observation only, and showed no persistence or adverse outcomes. LEPP is characterized by intraglandular cribriform/solid architecture, positive ER/PR, PTEN loss, and PIK3CA &PTEN mutations. While our findings indicate that LEPP is of neoplastic nature, for now we advise against diagnosing LEPP as endometrial carcinoma or hyperplasia since LEPP has a particular clinico-pathologic context (concurrent gestation), distinct morphology (purely intraepithelial complex growth) and indolent outcome. Thus, it should be distinguished from endometrial intraepithelial neoplasia and carcinoma for which therapeutic interventions are indicated.
Keywords: Endometrial proliferation of pregnancy; PIK3CA; PTEN; endometrial intraepithelial neoplasia; progesterone