Precursor Lesions of Endometrial Carcinoma

  • Lora Hedrick EllensonEmail author
  • Brigitte M. Ronnett
  • Robert J. Kurman
Reference work entry


Endometrial hyperplasia often precedes the development of endometrioid carcinoma, the most common type of endometrial carcinoma. More recently, studies have found that the risk of endometrial hyperplasia is associated with increasing body mass index and nulliparity [24]. In addition, obesity, anovulatory cycles, and exogenous hormones are associated with both endometrioid carcinoma and hyperplasia. All of these factors are thought to result in unopposed estrogen stimulation of the endometrium. The role of unopposed estrogen stimulation in the development of endometrial hyperplasia and carcinoma is further supported by studies demonstrating elevated serum estrogen levels in patients with endometrioid carcinoma [14, 72]. However, other histologic types of endometrial carcinoma appear to be unrelated to hormonal factors and hyperplasia [81]. Serous carcinoma is the prototypic endometrial carcinoma that is not related to estrogenic stimulation or hyperplasia. It usually arises in atrophic endometrium through a precursor lesion called endometrial intraepithelial carcinoma (EIC). Over the past 3 decades, clinicopathologic, immunohistochemical, and molecular genetic studies have provided data to support the development of a dualistic model of endometrial carcinogenesis. In this model, two types of precursor lesions precede the two most common types of endometrial carcinoma. Atypical hyperplasia (AH) is recognized as the precursor for endometrioid carcinoma and endometrial intraepithelial carcinoma (EIC) is recognized as the precursor for serous carcinoma. The following discussion summarizes current knowledge about these precursor lesions including their differential diagnosis, treatment, and relationship to endometrial carcinoma.


Endometrial Carcinoma Serous Carcinoma Endometrial Hyperplasia Atypical Hyperplasia Endometrial Biopsy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Ambros RA et al (1995) Endometrial intraepithelial carcinoma: a distinctive lesion specifically associated with tumors displaying serous differentiation. Hum Pathol 26:1260–1267PubMedCrossRefGoogle Scholar
  2. 2.
    Ausems EW, van der Kamp JK, Baak JP (1985) Nuclear morphometry in the determination of the prognosis of marked atypical endometrial hyperplasia. Int J Gynecol Pathol 4:180–185PubMedCrossRefGoogle Scholar
  3. 3.
    Ayhan A, Yarali H, Ayhan A (1991) Endometrial carcinoma: a pathologic evaluation of 142 cases with and without associated endometrial hyperplasia. J Surg Oncol 46:182–184PubMedCrossRefGoogle Scholar
  4. 4.
    Baak JP (1986) Further evaluation of the practical applicability of nuclear morphometry for the prediction of the outcome of atypical endometrial hyperplasia. Anal Quant Cytol Histol 8:46–48PubMedGoogle Scholar
  5. 5.
    Baak JP, Kuik DJ, Bezemer PD (1994) The additional prognostic value of morphometric nuclear arrangement and DNA-ploidy to other morphometric and stereologic features in endometrial hyperplasias. Int J Gynecol Cancer 4:289–297PubMedCrossRefGoogle Scholar
  6. 6.
    Baak JP et al (1988) Architectural and nuclear morphometrical features together are more important prognosticators in endometrial hyperplasias than nuclear morphometrical features alone. J Pathol 154:335–341PubMedCrossRefGoogle Scholar
  7. 7.
    Baak JP et al (1992) Assessment of the risk on endometrial cancer in hyperplasia, by means of morphological and morphometrical features. Pathol Res Pract 188:856–859PubMedCrossRefGoogle Scholar
  8. 8.
    Baak JP et al (2001) Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias. Am J Surg Pathol 25:930–935PubMedCrossRefGoogle Scholar
  9. 9.
    Baergen RN et al (2001) Early uterine serous carcinoma: clonal origin of extrauterine disease. Int J Gynecol Pathol 20:214–219PubMedCrossRefGoogle Scholar
  10. 10.
    Beckner ME, Mori T, Silverberg SG (1985) Endometrial carcinoma: nontumor factors in prognosis. Int J Gynecol Pathol 4:131–145PubMedCrossRefGoogle Scholar
  11. 11.
    Bergeron C et al (1999) A multicentric European study testing the reproducibility of the WHO classification of endometrial hyperplasia with a proposal of a simplified working classification for biopsy and curettage specimens. Am J Surg Pathol 23:1102–1108PubMedCrossRefGoogle Scholar
  12. 12.
    Beutler HK, Dockerty MB, Randall LM (1963) Precancerous lesions of the endometrium. Am J Obstet Gynecol 86:433–443PubMedGoogle Scholar
  13. 13.
    Bokhman JV (1983) Two pathogenetic types of endometrial carcinoma. Gynecol Oncol 15:10–17PubMedCrossRefGoogle Scholar
  14. 14.
    Brinton LA et al (1992) Reproductive, menstrual, and medical risk factors for endometrial cancer: results from a case-control study. Am J Obstet Gynecol 167:1317–1325PubMedGoogle Scholar
  15. 15.
    Campbell PE, Barter RA (1961) The significance of atypical endometrial hyperplasia. J Obstet Gynaecol Br Commonw 68:668–672PubMedCrossRefGoogle Scholar
  16. 16.
    Carcangiu ML, Tan LK, Chambers JT (1997) Stage IA uterine serous carcinoma: a study of 13 cases. Am J Surg Pathol 21:1507–1514PubMedCrossRefGoogle Scholar
  17. 17.
    Chamlian DL, Taylor HB (1970) Endometrial hyperplasia in young women. Obstet Gynecol 36:659–666PubMedGoogle Scholar
  18. 18.
    Crum CP, Richart RM, Fenoglio CM (1981) Adenoacanthosis of endometrium: a clinicopathologic study in premenopausal women. Am J Surg Pathol 5:15–20PubMedCrossRefGoogle Scholar
  19. 19.
    Dawagne MP, Silverberg SG (1982) Foam cells in endometrial carcinoma–a clinicopathologic study. Gynecol Oncol 13:67–75PubMedCrossRefGoogle Scholar
  20. 20.
    Deligdisch L, Cohen CJ (1985) Histologic correlates and virulence implications of endometrial carcinoma associated with adenomatous hyperplasia. Cancer 56:1452–1455PubMedCrossRefGoogle Scholar
  21. 21.
    Demopoulos RI, Greco MA (1983) Mucinous metaplasia of the endometrium: ultrastructural and histochemical characteristics. Int J Gynecol Pathol 1:383–390PubMedCrossRefGoogle Scholar
  22. 22.
    Dunton CJ et al (1996) Use of computerized morphometric analyses of endometrial hyperplasias in the prediction of coexistent cancer. Am J Obstet Gynecol 174:1518–1521PubMedCrossRefGoogle Scholar
  23. 23.
    Enomoto T et al (1993) Alterations of the p53 tumor suppressor gene and its association with activation of the c-K-ras-2 protooncogene in premalignant and malignant lesions of the human uterine endometrium. Cancer Res 53:1883–1888PubMedGoogle Scholar
  24. 24.
    Epplein M et al (2008) Risk of complex and atypical endometrial hyperplasia in relation to anthropometric measures and reproductive history. Am J Epidemiol 168:563–570; discussion 571–576Google Scholar
  25. 25.
    Esteller M et al (1999) hMLH1 promoter hypermethylation is an early event in human endometrial tumorigenesis. Am J Pathol 155:1767–1772PubMedCrossRefGoogle Scholar
  26. 26.
    Ferenczy A, Gelfand M (1989) The biologic significance of cytologic atypia in progestogen-treated endometrial hyperplasia. Am J Obstet Gynecol 160:126–131PubMedGoogle Scholar
  27. 27.
    Fluhmann CF (1954) Comparative studies of squamous metaplasia of the cervix uteri and endometrium. Am J Obstet Gynecol 68:1447–1463PubMedGoogle Scholar
  28. 28.
    Gal D (1986) Hormonal therapy for lesions of the endometrium. Semin Oncol 13:33–36PubMedGoogle Scholar
  29. 29.
    Greenblatt RB, Gambrell RD Jr, Stoddard LD (1982) The protective role of progesterone in the prevention of endometrial cancer. Pathol Res Pract 174:297–318PubMedCrossRefGoogle Scholar
  30. 30.
    Grimes DA (1982) Diagnostic dilation and curettage: a reappraisal. Am J Obstet Gynecol 142:1–6PubMedGoogle Scholar
  31. 31.
    Gucer F et al (1998) Concomitant endometrial hyperplasia in patients with endometrial carcinoma. Gynecol Oncol 69:64–68PubMedCrossRefGoogle Scholar
  32. 32.
    Gusberg SB, Kaplan AL (1963) Precursors of Corpus Cancer. IV. Adenomatous Hyperplasia as Stage O Carcinoma of the Endometrium. Am J Obstet Gynecol 87:662–678PubMedGoogle Scholar
  33. 33.
    Hall TE, Stapleton JJ, McCance JM (1982) The isolated finding of histiocytes in Papanicolaou smears from postmenopausal women. J Reprod Med 27:647–650PubMedGoogle Scholar
  34. 34.
    Hayes MP et al (2006) PIK3CA and PTEN mutations in uterine endometrioid carcinoma and complex atypical hyperplasia. Clin Cancer Res 12:5932–5935PubMedCrossRefGoogle Scholar
  35. 35.
    Hendrickson MR, Kempson RL (1980) Endometrial epithelial metaplasias: proliferations frequently misdiagnosed as adenocarcinoma. Report of 89 cases and proposed classification. Am J Surg Pathol 4:525–542PubMedCrossRefGoogle Scholar
  36. 36.
    Hendrickson MR, Kempson RL (1980) Surgical pathology of the uterine corpus, vol 12. Saunders, PhiladelphiaGoogle Scholar
  37. 37.
    Hertig AT, Sommers SC (1949) Genesis of endometrial carcinoma: study of prior biopsies. Cancer 2:946–956, illustGoogle Scholar
  38. 38.
    Hunter JE et al (1994) The prognostic and therapeutic implications of cytologic atypia in patients with endometrial hyperplasia. Gynecol Oncol 55:66–71PubMedCrossRefGoogle Scholar
  39. 39.
    Janicek MF, Rosenshein NB (1994) Invasive endometrial cancer in uteri resected for atypical endometrial hyperplasia. Gynecol Oncol 52:373–378PubMedCrossRefGoogle Scholar
  40. 40.
    Jarboe EA et al (2009) Evidence for a latent precursor (p53 signature) that may precede serous endometrial intraepithelial carcinoma. Mod Pathol 22:345–350PubMedCrossRefGoogle Scholar
  41. 41.
    Kaku T et al (1992) Endometrial metaplasia associated with endometrial carcinoma. Obstet Gynecol 80:812–816PubMedGoogle Scholar
  42. 42.
    Kaku T et al (1996) Endometrial carcinoma associated with hyperplasia. Gynecol Oncol 60:22–25PubMedCrossRefGoogle Scholar
  43. 43.
    Kaminski PF, Stevens CW (1985) The value of endometrial sampling in abnormal uterine bleeding. Am J Gynecol Health II:33–36Google Scholar
  44. 44.
    Kendall BS et al (1998) Reproducibility of the diagnosis of endometrial hyperplasia, atypical hyperplasia, and well-differentiated carcinoma. Am J Surg Pathol 22:1012–1019PubMedCrossRefGoogle Scholar
  45. 45.
    Kim YB et al (1997) Progestin alone as primary treatment of endometrial carcinoma in premenopausal women. Report of seven cases and review of the literature. Cancer 79:320–327PubMedCrossRefGoogle Scholar
  46. 46.
    King A, Seraj IM, Wagner RJ (1984) Stromal invasion in endometrial adenocarcinoma. Am J Obstet Gynecol 149:10–14PubMedGoogle Scholar
  47. 47.
    Kraus FT (1985) High-risk and premalignant lesions of the endometrium. Am J Surg Pathol 9:31–40CrossRefGoogle Scholar
  48. 48.
    Kumar NB, Hart WR (1982) Metastases to the uterine corpus from extragenital cancers. A clinicopathologic study of 63 cases. Cancer 50:2163–2169PubMedCrossRefGoogle Scholar
  49. 49.
    Kurman RJ, Kaminski PF, Norris HJ (1985) The behavior of endometrial hyperplasia. A long-term study of “untreated” hyperplasia in 170 patients. Cancer 56:403–412PubMedCrossRefGoogle Scholar
  50. 50.
    Kurman RJ, Norris HJ (1982) Evaluation of criteria for distinguishing atypical endometrial hyperplasia from well-differentiated carcinoma. Cancer 49:2547–2559PubMedCrossRefGoogle Scholar
  51. 51.
    Kurman RJ, Scully RE (1976) Clear cell carcinoma of the endometrium: an analysis of 21 cases. Cancer 37:872–882PubMedCrossRefGoogle Scholar
  52. 52.
    Kurman RJ et al (2000) Norethindrone acetate and estradiol-induced endometrial hyperplasia. Obstet Gynecol 96:373–379PubMedCrossRefGoogle Scholar
  53. 53.
    Lacey JV Jr et al (2008) Endometrial carcinoma risk among women diagnosed with endometrial hyperplasia: the 34-year experience in a large health plan. Br J Cancer 98:45–53PubMedCrossRefGoogle Scholar
  54. 54.
    Lacey JV Jr et al (2008) Risk of subsequent endometrial carcinoma associated with endometrial intraepithelial neoplasia classification of endometrial biopsies. Cancer 113:2073–2081PubMedCrossRefGoogle Scholar
  55. 55.
    Lee KR, Scully RE (1989) Complex endometrial hyperplasia and carcinoma in adolescents and young women 15 to 20 years of age. A report of 10 cases. Int J Gynecol Pathol 8:201–213PubMedCrossRefGoogle Scholar
  56. 56.
    Lehman MB, Hart WR (2001) Simple and complex hyperplastic papillary proliferations of the endometrium: a clinicopathologic study of nine cases of apparently localized papillary lesions with fibrovascular stromal cores and epithelial metaplasia. Am J Surg Pathol 25:1347–1354PubMedCrossRefGoogle Scholar
  57. 57.
    Levine RL et al (1998) PTEN mutations and microsatellite instability in complex atypical hyperplasia, a precursor lesion to uterine endometrioid carcinoma. Cancer Res 58:3254–3258PubMedGoogle Scholar
  58. 58.
    Lidor A et al (1986) Histopathological findings in 226 women with post-menopausal uterine bleeding. Acta Obstet Gynecol Scand 65:41–43PubMedCrossRefGoogle Scholar
  59. 59.
    Lin MC et al (2009) Squamous morules are functionally inert elements of premalignant endometrial neoplasia. Mod Pathol 22:167–174PubMedCrossRefGoogle Scholar
  60. 60.
    Longacre TA et al (1995) Proposed criteria for the diagnosis of well-differentiated endometrial carcinoma. A diagnostic test for myoinvasion. Am J Surg Pathol 19:371–406PubMedCrossRefGoogle Scholar
  61. 61.
    Masterton R, Armstrong EM, More IA (1975) The cyclical variation in the percentage of ciliated cells in the normal human endometrium. J Reprod Fertil 42:537–540PubMedCrossRefGoogle Scholar
  62. 62.
    Mazur MT (1981) Atypical polypoid adenomyomas of the endometrium. Am J Surg Pathol 5:473–482PubMedCrossRefGoogle Scholar
  63. 63.
    McKenney JK, Longacre TA (2009) Low-grade endometrial adenocarcinoma: a diagnostic algorithm for distinguishing atypical endometrial hyperplasia and other benign (and malignant) mimics. Adv Anat Pathol 16:1–22PubMedCrossRefGoogle Scholar
  64. 64.
    Mittal K et al (2009) Presence of endometrial adenocarcinoma in situ in complex atypical endometrial hyperplasia is associated with increased incidence of endometrial carcinoma in subsequent hysterectomy. Mod Pathol 22:37–42PubMedCrossRefGoogle Scholar
  65. 65.
    Mutter GL (2000) Endometrial intraepithelial neoplasia (EIN): will it bring order to chaos? The Endometrial Collaborative Group. Gynecol Oncol 76:287–290PubMedCrossRefGoogle Scholar
  66. 66.
    Mutter GL, Chaponot ML, Fletcher JA (1995) A polymerase chain reaction assay for non-random X chromosome inactivation identifies monoclonal endometrial cancers and precancers. Am J Pathol 146:501–508PubMedGoogle Scholar
  67. 67.
    Mutter GL et al (2000) Endometrial precancer diagnosis by histopathology, clonal analysis, and computerized morphometry. J Pathol 190:462–469PubMedCrossRefGoogle Scholar
  68. 68.
    Nguyen TN et al (1998) Clinical significance of histiocytes in the detection of endometrial adenocarcinoma and hyperplasia. Diagn Cytopathol 19:89–93PubMedCrossRefGoogle Scholar
  69. 69.
    Norris HJ, Tavassoli FA, Kurman RJ (1983) Endometrial hyperplasia and carcinoma. Diagnostic considerations. Am J Surg Pathol 7:839–847PubMedGoogle Scholar
  70. 70.
    Novak E, Rutledge F (1948) Atypical endometrial hyperplasia simulating adenocarcinoma. Am J Obstet Gynecol 55:46–63PubMedGoogle Scholar
  71. 71.
    Nucci MR et al (1999) Mucinous endometrial epithelial proliferations: a morphologic spectrum of changes with diverse clinical significance. Mod Pathol 12:1137–1142PubMedGoogle Scholar
  72. 72.
    Potischman N et al (1996) Case-control study of endogenous steroid hormones and endometrial cancer. J Natl Cancer Inst 88:1127–1135PubMedCrossRefGoogle Scholar
  73. 73.
    Quddus MR et al (1999) p53 immunoreactivity in endometrial metaplasia with dysfunctional uterine bleeding. Histopathology 35:44–49PubMedCrossRefGoogle Scholar
  74. 74.
    Randall TC, Kurman RJ (1997) Progestin treatment of atypical hyperplasia and well-differentiated carcinoma of the endometrium in women under age 40. Obstet Gynecol 90:434–440PubMedCrossRefGoogle Scholar
  75. 75.
    Reed SD et al (2009) Progestin therapy of complex endometrial hyperplasia with and without atypia. Obstet Gynecol 113:655–662PubMedGoogle Scholar
  76. 76.
    Rorat E, Wallach RC (1984) Papillary metaplasia of the endometrium: clinical and histopathologic considerations. Obstet Gynecol 64:90S–92SPubMedCrossRefGoogle Scholar
  77. 77.
    Scully RE, Bonfiglio TA, Kurman RJ, Silverberg SG, Wilkinson EJ (1994) Histologic typing of female genital tract tumors (international histological classification of tumors), 2nd edn. Springer, New York, pp 1–189Google Scholar
  78. 78.
    Shah SS, Mazur MT (2008) Endometrial eosinophilic syncytial change related to breakdown: immunohistochemical evidence suggests a regressive process. Int J Gynecol Pathol 27:534–538PubMedCrossRefGoogle Scholar
  79. 79.
    Sherman ME, Bur ME, Kurman RJ (1995) p53 in endometrial cancer and its putative precursors: evidence for diverse pathways of tumorigenesis. Hum Pathol 26:1268–1274PubMedCrossRefGoogle Scholar
  80. 80.
    Sherman ME et al (1992) Uterine serous carcinoma. A morphologically diverse neoplasm with unifying clinicopathologic features. Am J Surg Pathol 16:600–610PubMedCrossRefGoogle Scholar
  81. 81.
    Sherman ME et al (1997) Risk factors and hormone levels in patients with serous and endometrioid uterine carcinomas. Mod Pathol 10:963–968PubMedGoogle Scholar
  82. 82.
    Silver MM, Miles P, Rosa C (1991) Comparison of Novak and Pipelle endometrial biopsy instruments. Obstet Gynecol 78:828–830PubMedGoogle Scholar
  83. 83.
    Silver SA, Sherman ME (1998) Morphologic and immunophenotypic characterization of foam cells in endometrial lesions. Int J Gynecol Pathol 17:140–145Google Scholar
  84. 84.
    Silverberg SG, Kurman RJ (1992) Atlas of tumor pathology. Tumors of the uterine corpus and gestational trophoblastic disease, third series, fascicle 3. Armed Forces Institute of Pathology, Washington, D.CGoogle Scholar
  85. 85.
    Soslow RA, Pirog E, Isacson C (2000) Endometrial intraepithelial carcinoma with associated peritoneal carcinomatosis. Am J Surg Pathol 24:726–732PubMedCrossRefGoogle Scholar
  86. 86.
    Spiegel GW (1995) Endometrial carcinoma in situ in postmenopausal women. Am J Surg Pathol 19:417–432PubMedCrossRefGoogle Scholar
  87. 87.
    Stovall TG, Ling FW, Morgan PL (1991) A prospective, randomized comparison of the Pipelle endometrial sampling device with the Novak curette. Am J Obstet Gynecol 165:1287–1290PubMedGoogle Scholar
  88. 88.
    Tashiro H et al (1997) p53 gene mutations are common in uterine serous carcinoma and occur early in their pathogenesis. Am J Pathol 150:177–185PubMedGoogle Scholar
  89. 89.
    Tavassoli F, Kraus FT (1978) Endometrial lesions in uteri resected for atypical endometrial hyperplasia. Am J Clin Pathol 70:770–779PubMedGoogle Scholar
  90. 90.
    Terakawa N et al (1997) The behavior of endometrial hyperplasia: a prospective study. Endometrial Hyperplasia Study Group. J Obstet Gynaecol Res 23:223–230PubMedGoogle Scholar
  91. 91.
    The Postmenopausal Estrogen/Progestin Interventions (PEPI) Trial (1996) Effects of hormone replacement therapy on endometrial histology in postmenopausal women. JAMA 275:370–375CrossRefGoogle Scholar
  92. 92.
    Trimble CL et al (2006) Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. Cancer 106:812–819PubMedCrossRefGoogle Scholar
  93. 93.
    Welch WR, Scully RE (1977) Precancerous lesions of the endometrium. Hum Pathol 8:503–512PubMedCrossRefGoogle Scholar
  94. 94.
    Wheeler DT, Bristow RE, Kurman RJ (2007) Histologic alterations in endometrial hyperplasia and well-differentiated carcinoma treated with progestins. Am J Surg Pathol 31:988–998PubMedCrossRefGoogle Scholar
  95. 95.
    Wheeler DT et al (2000) Minimal uterine serous carcinoma: diagnosis and clinicopathologic correlation. Am J Surg Pathol 24:797–806PubMedCrossRefGoogle Scholar
  96. 96.
    Widra EA et al (1995) Endometrial hyperplasia and the risk of carcinoma. Int J Gynecol Cancer 5:233–235PubMedCrossRefGoogle Scholar
  97. 97.
    Zaino RJ et al (2006) Reproducibility of the diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. Cancer 106:804–811PubMedCrossRefGoogle Scholar
  98. 98.
    Zaman SS, Mazur MT (1993) Endometrial papillary syncytial change. A nonspecific alteration associated with active breakdown. Am J Clin Pathol 99:741–745PubMedGoogle Scholar
  99. 99.
    Zhang X et al (2009) Molecular identification of “latent precancers” for endometrial serous carcinoma in benign-appearing endometrium. Am J Pathol 174:2000–2006PubMedCrossRefGoogle Scholar
  100. 100.
    Zheng W et al (1998) p53 immunostaining as a significant adjunct diagnostic method for uterine surface carcinoma: precursor of uterine papillary serous carcinoma. Am J Surg Pathol 22:1463–1473PubMedCrossRefGoogle Scholar
  101. 101.
    Zheng W et al (2004) Endometrial glandular dysplasia: a newly defined precursor lesion of uterine papillary serous carcinoma. Part I: morphologic features. Int J Surg Pathol 12:207–223PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Lora Hedrick Ellenson
    • 1
    Email author
  • Brigitte M. Ronnett
    • 2
  • Robert J. Kurman
    • 3
  1. 1.Department of Pathology and Laboratory MedicineWeill Cornell Medical College and New York Presbyterian HospitalNew YorkUSA
  2. 2.Department of Pathology, Division of Gynecologic PathologyJohns Hopkins University School of MedicineBaltimoreUSA
  3. 3.Departments of Gynecology, Obstetrics, Pathology and Oncology, Division of Gynecologic PathologyJohns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations