Final validation of the ProMisE molecular classifier for endometrial carcinoma in a large population-based case series

Immunotherapy and PARP inhibitors as first-line treatment in endometrial cancer: A systematic review and network meta-analysis

BACKGROUND

Several first-line therapeutic strategies have been evaluated alongside platinum-based chemotherapy in advanced or recurrent endometrial cancer (a/rEC). However, the optimal approach remains unclear.

METHODS

A systematic review was conducted to identify randomized control trials (RCTs) that evaluate first-line therapeutic strategies in a/rEC involving immune checkpoint inhibitors (ICI) and PARP inhibitors (PARPi). A network meta-analysis with a frequentist framework using random-effects and an extracted individual patient data meta-analysis were performed. The primary endpoint was progression-free survival (PFS) by MMR status, p53 status within the MMRp population and PD-L1 status.

RESULTS

A total of 3210 patients with EC were included. In the MMRp population, the combination (ICI and PARPi) showed a not statistically significant PFS benefit compared with each agent alone. In MMRp p53-abnormal patients (n = 590), combining PARPi and ICI statistically improved PFS compared to ICI alone (HR=0.47, 95 %CI 0.40-0.94) with a numerically better outcome compared to PARPi alone (HR=0.63, 95 %CI 0.26-1.57). No benefit from PARPi was observed in the p53 wild-type MMRp population. PD-L1-positivity (n = 1121) appears to predict more benefit from the addition of ICI and PARPi, with a larger benefit of combination therapy. In the MMRd population (n = 769), the best outcomes were observed with ICI alone, with no additional benefit of PARPi. Grade 3 or greater treatment-related adverse events were seen in 75.1 % patients treated with the combination.

CONCLUSIONS

The addition of the combination of ICI and PARPi to platinum-based chemotherapy provides greatest benefit to p53-abnormal MMRp patients. PD-L1 is a potentially useful biomarker with PD-L1-positive tumors more likely to respond to ICI. Implementation of biomarkers is crucial to redefine the treatment paradigm in a/rEC.

Are all mismatch repair deficient endometrial cancers created equal? A large, retrospective, tertiary center experience

BACKGROUND

One third of endometrial carcinomas (ECs) presents with mismatch repair deficiency (MMRd). Of these, 70 % are caused by somatic hypermethylation of MLH1 promoter; the remaining cases are determined by Lynch syndrome or double somatic inactivation of MMR genes. Although associated with good-intermediate prognosis, heterogeneity in treatment response and survival has been reported among MMRd ECs. We aim to investigate differences in pathologic aggressiveness and event-free survival (EFS) among three MMRd EC subtypes, classified by immunohistochemistry (IHC) and MLH1 methylation analysis.

METHODS

Subjects undergone surgical staging for EC were retrospectively included. IHC analysis was performed in all patients to assess MMR and p53 status. Methylation analysis was performed in MMRd patients with IHC-negative MLH1. The MMRd population was classified into: 1)MLH1-hypermethylated (MLH1-HyMet); 2)MLH1-unmethylated (MLH1-UnMet); 3)IHC-negative MSH2 and/or MSH6 or PMS2 alone (non-MLH1).

RESULTS

Of 1171 patients undergoing surgical staging and IHC assessment, 362 (30.9 %) were classified as MMRd and included in the analysis. Among these, 59.7 % (n = 216) were MLH1-HyMet, 11 % (n = 40) MLH1-UnMet, and 29.3 % (n = 106) non-MLH1. Compared to MLH1-UnMet and non-MLH1, MLH1-HyMet was associated with older age, higher BMI, larger tumor size, deeper myometrial invasion, substantial lymphovascular space invasion, lower frequency of early-stage and low-risk disease. EFS was similar when comparing the MMRd subtypes, even after adjusting for stage and tumor histology. However, a trend of MLH1-HyMet toward poorer prognosis can be observed, particularly in the advanced/metastatic setting.

CONCLUSIONS

MLH1-hypermethylated MMRd ECs display more aggressive clinicopathologic features compared to the other MMRd subgroups. However, although a suggestive trend toward poorer EFS was observed in the hypermethylated subset, particularly in the advanced setting, no significant differences in prognosis were detected among the MMRd subtypes.

Papillary and ductal patterns of mesonephric-like adenocarcinomas are often overlooked: a retrospective revaluation of over 1000 endometrial carcinomas

AIMS

Mesonephric-like adenocarcinoma (MLA) of the endometrium is often a diagnostic challenge, due to its morphological resemblance to other more common Müllerian neoplasms. This study aimed to retrospectively identify overlooked MLA in a large endometrial carcinoma cohort, using a combination of immunohistochemistry (IHC), morphology and KRAS sequencing.

METHODS AND RESULTS

IHC was conducted on 1094 endometrial carcinomas, identifying 16 potential MLA cases based on GATA3+ and/or TTF1+ and ER- staining patterns, which subsequently underwent detailed histological review, KRAS sequencing and ProMisE molecular classification. Of the IHC screen-positive cases, one was positive for both GATA3 and TTF1, nine were positive for GATA3 only and six were positive for TTF1 only. All IHC screen-positive cases were POLE wild-type. All five tumours in the NSMP category showed morphological features of MLA, while the three MMRd and eight p53abn tumours did not show MLA morphology. The five cases diagnosed as MLA on review were all originally diagnosed as low-grade endometrioid adenocarcinoma probably because of rare morphological patterns, being predominantly papillary or ductal. Four of the five cases harboured a KRAS mutation.

CONCLUSION

This study highlights the importance of a comprehensive diagnostic approach for accurately identifying endometrial MLA and for pathologists to be aware of papillary and ductal patterns in endometrial carcinoma assessment. Further exploration into the molecular landscape of MLA is essential for refining diagnostic criteria and developing targeted therapies.

Pattern of recurrence of the molecular subgroups in stage I high-grade endometrial cancer

OBJECTIVE

Patterns of recurrence may impact the possibilities for salvage treatment and prognosis of patients with endometrial carcinoma (EC). We evaluated the recurrence rate and distribution pattern of the molecular EC subgroups in patients with stage I high-grade disease without adjuvant treatment and those staged by lymphadenectomy.

METHOD

412 high-grade EC from the Danish Gynecological Cancer Database were molecularly profiled and classified into POLE mutant (POLEmut), mismatch repair deficient (MMRd), p53-abnormal (p53abn) or no specific molecular profile (NSMP) EC. Patients with stage II-IV (FIGO 2009) or residual disease after surgery were excluded. Crude and actuarial recurrence rates were calculated.

RESULTS

Stage I high-grade POLEmut and MMRd EC rarely recurred (5-year overall recurrence rate 7 % (95 % CI 3-16) and 6 % (95 % CI 2-22), respectively), also when not receiving adjuvant treatment. Stage I high-grade NSMP and p53abn EC had high recurrence rates (5-year overall recurrence rate 29 % (95 % CI 16-48) and 35 % (95 % CI 27-45), respectively), mostly presenting with abdominal (NSMP EC n = 1 (3.0 %); p53abn EC n = 28 (22.4 %)) or distant recurrences (NSMP EC n = 8 (24.2 %); p53abn EC n = 21 (16.8 %)).

CONCLUSION

Stage I high-grade EC present more frequently with abdominal and distant recurrences rather than isolated loco-regional recurrences, independently of molecular subgroup. Stage I high-grade POLEmut EC and MMRd EC have a favorable prognosis with few recurrences, even with no adjuvant treatment. Stage I high-grade NSMP and p53abn EC have a high recurrence rate, frequently with abdominal or distant recurrences, underscoring the need to investigate more effective adjuvant systemic treatments for these patients.

Comparative analysis of European guideline-based clinicopathological risk groups and the International Federation of Gynecology and Obstetrics staging system for endometrial cancer

OBJECTIVE

To investigate the correlation between endometrial cancer risk groups, as defined by the 2021 European guidelines, and the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system. Further, we aimed to evaluate the additional prognostic capability of the staging system within individual risk groups.

STUDY DESIGN

This retrospective cohort study included patients who underwent primary treatment for endometrial cancer at a single tertiary center. Each case was classified into a molecular-integrated risk group according to the 2021 joint guidelines from the European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP). Staging was performed using the FIGO 2023 criteria with molecular classification.

RESULTS

Data from 1044 patients were analyzed. Median follow-up was 70 months. Stage IA2, stage IB, and stage IVB were the most prevalent stages among the ESGO-ESTRO-ESP low-risk, intermediate risk, and advanced-metastatic groups, accounting for 80 %, 75 %, and 54 % of the cases, respectively. The stage distribution was more heterogeneous in the high-intermediate risk and high-risk groups, with stage IIA comprising 36 % and stage IICmp53abn comprising 35 % of cases in these groups. The FIGO staging system further stratified survival outcomes especially in the high-intermediate and high-risk groups. Stage IIC included a substantial number of cases from the intermediate risk (n = 23), high-intermediate risk (n = 48), and high-risk (n = 27) groups. Risk groups were associated with survival within this stage.

CONCLUSIONS

ESGO-ESTRO-ESP high-intermediate risk and high-risk endometrial cancers exhibited the greatest variability in terms of stage distribution and survival outcomes. Stage IIC, the most heterogeneous stage concerning risk groups, showed an association between risk groups and survival.

Association of peripheral monocytic myeloid-derived suppressor cells with molecular subtypes in single-center endometrial cancer patients receiving carboplatin + paclitaxel/avelumab (MITO-END3 trial)

The MITO-END3 trial compared carboplatin and paclitaxel (CP) with avelumab plus carboplatin and paclitaxel (CPA) as first-line treatment in endometrial cancer (EC) patients and demonstrated a significant interaction between avelumab response and mismatch repair status. To investigate prognostic/predictive biomarker, 29 MITO-END3-EC patients were evaluated at pretreatment (B1) and at the end of CP/CPA treatment (B2) for peripheral myeloid-derived suppressor cells (MDSC) and Tregs. At B2, effector Tregs frequency was significantly higher in patients treated with CPA as compared to CP (p = 0.038). Both treatments (CP/CPA) induced significant decrease in peripheral M-MDSC (- 5.41%) in TCGA 2-MSI-high as compared to TCGA-category 4 tumors (p = 0.004). In accordance, both treatments induced M-MDSCs (+ 5.34%) in MSS patients as compared to MSI-high patients (p = 0.001). Moreover, in a subgroup of patients, primary tumors were highly infiltrated by M-MDSCs in MSS as compared to MSI-high ECs. A post hoc analysis displayed higher frequency of M-MDSCs (p = 0.020) and lower frequency of CD4+ (p < 0.005) at pretreatment in EC patients as compared to healthy donors. In conclusion, the peripheral evaluation of MDSCs and Tregs correlated with molecular features in EC treated with CP/CPA and may add insights in identifying EC patients responder to first-line chemo/chemo-immunotherapy.

Activated immune infiltrates expand opportunities for targeted therapy in p53-abnormal endometrial carcinoma

Tumor protein p53 mutated/abnormal (p53abn) endometrial carcinomas account for over 50% of deaths but comprise only 15% of all endometrial carcinomas. Most patients show limited response to standard-of-care chemotherapy with or without radiotherapy, and only a minority of cases are amenable to targeted therapies like poly-ADP ribose polymerase (PARP) inhibitors and HER2-directed therapies. Recent immunotherapy clinical trials have demonstrated remarkable efficacy, not only in mismatch repair deficient (MMRd) tumors but also in a subset of mismatch repair-proficient (MMRp) tumors. However, the immune microenvironment and its relationship to other therapeutic targets in MMRp endometrial carcinoma remains poorly understood. Here, we characterize the immune microenvironment of p53abn endometrial carcinoma, the most clinically aggressive subtype of MMRp endometrial carcinoma, and correlate antitumor immune signatures with other targetable alterations. We accrued 256 treatment-naïve p53abn endometrial carcinomas and systemically profiled T-cell, B-cell, myeloid, and tumor-cell populations with multiplex immunofluorescence to assess the tissue localization and functional status of immune cells. Shallow whole-genome sequencing was performed on a subset of 126 cases. Patterns of immune infiltration were compared to survival outcomes and mutational signatures. Mixture modeling divided p53abn endometrial carcinoma into tumor-infiltrating lymphocyte (TIL)-rich and TIL-poor subsets. Over 50% of tumors were TIL-rich. TIL-rich cases overexpressed targetable immune evasion molecules and were associated with longer overall and disease-specific survival in multivariate analysis. This effect was particularly pronounced in advanced stage disease and in patients who did not receive adjuvant chemotherapy. TIL did not associate with homologous recombination deficient mutational signatures or HER2 amplification. Our findings demonstrate a biological rationale for immunotherapy in a substantial subset of patients with p53abn endometrial cancer and may help inform combination therapies with immune checkpoint inhibition, PARP inhibitors, and anti-HER2 agents. © 2025 The Author(s). The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.

The prognostic potential of molecular subtypes including estrogen receptor status in endometrioid ovarian cancer

BACKGROUND

The Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) has been shown to be applicable to endometrioid ovarian cancer (ENOC), classifying tumors into four molecular subgroups: POLE mutated (POLEmut), mismatch repair deficient (MMRd), p53 abnormal (p53abn), and no specific molecular profile (NSMP). However, the large NSMP subgroup in ENOC limits its clinical applicability. Incorporating estrogen receptor (ER) status has improved prognostic accuracy in NSMP endometrial cancer. Therefore, this study investigated the prognostic value of ER status in the molecular subgroups of ENOC.

METHODS

In this multicenter, retrospective cohort study, paraffin-embedded tumor tissue from surgically treated ENOC patients (1994-2021) was used for molecular classification. ER status was determined by immunohistochemistry. Survival analysis was performed using the log-rank test and Cox proportional hazards model.

RESULTS

Of the 167 included patients, 1.2 % had a POLEmut tumor, 6.6 % an MMRd tumor, 11.4 % a p53abn tumor, and 80.8 % an NSMP tumor. ER status was negative in 12 % of tumors, correlating with a significantly lower 10-year overall survival rate compared to ER-positive tumors (HR 3.51, 95 % CI 1.75-7.01, p < .001). No ER-negative tumors were found in the POLEmut and MMRd subgroups, and ER status was not prognostic in the p53abn subgroup. In the NSMP subgroup, 11.1 % of tumors were ER-negative, showing a worse 10-year overall survival rate (HR 3.92, 95 % CI 1.67-9.21, p = .002).

CONCLUSION

ER status improves prognostic stratification within the NSMP subgroup in ENOC, with ER-negative tumors associated with a worse prognosis. These findings may lead to more personalized treatment strategies for ENOC.

ECPPF stratification identifies occult high-risk subgroups in stage I, grade 1 or 2, ≤50 % invasive endometrial cancer: Candidates for adjuvant therapy

OBJECTIVE

To determine whether stratification with ECPPF (E2F1 + CCNA2 log2 expression and POLE, PPP2R1A, and FBXW7 variants) could identify occult cases of high-risk endometrial cancer (EC) in a traditionally low-risk cohort.

METHODS

We identified 97 cases of clinicopathologic low-risk endometrioid EC (defined as stage I, grade 1 or 2, limited [≤50 %] myometrial invasion) from The Cancer Genome Atlas (TCGA). Twelve cases had POLE mutations (mu) and 15 had PPP2R1Amu or FBXW7mu. Log2 CCNA2 + E2F1 expression was low (<4.75) for 56 cases and high (>4.75) for 19 (termed CCNA2 + E2F1 low or high, respectively). CCNA2 + E2F1 high and PPP2R1Amu/FBXW7mu were simultaneously present for 5 cases. Survival comparisons were based on log-rank tests.

RESULTS

Five-year progression-free survival (PFS) curves for POLEmu and CCNA2 + E2F1 low differed substantially from CCNA2 + E2F1 high and PPP2R1mu/FBXW7mu cases (P < .001). The latter 2 subgroups, combined (n = 29) and designated as molecular high risk (MHR), had an estimated 5-year PFS <50 %. Adverse outcomes were associated with MHR for cases harboring CTNNB1mu (P < .001), ARID1Amu (P = .03), and PTENmu (P = .002). TCGA classification was not prognostically significant for this cohort (P = .10), but ECPPF MHR identified compromised subgroups within major TCGA subclasses (P = .004). CCNA2 + E2F1 high and expression of its downstream targets were positively correlated (P < .001) with expression of genes involved in chemoresistance (ie, homologous recombination, cell cycle regulation, antiapoptotic processes).

CONCLUSIONS

ECPPF supports a taxonomy in which occult, high-risk disease is identified among cases traditionally considered low risk. With high-risk cases unlikely to respond to current first-line chemotherapy, case identification should prompt proactive therapeutic intervention with alternative molecular-based treatment targets.

Exploring endometrial cancer risk stratification by copy number assessment

BACKGROUND

Contemporary management of endometrial cancer includes molecular classification. The primary objective of this study was to assess the prognostic significance of copy number changes evidenced by loss of heterozygosity (LOH) or allelic imbalance (AI).

METHODS

Sequencing including TP53, POLE and MSI testing was performed. AI/LOH at 5 polymorphic markers (D2S123, D5S2346, D17S250, D17S516 and D17S1818) was assessed. Micro-satellite stable (MSS) endometrial tumors were classified as having evidence of AI/LOH or no evidence of AI/LOH.

RESULTS

482 MSS cases were evaluated for AI/LOH status. There were 226 (46.5 %) tumors with evidence of AI/LOH at ≥1 of the 5 markers and these were significantly associated with patients of older age and lower body mass index as well as tumors that were non-endometrioid histology, higher grade, demonstrated LVSI, and presented at more advanced stage. Most patients who developed recurrent disease had a tumor with AI/LOH (82.1 %). 3-year progression-free survivals (PFS) were 79.5 % in the AI/LOH group vs 95.6 % in the no AI/LOH group (p < 0.0001). TP53 mutation status was associated with PFS. 3-year PFS was significantly worse for the TP53 mutated group at 55 % vs 96 % in TP53 wild-type (p < 0.0001). Of the 373 cases classified as having no specific molecular profile there was a 6.2 % recurrence rate with AI/LOH and 3.3 % recurrence with no AI/LOH.

CONCLUSIONS

AI/LOH assessment at a limited number of markers identifies endometrial cancers with higher risk features that are more likely to recur. Copy-number assessment utilizing clinically accessible testing strategies can provide an opportunity for improved risk stratification.

The key role of natural products in the fight against endometrial Cancer

Endometrial cancer (EC) is a common malignant disease in women, originating from the endometrial tissue. Over the past few decades, the global incidence rate of EC has gradually increased, and the affected population has become progressively younger. Traditional treatment methods, such as surgery and adjuvant therapy, have considerable toxic side effects. Furthermore, their therapeutic effectiveness is significantly very uncertain. Therefore, the search for a new type of treatment for EC is a top priority. Natural products are a class of compounds found in nature that have a wide range of biological functions; their derivatives have chemical structures that show great potential for developing new drugs. The latest studies have found that certain natural products, such as flavonoids, plant polyphenols, terpenoids and alkaloids, have inhibitory effects on EC cells in non-clinical models and animal studies. Despite challenges, including low extraction and bioavail ability, the potential of natural products for treating EC is still highly regarded by the scientific community. In the future, as research on natural products deepens and is combined with modern drug design and delivery technologies, it is hoped that more efficient and less toxic anti-cancer drugs will be developed, thereby offering EC patients more treatment options and hope. This article summarises the possible molecular mechanisms of various natural products and their bioactive components with regard to EC cells, as well as the latest research, to provide new ideas for further research and drug development.

Ladies project: large database in endometrial cancers for a personalized treatment

PURPOSE

To compare Italian use with current international guidelines and to evaluate oncological outcomes and toxicity patterns of adjuvant radiation therapy (RT) for endometrial cancer (EC) in Italian women.

MATERIALS AND METHODS

To conduct a retrospective multicentre Italian study a large database was set up. Inclusion criteria were: accrual between 2010 and 2020, treatment with surgery, post-operative external beam RT (EBRT) and/or interventional radiotherapy (IRT) associated or not with adjuvant chemotherapy. Oncological outcomes, acute and late toxicities were analysed according to RT schedule and risk group.

RESULTS

A total of 1848 patients, from 16 Italian RT centres were enrolled (median age 65 years, range 27-88). All patients received post-operative RT associated with chemotherapy in 31%. Patients were stratified on the basis of standard risk factors (Bosse et al. in Eur J Cancer 51:1742-50, 2015). After merging intermediate and high-intermediate risk classes into one intermediate group and including advanced and oligometastatic disease in the high-risk group, the low-risk group encompassed 124 patients, the intermediate-risk 1140, and the high risk 576. No low-risk patient developed local relapse (LR). Multivariate analysis showed that intermediate risk patients had a 2.5-fold increased risk of LR if treated with IRT alone vs EBRT-IRT boost. RT schedule did not impact significantly on LR in high risk patients. All acute toxicity parameters were highest in patients who received EBRT with simultaneous integrated boost (EBRT-SIB) and lowest in patients who received only IRT (p < 0.0001). Late toxicity was highest patients who received EBRT-SIB and lowest in those who were given EBRT with sequential boost (p < 0.0001).

CONCLUSIONS

This retrospective study showed that Italian administration of adjuvant RT for EC is in accordance with current international guidelines. IRT alone for low-risk patients and EBRT associated with vaginal IRT remain standard adjuvant approaches for EC.

Disparities in Endometrial Cancer Mortality: Will Increasing Use of Targeted Therapies Widen the Gap?

IMPORTANCE

Incidence and mortality in endometrial cancer (EC) have been steadily increasing in the United States over the past two decades, with Black women experiencing disproportionately higher rates of advanced disease and cancer mortality. Recent treatment advances show promising improvements in EC survival, but as seen in other malignancies, access to and clinical benefits of these novel therapies are often not equitably shared.

OBSERVATIONS

In some gynecologic malignancies such as ovarian cancer, Black women are less likely than White women to receive targeted therapies for treatment of their disease. The reasons for this are multifactorial and include higher medication costs, decreased rates of insurance coverage, lower median income, lower rates of clinical trial enrollment, and lack of social support among Black patients. Several studies have examined racial differences in molecular tumor classification in EC, and these have shown that Black women are at least equally eligible for use of immunotherapy on the basis of tumor classification alone.

CONCLUSION AND RELEVANCE

Immunotherapy is a recent addition to treatment of some advanced and recurrent ECs. On the basis of these findings alone, use of immunotherapy should be increased among Black patients given their higher rates of advanced disease at diagnosis. Yet trends in treatment of other malignancies raise concerns that Black patients may not have adequate access to targeted and immunotherapy agents for treatment of EC in the coming years.

Platinum free interval and clinical benefit of the second-line chemotherapy in recurrent uterine and ovarian carcinosarcoma: a retrospective cohort analysis

OBJECTIVE

Uterine and ovarian carcinosarcomas (OCSs) are rare and aggressive neoplasms. We assessed whether progression free survival after initial treatment (PFS1) was associated with the clinical benefit of chemotherapy after progression, estimated as overall survival (OS) after progression/relapse.

METHODS

All consecutive patients treated with chemotherapy for stage I-IV uterine/OCS in Cochin University Hospital between 2010 and 2022 were included in this retrospective cohort. Association between PFS1 and OS after progressive disease (PD) was determined by Cox regression. Optimal PFS1 threshold for OS after PD prediction was determined by a time-dependent receiver operating characteristic-curve analysis.

RESULTS

Forty patients treated for endometrial (n=32) or OCS (n=8) were included. Median PFS1 and OS after PD were 16 months 95% confidence interval (95% CI=11-not available [NA]) and 6 months (95% CI=2-15). In patients who relapsed/progressed (n=20), OS after PD was anticipated by PFS1 (Pearson r=0.61; area under the curve=0.79; 95% CI=0.6-1). At the threshold of PFS1 ≤/>9 months (n=6/n=7), median OS post PD were 2 months (0.1-NA) and 15 months (6-NA), for patients treated with platinum/anthracycline based chemotherapy in second line. Patients receiving best supportive care alone (n=7) had a median OS post PD of 8 months (1.3-NA).

CONCLUSION

Our results highlight that a subgroup of carcinosarcomas patients exhibits a durable benefit from chemotherapy in the relapse settings, and suggest the use of PFS1, as a proxy of platinum-sensitivity, to select patients who might derive higher clinical benefit of a 2nd line of chemotherapy.

Low-Grade Endometrial Cancer with Abnormal p53 Expression as a Separate Clinical Entity: Insights from RNA Sequencing and Immunohistochemistry

Background: A molecular classification of endometrial cancer was developed based on an analysis of The Cancer Genome Atlas. In this classification, the group characterized by abnormal p53 immunohistochemical expression showed the poorest prognosis. However, there may be no need to apply a molecular classification in low-grade endometrial cancer. In this study, we investigated the clinical significance of abnormal p53 immunohistochemical expression in low-grade endometrial cancer. Methods: We obtained nine frozen samples of endometrial cancer [low-grade endometrial cancer with wild-type p53 expression (EClop53wt group): n = 3, low-grade endometrial cancer with abnormal p53 expression (EClop53ab group): n = 3, and high-grade endometrial cancer (EChi group): n = 3]. RNA sequencing was performed for each sample. All the samples passed RNA quality control. In addition, an immunohistochemical analysis was performed for 44 formalin-fixed paraffin-embedded samples. Results: Differentially expressed genes were identified in the RNA sequencing results (1811 genes between the EClop53ab group and the EChi group, and 1088 genes between the EClop53ab group and the EClop53wt group). In a principal component analysis, the EClop53ab group was more similar to the EClop53wt group than to the EChi group. In the immunohistochemical analysis, L1CAM expression was significantly less frequently observed in the EClop53ab group than in the EChi group. Moreover, p21 expression tended to be more frequently observed in the EClop53ab group than in the EChi group. Conclusions: In this study, the RNA sequencing and immunohistochemical results revealed that the EClop53ab group is a separate entity from the EChi group. While the abnormal p53 group is considered the most prognostically unfavorable in molecular classification, these findings suggest that routine molecular profiling is not necessary for patients with low-grade endometrial cancer. However, there is insufficient evidence to modify adjuvant treatment in low-grade endometrial cancer patients. Further investigation is needed on the clinical application of molecular classification to low-grade endometrial cancer.

Updates and controversies in the management of uterine serous carcinoma and uterine carcinosarcoma

Uterine serous carcinoma and uterine carcinosarcoma are among the rarest but most lethal endometrial cancer sub-types, accounting for 15% of all cases, and are responsible for more than 50% of related deaths. These malignancies are distinguished by a high likelihood of metastasis and multisite recurrence, making them biologically different from other endometrial cancer sub-types. This review aims to analyze the existing evidence regarding molecular classification, new biomarkers, and innovative treatment approaches for these high-risk tumors. Herein, we explored the role of biomarkers, including HER2, TP53, and mismatch repair deficiency/microsatellite instability hypermutated and their influence on treatment strategies, surveillance approaches, the potential role of circulating tumor deoxyribonucleic acid, novel precision-based treatment options, and disparate survival outcomes for non-Hispanic Black and other underserved minority patients, along with strategies to improve outcomes for these patients. Substantial progress has been made in the last 5 years, prompting the following question: What lies ahead in the next 5 years? Our current understanding of uterine serous carcinoma and carcinosarcoma underscores the necessity of continuing to prioritize biomarker-driven therapies and the development of novel treatments through clinical trials while integrating these new strategies with traditional approaches, such as surgical resection and cytotoxic chemotherapy.

Initiation of molecular testing of endometrial carcinomas in a population-based setting: practical considerations and pitfalls

AIMS

Since the publication of The Cancer Genome Atlas (TCGA) molecular Classification of endometrial carcinomas in 2013, multiple studies have demonstrated the prognostic and therapeutic importance of this. However, there is great variability on whether and how this is undertaken in different institutions, and this is often dependent on resources and availability of molecular testing. Points of controversy include whether molecular classification is needed on all endometrial carcinomas and whether pure molecular testing is undertaken or a surrogate such as the ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) Classifier. Herein we report our experience instigating molecular classification of endometrial carcinomas in Northern Ireland.

METHODS AND RESULTS

From 1st March 2023, all endometrial carcinomas diagnosed on biopsy in the four pathology laboratories in Northern Ireland were referred to the central molecular pathology laboratory for genomic analysis using a custom next-generation sequencing (NGS) panel; the NGS panel included the entire coding regions of polymerase epsilon (POLE) and TP53 genes, as well as microsatellite instability (MSI) analysis. All cases also underwent immunohistochemical staining with oestrogen receptor (ER), p53, and the mismatch repair (MMR) proteins MLH1, PMS2, MSH2, and MSH6. The molecular results were available by the time of surgery (if a hysterectomy was performed) allowing integration into the final pathology report where a TCGA molecular type was assigned. Two hundred and sixty-seven endometrial carcinomas underwent molecular testing; in five cases, there was insufficient material for testing, leaving 262 cases. The TCGA groups were POLEmut (19; 7.3%), MMRd (63; 24%), p53abn (62; 23.7%), and no specific molecular profile (NSMP) 118 (45%). Seventeen tumours (6.5%) were "multiple-classifiers": five POLEmut-p53abn, two POLEmut-MMRd, one POLE-MMRd-p53abn (all included in the POLEmut TCGA group), and nine MMRd-p53abn (included in the MMRd group).

CONCLUSION

This represents one of the first population-based studies investigating the prevalence of the different TCGA molecular groups of endometrial carcinomas in an unselected population. Performing molecular testing on biopsies enables management to be tailored to the molecular group and allows integration of the TCGA group into the report of the final resection specimen. We hope our experience will facilitate other laboratories in undertaking TCGA molecular classification.

Proteomic Changes Associated With Endogenous FBXW7 Mutations in Moderately Differentiated Endometrial Cancer Cells Include Increased TROP2 and Galectin-3 Levels

BACKGROUND

Endometrial cancer (EC) is the fourth most commonly diagnosed cancer among women in the US and the fifth leading cause of cancer death in this population. The FBXW7 tumor suppressor gene is frequently mutated in all molecular subtypes of EC. The encoded protein is part of a ubiquitin ligase complex that targets substrate proteins for ubiquitination and, in most instances, proteasome-mediated degradation.

AIMS

The purpose of this investigation was to identify the proteomic changes associated with endogenous FBXW7 mutations in EC.

MATERIALS & METHODS

Quantitative LC-MS/MS was used to identify significant (p < 0.05) differences in the proteomes and phosphoproteomes of two FBXW7-mutated EC cell lines, HEC-1-BFBXW7-R367X and JHUEM-1FBXW7-R505C, as compared to isogenic mutation-corrected cell lines. Western blotting was performed to orthogonally validate a subset of protein changes.

RESULTS

Analysis of LC-MS/MS results identified 397 total proteins and/or phosphoproteins with significantly different levels in both HEC-1-BFBXW7-R367X and JHUEM-1FBXW7-R505C, as compared to isogenic mutation-corrected cell lines. This protein set included increased levels of TROP2, galectin-3, ASS1, and PLCG2 in both HEC-1-BFBXW7-R367X and JHUEM-1FBXW7-R505C cells; these perturbations orthogonally validated by western blotting.

CONCLUSION

This study provides novel insights into the proteomic and phosphoproteomic effects of the endogenous FBXW7-R367X and FBXW7-R505C mutations in EC cells, including increased levels of galectin-3, a potentially druggable target, and of TROP2, which is a druggable target in EC.

Immunotherapy for endometrial cancer

Advanced recurrent endometrial cancer (EC) has a poor prognosis and new treatment options are needed. In 2013, EC was classified by genomic analysis into four groups: the POLE ultra-mutated group, the MSI-high hypermutated group (MSI-H), the copy number low group, and the copy number high group. The prognosis differs based on the classification, which should enable the individualization of treatment. The MSI-H and POLE types can induce PD-L1 expression in cancer cells. Among the gynecological cancers, EC exhibits the highest levels of PD-1 and PD-L1 expression and has the highest proportion of MSI-H. Thus, an immune checkpoint inhibitor (ICI) is expected to be effective. The first ICI to show efficacy in recurrent EC was the anti-PD1 antibody pembrolizumab, which exhibited efficacy in MSI-H EC. The combination of pembrolizumab and the multi-kinase inhibitor lenvatinib significantly prolongs OS/PFS compared with single-agent chemotherapy in previously treated recurrent EC, regardless of MSI status. ICIs are now moving from second-line and beyond to first-line treatment regimens. The efficacy of paclitaxel plus carboplatin (TC) and ICI combinations compared with TC have been demonstrated, including an ongoing Phase III trial comparing chemotherapy with the combination of pembrolizumab and lenvatinib. Although ICIs are becoming the mainstay of EC, they cause systemic inflammatory side effects known as irAEs. The incidence of irAEs is higher for combination therapy with CT or lenvatinib compared with ICI therapy alone. Even though they are rarely fatal, irAEs should be addressed promptly.

Development of Antibody-Drug Conjugates for Malignancies of the Uterine Corpus: A Review

Despite recent advances in cancer treatment, the prognosis for uterine malignancies (carcinoma and sarcoma) requires further improvement. Antibody-drug conjugates (ADCs) have emerged as a novel class of anti-cancer therapeutic agents, and multiple ADCs have been approved for other types of cancer. In 2024, trastuzumab deruxtecan received approval from the US Food and Drug Administration for cancer types and became the first ADC approved for the treatment of uterine malignancies. Many ADCs are currently being investigated in uterine malignancies, and therefore, there is a need to gain a deeper understanding of ADCs. In this article, we aim to provide a comprehensive overview of the advancements in ADCs. The contents of this article include the structure and mechanism of action, an analysis of recent clinical trials, and expected future clinical questions. This article also focuses on uterine sarcoma, which is not often highlighted as a target for ADC treatment.

Olaparib combined to metronomic cyclophosphamide and metformin in women with recurrent advanced/metastatic endometrial cancer: the ENDOLA phase I/II trial

Endometrial cancers are characterized by frequent alterations in the PI3K-AKT-mTor, IGF1 and DNA repair signaling pathways. Concomitant inhibition of these pathways was warranted. ENDOLA phase I/II trial (NCT02755844) was designed to assess the safety/efficacy of the triplet combination of the PARP inhibitor olaparib, metronomic cyclophosphamide (50 mg daily), and PI3K-AKT-mTor inhibitor metformin (1500 mg daily) in women with recurrent endometrial carcinomas. Olaparib dose-escalation (100-300 mg twice-a-day (bid)) was used to determine the recommended-phase II-trial-dose (RP2D, primary endpoint), followed by an expansion cohort to determine the non-progression rate at 10 weeks (NPR-10w, secondary endpoint). 31 patients were treated. Olaparib RP2D was defined as 300 mg bid. The tolerability was acceptable, and grade 3-4 adverse events (51% patients) were mainly hematological. The NPR-10w was 61.5%, and the median progression-free survival (mPFS) was 5.2 months. In a post-hoc analysis, when explored by molecular subtypes/alterations, longer PFS were observed in patients with tumors characterized by a non-specific-molecular-profile (NSMP, n = 4; mPFS, 9.1 months), and by both TP53 altered & high number of large genomic alterations (LGA ≥ 8)(n = 10, mPFS, 8.6 months)). The analyses about kinetics of circulating biomarkers and pharmacodynamic effects are not reported here. In total, the benefit/toxicity ratio of the all-oral olaparib/cyclophosphamide/metformin regimen was favorable in heavily pretreated patients with recurrent endometrial cancer.

Diagnostic Value of ADC in Distinguishing Endometrial Cancer from Atypical Endometrial Hyperplasia and Within Molecular Subtypes

Purpose

The study aimed to evaluate the effectiveness of using specific indicators, particularly the apparent diffusion coefficient (ADC), alone or in combination to differentiate endometrial cancer (EC) from atypical endometrial hyperplasia (AEH) and to explore non-invasive biomarkers for the molecular classification of EC.

Methods

A retrospective analysis was conducted on 300 EC and 126 AEH cases who had undergone preoperative magnetic resonance imaging, complete blood count, coagulation profile testing, and tumor biomarkers assessment. Postoperative molecular classification was conducted on 76 EC samples. Diagnostic values were assessed using receiver operating characteristic (ROC) analysis and binary logistic regression with forward selection to determine the optimal indicator combinations. Furthermore, this study evaluated the variability of parameters across EC molecular subtypes.

Results

The ADC effectively balanced sensitivity and specificity in differentiating EC from AEH. An optimal diagnostic model including age, fibrinogen, and ADC achieved the area under the curve (AUC) of 0.9143, with 84.67% sensitivity and 88.89% specificity. ADC values were found to be lower in EC cases that exhibited a higher Ki-67 index or a higher histological grade. Notably, the NSMP subtype presented significantly higher ADC values compared to the other three molecular subtypes. The p53abn subtype exhibited the highest prevalence of abnormal HE4 levels and patients aged ≥65 (both 6/12, 50%) yet normal CA125 and CA19-9 levels.

Conclusion

This retrospective study demonstrated that ADC, especially when combined with age and fibrinogen, is a valuable biomarker for distinguishing EC from AEH. In addition to indicating the Ki-67 index and histological grade, ADC values also serve as a promising tool for identifying the NSMP subtype within EC. Future studies should focus on multi-center, prospective studies with larger sample sizes to validate and refine the diagnostic value of ADC in differentiating EC from AEH, as well as in the molecular classification of EC.

Uterine Carcinosarcoma-A Retrospective Cohort Analysis from a Tertiary Centre on Epidemiology, Management Approach, Outcomes and Survival Patterns

BACKGROUND/OBJECTIVES

Uterine carcinosarcoma (UCS) refers to a rare high-grade aggressive epithelial non-endometrioid endometrial carcinoma, with tumour cells demonstrating epithelial-mesenchymal metaplastic transition and composed of both carcinomatous epithelial and sarcomatous (homologous or heterologous) components.

METHODS

The aim of this study was to evaluate the epidemiology, management approach, outcomes and survival patterns of patients with UCS. Seventy-seven cases of UCS treated with primary surgery in a single tertiary centre underwent retrospective cohort analysis across a ten-year period. Observational data on clinicopathological variables and treatment pathways were reviewed and independent risk factors for relapse and mortality were analysed.

RESULTS

The 5-year disease-free and overall survival rates were 52.10% and 46.6%, respectively. Cervical stromal involvement was independently related to disease-free survival (HR = 6.26; 95%CI 1.82-21.59; p = 0.004) and overall survival (HR = 3.64; 95%CI 1.42-9.38; p = 0.007), whilst sarcomatous component type was independently related to recurrence only (HR = 3.62; 95%CI 1.38-9.51; p = 0.009) after adjusting for other pathological and treatment variables. No significant difference in recurrence or mortality was found when comparing the performance of pelvic lymph node dissection (p = 0.803 and p = 0.192 respectively) or the administration of adjuvant treatment (p = 0.546 and p = 0.627 respectively).

CONCLUSIONS

Whilst our data suggests an encouraging similarity in overall survival rates compared with the literature, UCS continues to represent significant treatment challenges-with a paucity of guidelines available. Data regarding molecular analysis was not systemically available in our cohort, the more recent introduction of which (alongside the revision of endometrial cancer staging) will undoubtedly provide UCS patients with improved therapeutic options in the future.

Molecular characterization of mixed-histology endometrial carcinoma provides prognostic and therapeutic value over morphologic findings

We performed molecular analysis of a single-institution cohort of clinically diagnosed mixed-histology endometrial carcinoma (MEC). A gynecologic pathologist confirmed that 72 cases met diagnostic criteria for MEC based on WHO 2020 guidelines, and these were molecularly classified using both a DNA-based and histologic approach. Tumors were classified as: POLE-mutated (13.9%), microsatellite instability (MSI)-high/mismatch repair deficient (MMRd) (26.4%), TP53/p53 abnormal (p53abnl) (48.6%), no specific molecular profile (NSMP) (11.1%). Recurrence risk significantly differed based upon molecular class, but not histology. 44% of MEC cases had a HER2 IHC score of 2-3+, and this was not limited to p53abnl tumors. Transcriptional analysis demonstrated 93 differentially expressed genes between p53abnl and NSMP tumors, including many associated with the innate immune response and DNA damage repair. While p53abnl and NSMP tumors have similarly poor outcomes, transcriptome analysis revealed biologic differences that could impact targeted therapeutics in this high-risk group.

The impact of integrated genomic analysis on molecular classifications and prognostic risk stratification in endometrial cancer: a Chinese experience

Background

The molecular classification of endometrial cancer (EC), as proposed by The Cancer Genome Atlas (TCGA), has transformed tumor classification, but there is a lack of extensive research on the molecular profiles and subtyping of endometrial cancer patients in China.

Methods

200 EC patients were classified into the following four molecular types: (i) POLEmut; (ii) MSI-H; (iii) TP53mut; (iv) NSMP. This study aimed to investigate the molecular characteristics of EC patients at a single center by large-scale next generation sequencing(NGS), including clinicopathological features and gene mutations in patients with distinct molecular types, and to assess the relevance of molecular subtyping for postoperative adjuvant therapy.

Results

NSMP group was the most prevalent, comprising 46.0% (92/200) of cases, followed by the TP53mut group at 17.5% (35/200), the MSI-H group at 23.5% (47/200), and the POLEmut group at 13.0% (26/200). CTNNB1 mutations were common in the POLEmut group but rare in the TP53mut group. With the application of the new European Society for Medical Oncology (ESMO) 2022 classification, 27 patients (14.1%) were reclassified. Concordance between the two classifications regarding postoperative risk was observed in 85.9% (165/192) of cases. Seven patients (3.6%) were downstaged, and twenty patients (10.4%) were upgraded. Additionally, the analysis revealed that eleven genes were significantly mutated in patients with lymphovascular space invasion (LVSI) compared to those without LVSI. Notably, NSD3 and POLD1 were highly mutated in patients with lymphatic metastasis compared to those without lymphatic metastasis. Conclusively, large-scale NGS has revolutionized EC management by facilitating rapid molecular subtype identification, guiding tailored adjuvant therapies, targeted treatments, and immunotherapies, and efficiently screening for Lynch syndrome, thereby significantly improving patient outcomes.

Treatment strategies for advanced and recurrent endometrial cancer using immune checkpoint inhibitors

Doxorubicin + cisplatin and paclitaxel + carboplatin are standard chemotherapy regimens for endometrial cancer. The development of PD-1 and PDL-1 antibody drugs has led to the use of these agents for endometrial cancer in other countries. The KEYNOTE-775 trial for advanced or recurrent endometrial cancer demonstrated the benefits of pembrolizumab and lenvatinib combination therapy, and the results of this trial led to the approval of its coverage for recurrent cancer by the Japanese health insurance system. Currently, treatment with immune checkpoint inhibitors is transitioning from second-line to first-line therapy. In a global randomized phase III study, the drugs dostarlimab, durvalumab, and atezolizumab, which are not yet approved in Japan, showed better results in the study arms than in the control arm. Additionally, biomarkers have been developed for endometrial cancer, enabling gynecologists to pursue treatment options based on the biomarkers detected for better treatment outcomes. In this article, we review the clinical trials of immune checkpoint inhibitors for advanced or recurrent endometrial cancer.

Molecular classification of endometrial cancers (EC) and association with relapse-free survival (RFS) and overall survival (OS) outcomes: Ancillary analysis of GOG-0258

PURPOSE

Determine if molecular classification using mismatch repair (MMR) and p53 protein expression predicts recurrence-free survival (RFS) and overall survival (OS) in endometrial cancer (EC) patients treated with chemotherapy and radiation (CRT) versus chemotherapy (CT).

METHODS

GOG-0258, a phase III randomized trial (NCT00942357), compared CRT to CT. Immunohistochemistry assessed MMR and p53 status. Kaplan-Meier curves and adjusted Cox models analyzed survival outcomes by molecular subtype.

RESULTS

ECs classified as deficient MMR (dMMR) (27 %), p53 abnormal (p53abn) (24 %), and p53 wild type (p53wt) (49 %). p53abn were more frequent in patients that were older, Black, and had serous histology (p < 0.001). Median follow up was 113 months. Five-year RFS and OS were worse with p53abn (29 % [Hazard Ratio (HR) = 3.39 (95 % Confidence Interval (CI): 2.34-4.91)] and 39 % [HR = 4.64 (95 % CI: 3.16-6.79)] compared to those with p53wt (referent) (p < 0.001). The five-year RFS and OS for dMMR cancers were (58 % [HR = 1.30 (95 % CI: 0.85-1.97)] and 77 % [HR = 1.53 (95 % CI: 0.99-2.36)] compared to those with p53wt (69 % and 85 %). After adjusting for age, gross residual disease, and treatment, p53wt improved RFS with CRT compared to CT in an exploratory analysis (77 % vs 60 %; HR = 0.54 (95 % CI: 0.32-0.94). The 5-year and 10-year OS rates were similar in CRT compared to CT in all subgroups.

CONCLUSION

Molecular classification appears to be predictive and prognostic, with worse survival in those with p53abn tumors. In an exploratory analysis, p53wt appears to predict improved RFS, favoring CRT over CT. There was no difference in treatment efficacy based on molecular subtype for OS.

The advent of immune checkpoint inhibition for the treatment of patients with primary advanced or recurrent dMMR/MSI high endometrial cancer in 2025

PURPOSE OF REVIEW

The Cancer Genome Atlas identified four distinct molecular subtypes of endometrial cancer (EC): POLE mutated, mismatch repair deficient (dMMR), copy number low, and copy number high. The goal of this review is to summarize the profound clinical implications of molecular subtyping, particularly in guiding treatment decisions for dMMR and microsatellite instability high (MSI-H) EC.

RECENT FINDINGS

Clinical trials have demonstrated the remarkable efficacy of immunotherapy in dMMR/MSI-H EC tumors. Trials including GARNET, KEYNOTE-158, NRG GY-018, and RUBY have shown significant improvements in clinical outcomes for patients with advanced and recurrent disease, leading to FDA approvals for immunotherapy in both frontline and recurrent EC treatment settings.Building on these successes, recent studies, including DUO-E, are exploring combination therapies to enhance the efficacy of immunotherapy in EC. Simultaneously, trials including NRG GY-020, are investigating the potential benefits of immunotherapy in early-stage disease.

SUMMARY

Immunotherapy therapy has revolutionized the treatment of endometrial cancer in both upfront and recurrent settings, with molecular subtyping identifying patients most likely to benefit, especially those with dMMR/MSI-H tumors.

A fully next-generation sequencing-based method of classifying molecular sub-types of endometrial cancer retains prognostic value and expands biomarker targets

OBJECTIVE

The molecular classification of endometrial cancer into POLE-ultra-mutated, mismatch repair-deficient, p53-mutated, and no specific molecular profile sub-types has significant prognostic value and is recommended in the evaluation of all patients with endometrial cancer. Nonetheless, there has been inconsistent clinical implementation. One possible barrier is the current practice of using several different assays, each with its own result, that subsequently need to be integrated. We developed a single, fully next-generation sequencing (NGS)-based assay that sub-types endometrial samples and evaluated it against an existing algorithm.

METHODS

Molecular sub-typing was retrospectively performed on 142 formalin-fixed, paraffin-embedded endometrial cancer samples using a clinically validated NGS panel targeting 133 genes and additional loci for micro-satellite instability and tumor mutational burden. In parallel, these same samples were classified by the World Health Organization algorithm using mismatch repair and p53 immunohistochemistry, and POLE sequencing. Concordance between algorithms was assessed, and the prognostic value of each was evaluated. We further explored racial disparities in outcomes and assessed other prognostic and potentially therapeutic biomarkers.

RESULTS

The sequencing-based method was highly concordant with the World Health Organization algorithm (136/142 patients, Cohen's κ = 0.94) and retained prognostic value, with a significant difference in overall survival and progression-free survival by sub-type, and similar stratification to that initially identified in The Cancer Genome Atlas analysis. In addition, 11 cases had sequence variants in the previously established prognostic biomarker CTNNB1, and 3 cases had potentially targetable sequence variants in ERBB2. Endometrial cancer outcomes in Black individuals were worse, in part owing to the increased incidence of sub-types with a poor prognosis.

CONCLUSIONS

A fully sequencing-based assay streamlines molecular classification of endometrial cancer and retains the prognostic value of other validated methods, which may aid clinical implementation. The additional genomic information obtained with an NGS panel, beyond the classification markers, can broaden potentially applicable therapies.

Serum CA125 levels in the context of ProMisE molecular classification provides pre-operative prognostic information that can direct endometrial cancer management

OBJECTIVE

Previous research suggests serum CA125 reflects extra-uterine disease in patients with endometrial carcinoma (EC). Our objective was to determine if CA125 can identify patients with extra-uterine and/or nodal metastases, the association of this biomarker with EC molecular subtype, and to explore an optimal cutoff in this context.

METHODS

We assessed the association of CA125 levels with clinicopathologic and outcomes data on a cohort of 1107 molecularly classified EC.

RESULTS

Abnormal CA125 (>35kU/L) was associated with higher stage and lymph node metastases (LNM) in all EC and in each molecular subtype on univariate (p < 0.01) and multivariate (p < 0.05) analyses. POLEmut had the lowest median CA125 level and proportion of CA125 abnormal patients, and p53abn the highest proportion (p < 0.001). CA125 > 35 kU/L had a sensitivity of 0.82, specificity 0.53, positive-predictive-value 0.92, and negative-predictive-value 0.31 for LNM, with similar values for stage>I. CA125 > 35 kU/L was associated with worse overall (OS), disease-specific (DSS), and progression-free survival (PFS) in all EC, p53abn (OS, DSS, PFS), NSMP (OS, DSS), and MMRd (OS, DSS) subtypes. CA125 > 35 kU/L demonstrated a relative risk (RR) of 2.50 with presence of stage III/IV disease (p < 0.001) and RR 18.4 for the presence of synchronous endometrial and ovarian carcinomas (SEOC)/co-existing adnexal malignancies (CAM) (p < 0.001). An exploratory cut point, optimized for correlation with DSS (CA125 > 24 kU/L) show similar association with clinical parameters and survival outcome.

CONCLUSIONS

CA125 levels are associated with molecular subtype, stage>I disease, and SEOC/CAM. CA125 remains a useful clinical tool in the triage of EC in the era of molecular classification.

Added prognostic value of sentinel lymph node mapping in endometrial cancer to molecular subgroups

OBJECTIVE

Treatment approaches for endometrial cancer became more personalized in the last decade, mainly due to two key advancements - sentinel lymph node (SLN) mapping and molecular classification. However, their prognostic interaction remains relatively unexplored.

METHODS

This retrospective cohort study included patients with endometrial cancer, who underwent surgical treatment including SLN mapping at the Bern University Hospital, Switzerland. Ultrastaging of the SLNs and a molecular analysis on the primary tumor was performed.

RESULTS

The study cohort included 206 patients, of which 197 tumor samples underwent molecular classification. 11.2 % were classified as POLEmut, 25.9 % as MMRd, 46.2 % as NSMP, and 16.8 % as p53abn. Overall, 834 SLN were removed. SLN macrometastasis were most prevalent in patients with p53abn tumors (24.2 %), followed by MMRd (13.7 %), NSMP (5.5 %), and POLEmut (0 %) tumors (p = .006). Mean follow-up time was 70.9 months. SLN macrometastasis was significantly associated with a higher risk of recurrence in the entire study cohort (p > .001) and the NSMP subgroup (p > .001). In the MMRd subgroup, SLN macrometastasis remained a significant predictor of recurrence (p = .030) and disease-specific death (p = .047) in multivariate Cox regression analysis. For patients with p53abn endometrial cancer, there was no association between SLN macrometastasis and risk of recurrence (p = .618) or disease specific death (p = .798).

CONCLUSIONS

SLN macrometastasis is an independent predictor of recurrence and disease-specific death in patients with MMRd endometrial cancer. In the subgroup of p53abn endometrial cancers, SLN macrometastasis did not have an added impact on oncological outcome.

Cervical stromal invasion and molecular characterization in stage II-IV endometrial cancers

OBJECTIVE

The optimal treatment for patients with cervical stromal invasion (CSI) in endometrial cancer (EC) remains unclear. We aimed to test the prognostic role of molecular classification in EC patients with CSI.

METHODS

A retrospective, multicenter review of EC patients with CSI was performed. EC cases were assigned to one of the molecular classes: POLE mutated (POLEmut), MMR deficient (MMRd), p53 abnormal (p53abn), or no specific molecular profile (NSMP). Three-year recurrence-free survival (RFS) from surgery was estimated using the Kaplan-Meier method. Cox proportional hazards regression models were fit to adjust for confounders.

RESULTS

Overall, 162 EC patients with CSI were identified: 70 (43.2 %) NSMP, 49 (30.2 %) p53abn, 40 (24.7 %) MMRd, 3 (1.9 %) POLEmut. POLEmut cases were excluded from further analysis, because of the small number of patients identified. At univariate analysis, molecular class was significantly associated with recurrence within 3 years after surgery (p = 0.04). Three-year RFS was 59.9 % (95 % confidence interval [CI], 46.1-77.8 %) for NSMP, 50.6 % (95 % CI, 34.9-73.2 %) for MMRd, and 33.1 % (95 % CI, 19.7-55.3 %) for p53abn. After adjusting for stage and grade, molecular class was no longer significantly associated with recurrence within three years (p = 0.28).

CONCLUSIONS

Traditional risk factors such as grade and stage remain critical in determining the prognosis of endometrial cancer with cervical stromal invasion. This study highlights the importance of integrating both molecular and morphological features in determining the prognosis of endometrial cancer, with particular emphasis on endometrioid histotypes.

Meta-analysis of the ability of mutational profiles on the cancer genome atlas to predict prognosis in endometrial carcinoma

BACKGROUND

In 2013, The Cancer Genome Atlas Research Network suggested that endometrial carcinoma patients may be reclassified into four molecular prognostic groups.

OBJECTIVE

To compare survival of endometrial carcinoma patients with different mutational profiles.

SEARCH STRATEGY

Studies reporting survival of endometrial carcinoma patients were identified through systematic searches of four databases.

SELECTION CRITERIA

We included relevant studies based on the literature type, data integrity and the methodological quality.

DATA COLLECTION AND ANALYSIS

The pooled survival data were compared among patients with different mutational profiles. Heterogeneity in the pooled data was assessed using the I2 statistic.

MAIN RESULTS

Data were meta-analyzed from nine studies involving 4755 patients, who were classified into the following mutational profiles: p53abn, 745 patients (15.6%); MMRd, 1454 patients (30.6%); POLEmut, 351 patients (7.4%); and p53wt, 2205 patients (46.4%). Compared to the p53wt group, the p53abn group showed significantly worse overall survival (OS) (HR 2.31, 95% CI: 1.67-3.19), progression-free survival (PFS) (HR 2.86, 95% CI: 1.45-5.64) and disease-specific survival (HR 2.60, 95% CI: 1.41-4.79); and the MMRd group showed significantly worse OS (HR 1.30, 95% CI: 1.11-1.53) and PFS (HR 1.27, 95% CI: 1.01-1.59). The POLEmut group, in contrast, showed similar survival as the p53wt group.

CONCLUSIONS

The four mutational profiles for patients with endometrial carcinoma in the Cancer Genome Atlas for Endometrial Cancer are associated with worse to better survival in the trend: p53abn < MMRd < POLEmut ≈ p53wt. Mutational profiling may be useful for stratifying endometrial carcinoma patients by survival risk, which in turn may improve their management.

Prognostic values of molecular subtypes and SWI/SNF protein expression in de-differentiated/undifferentiated endometrial carcinoma

AIMS

Classification and risk stratification of endometrial carcinoma (EC) has transitioned from histopathological features to molecular classification, e.g. the ProMisE classifier, identifying four prognostic subtypes: POLE mutant (POLEmut) with almost no recurrence or disease-specific death events, mismatch repair deficient (MMRd) and no specific molecular profile (NSMP), with intermediate outcome and p53 abnormal (p53abn) with poor outcomes. However, the applicability of molecular classification is unclear in rare but aggressive histotypes of EC, e.g. de-differentiated and undifferentiated endometrial cancers (DD/UDEC). Here, we aim to assembled a cohort of DD/UDEC from a single institution and analysed the prognostic significance of ProMisE molecular subtypes and the expression of SWItch/sucrose non-fermentable (SWI/SNF) chromatin remodelling complex members, previously implicated in the pathogenesis of DD/UDEC.

METHODS AND RESULTS

We accrued 88 DD/UDEC cases, assessed POLE status by Sanger sequencing and performed immunohistochemistry for p53, mismatch repair and SWI/SNF proteins on the tissue microarrays assembled. Assignment of molecular subtypes was possible in 80 tumours; POLE sequencing failed in the remaining eight cases. There were 12 (15%) POLEmut, 44 (55%) MMRd, 14 (17.5%) p53abn and 10 (12.5%) NSMP DD/UDEC. POLEmut DD/UDECs had excellent outcomes, but the other three molecular subtypes all had poor outcomes, with no significant differences among them. The loss of one or more SWI/SNF proteins [AT-rich interactive domain-containing protein 1A (ARID1A), ARID1B, SWI/SNF-related, matrix-associated, actin-dependent regulator of chromatin, subfamily A, member 4 (SMARCA4), SMARCA2], observed in 66% (55 of 83) cases, was not of prognostic significance.

CONCLUSIONS

These results indicate that all molecular subtypes of DD/UDEC except POLEmut behave in an aggressive fashion. Further study is needed to determine whether these molecular alterations can be targeted with adjuvant therapy, in order to improve outcomes of patients with DD/UDEC.

Analysis of Differences in the Classification of Endometrial Cancer Patients in Poland

Background: Endometrial cancer (EC) incidence and mortality have been steadily rising globally over recent decades. The introduction of advanced molecular technologies, such as next-generation sequencing (NGS) alongside the FIGO 2023 classification, presents opportunities for refined diagnostics and risk stratification. This study aimed to analyze differences in EC classification among oncology centers in southeastern Poland. Methods: Data were collected from 461 consecutive patients newly diagnosed with EC between 2022 and 2024 at four major oncology centers in southeastern Poland. Molecular and immunohistochemical (IHC) analyses were conducted on formalin-fixed paraffin-embedded (FFPE) tissues to identify key markers, including POLE mutations, MSI-H, and p53 status. Results: The application of the FIGO 2023 staging system revealed statistically significant inter-center differences, with Centers 1 and 4 diagnosing a higher proportion of early-stage cases. The most prevalent subtype was NSMP, observed in 51% of cases. MSI-H occurred in 13-36% of patients, depending on the center. p53 mutations ranged from 9% to 26%. POLE mutations were identified in 4% of patients overall. Significant variations in the molecular subtype distribution across centers highlight potential differences in diagnostic access or tumor biology. Conclusions: The findings demonstrate regional differences in EC staging and molecular profiles in Poland, potentially reflecting disparities in diagnostic resources, methodologies, or tumor characteristics. Addressing these variations through standardized diagnostic protocols and equitable access to molecular tools is critical for optimizing patient outcomes. Future research should focus on evaluating the impact of molecular markers on therapy response and prognosis to guide personalized treatment strategies.

Meta-analysis of the clinicopathologic features of endometrial cancer molecular staging

Objective

The 2013 TCGA identified four molecular subgroups of endometrial cancer; however, the data results for most of the pathological features were varied and of low value for clinical application. Therefore, a meta-analysis of articles related to the clinicopathological features of molecular typing was performed to observe how the prevalence of the four subgroups varied across different pathological features and whether they were associated with certain specific pathological features and to understand how molecular typing may influence current pathological assessments.

Methods

PubMed, Embase, Web of Science, CNKI, Wanfang, and VIP were searched from the time of library construction until May 2024, and the following data were extracted: histological type, FIGO grade, FIGO stage, LVSI, depth of muscularis propria infiltration, and lymph node status of each TCGA group. Two reviewers used the Cochrane Diagnostic Research Scale assessment, and the data were analyzed using Review Manager 5.4.1 and Stata 14.0.

Results

Fourteen diagnostic research papers were included in this study, with a total of 4,776 patients with endometrial cancer. Non-estrogen-related endometrial carcinoma (NEEC) vs. estrogen-related endometrial carcinoma (EEC) was low in polymerase epsilon (POLE) (OR = 0.49), microsatellite instability (MSI) (OR = 0.45), and copy number low (CNL) (OR = 0.11), while it was high in CNH (OR = 26.76). G3 EEC vs. G1-2 EEC POLE (OR = 1.98), MSI (OR = 1.74), and CNH (OR = 5.57) were high, whereas it was low in CNL (OR = 0.23), low in FIGO II-IV vs. FIGO I in POLE (OR = 0.39) and CNH (OR = 0.64), and high in FIGO II-IV vs. FIGO I in CNH (OR = 3.05). There was no difference in MSI prevalence in FIGO II-IV vs. FIGO I. POLE (OR = 0.64) and CNL (OR = 0.75) were low in myometrial invasion depths ≥50% and lower in myometrial invasion depths <50%, and CNL (OR) was higher in CNH (OR) than in myometrial invasion depths <50%. There was no difference in MSI between different myometrial invasion depths. MSI (OR = 1.69) and CNH (OR = 2.12) were higher in lymphatic vascular infiltration (LVSI) vs. no LVSI; CNL (OR = 0.39) was lower in LVSI than in no LVSI. There was no difference in POLE in the presence or absence of LVSI. Lymph node metastasis with and without lymph node metastasis in POLE (OR = 0.25) and CNL (OR = 0.31) were lower, and CNH (OR = 3.06) was higher in lymph node metastasis than in no lymph node metastasis. There was no difference in MSI in the presence or absence of lymph node metastasis.

Conclusions

POLE patients predominated in pathological features of early-stage endometrial cancer and had better prognosis. MSI patients were more likely to be found in EEC and G3 EEC as well as LVSI. Nearly half of G3 EEC as well as LVSI were present in MSI patients, and CNH patients were more likely to be found to have pathological features of advanced endometrial cancer and poor prognosis, providing evidence that CNH is a high-risk cancer. Patients with CNL were more likely to be found to have pathological features of early-stage endometrial cancer and good prognosis, and CNL was present in large numbers in both early-stage and late-stage endometrial cancers. CNL does not yet have a precise prognostic value.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024563661.

Patient-reported outcomes in the subpopulation of patients with mismatch repair-deficient/microsatellite instability-high primary advanced or recurrent endometrial cancer treated with dostarlimab plus chemotherapy compared with chemotherapy alone in the ENGOT-EN6-NSGO/GOG3031/RUBY trial

OBJECTIVE

In the ENGOT-EN6-NSGO/GOG3031/RUBY trial, dostarlimab+carboplatin-paclitaxel demonstrated significant improvement in progression free survival and a positive trend in overall survival compared with placebo+carboplatin-paclitaxel, with manageable toxicity, in patients with primary advanced or recurrent endometrial cancer. Here we report on patient-reported outcomes in the mismatch repair-deficient/microsatellite instability-high population, a secondary endpoint in the trial.

METHODS

Patients were randomized 1:1 to dostarlimab+carboplatin-paclitaxel or placebo+carboplatin-paclitaxel every 3 weeks for 6 cycles followed by dostarlimab or placebo monotherapy every 6 weeks for ≤3 years or until disease progression. Patient-reported outcomes, assessed with the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Endometrial Cancer Module, were prespecified secondary endpoints. A mixed model for repeated measures analysis, a prespecified exploratory analysis, was conducted to generate least-squares means to compare between-treatment differences while adjusting for correlations across multiple time points within a patient and controlling for the baseline value. Results are provided with 2-sided, nominal p values.

RESULTS

Of 494 patients enrolled, 118 were mismatch repair-deficient/microsatellite instability-high. In this population, mean change from baseline to end of treatment showed visual improvements in global quality of life (QoL), emotional and social function, pain, and back/pelvis pain for dostarlimab+carboplatin-paclitaxel. Meaningful differences (least-squares mean [standard error]) favoring the dostarlimab arm were reported for change from baseline to end of treatment for QoL (14.7 [5.45]; p=0.01), role function (12.7 [5.92]); p=0.03), emotional function (14.3 [4.92]; p<0.01), social function (13.5 [5.43]; p=0.01), and fatigue (-13.3 [5.84]; p=0.03).

CONCLUSIONS

Patients with mismatch repair-deficient/microsatellite instability-high primary advanced or recurrent endometrial cancer receiving dostarlimab+carboplatin-paclitaxel demonstrated improvements in several QoL domains over patients receiving placebo+carboplatin-paclitaxel. The observed improvements in progression free survival and overall survival while improving or maintaining QoL further supports dostarlimab+carboplatin-paclitaxel as a standard of care in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03981796.

Understanding the impact of spatial immunophenotypes on the survival of endometrial cancer patients through the ProMisE classification

OBJECTIVES

We focused on how the immunophenotypes based on the distribution of CD8-positive tumor-infiltrating lymphocytes (TILs) relate to the endometrial cancer (EC) molecular subtypes and patients' prognosis.

PATIENTS AND METHODS

Two cohorts of EC patients (total n = 145) were analyzed and categorized using the Molecular Risk Classifier for Endometrial cancer (ProMisE): POLEmut (POLE mutation), MMRd (mismatch repair deficiency), NSMP (no specific molecular profile), and p53abn (p53 abnormality). CD8-positive TILs, within the central tumor and the invasive margin, were examined by using immunohistochemical staining and advanced image-analysis software. It was investigated whether these immunophenotypes correlate with the molecular subtypes and patients' survival. RNA-sequencing (RNA-seq) was used to explore tumor-derived factors influencing these immunophenotypes.

RESULTS

Three distinct immunophenotypes (inflamed, excluded, and desert) based on the CD8-positive TIL patterns were identified in EC patients. Notably, the inflamed phenotype was most frequently observed in the POLEmut and MMRd subtypes, while the desert phenotype was predominant in the NSMP subtype; however, other immunophenotypes were also observed. All p53abn subtype showed the non-inflamed (excluded or desert) phenotype. The prognosis was markedly poorer in the patients with the non-inflamed phenotype than in those with the inflamed phenotype. The RNA-seq analysis showed that the expression of MYC target genes and type-1 interferon response genes was enriched in the non-inflamed phenotype in MMRd and NSMP subtypes, respectively.

CONCLUSION

Evaluating not only the molecular classification but also the immunophenotype may lead to more personalized immunotherapy in EC and elucidating the mechanisms that underlie the formation of the three immunophenotypes could lead to the discovery of new immunotherapy targets.

Prognostic and therapeutic implication of molecular classification including L1CAM expression in high-risk endometrial cancer

INTRODUCTION

The role of molecular classification and L1CAM in high-risk endometrial cancer is uncertain. We aimed to determine the association of molecular profiling and L1CAM with patterns of relapse and survival.

MATERIAL AND METHODS

This retrospective cohort study included patients referred to Department for Gynecologic Oncology, Oslo University Hospital between January 1, 2006 and December 31, 2017. L1CAM expression and molecular profiling according to ProMisE was performed. Main outcome was time to recurrence (TTR) and cancer specific survival (CSS).

RESULTS

Of 489 patients, 486 could be molecular classified. Thirty-seven (8 %) had POLE mutated tumors, 148 (30 %) had MMRd tumors, 189 (39 %) had p53 abnormal tumors, and 112 (23 %) had NSMP tumors. High L1CAM expression was observed in 256 (53 %), low in 227 (46 %) tumors (6 (1 %) missing). ProMisE was significant for TTR but not for CSS in multivariable analysis. L1CAM was significant in multivariable analysis for both TTR and CSS. In a multivariable model with ProMisE and L1CAM expression in the same multivariable model, ProMisE lost significance while L1CAM remained significant. Patients with POLE mutated tumors entailed an excellent prognosis while patients with p53 abnormal or L1CAM overexpressing tumors entailed a poor prognosis with a high frequency of distant recurrences. Patients with MMRd tumors, NSMP and p53 abnormal tumors with low L1CAM had an intermediate prognosis.

CONCLUSIONS

L1CAM is an additional adverse factor in the p53 abnormal and NSMP groups. These groups need special attention in studies intensifying adjuvant treatment.

The prognostic impact of molecular classification in endometrial cancer that undergoes fertility-sparing treatment

OBJECTIVE

No biomarkers are available to predict treatment response in patients with endometrial cancers who undergo fertility-sparing treatment. Therefore, we aimed to evaluate the prognostic role of molecular classification.

METHODS

Patients with endometrial cancer who underwent fertility-sparing treatment with progestins between 2005 and 2021 were retrospectively identified. Polymerase epsilon (POLE), TP53/p53, and mismatch repair (MMR) proteins were assessed to assign patients to molecular groups: POLE mutated (POLEmut), MMR deficient (MMRd), no specific molecular profile (NSMP), and p53 abnormal (p53abn). Treatment response was classified as complete, partial, stable disease, or progressive. Response at 6 months, best response, and recurrence after complete response were evaluated by molecular class.

RESULTS

In total, 33 patients were assigned to a molecular class and included in the analysis. Molecular testing detected 3 POLEmut (9%), 3 MMRd (9%), 25 NSMP (76%), and 2 p53abn (6%); 0 of 3 POLEmut (0%), 0 of 3 MMRd (0%), 6 of 25 NSMP (24%), and 1 of 2 p53abn (50%) achieved complete response within 6 months. In terms of best response during the entire treatment period, 2 of 3 POLEmut (67%), 2 of 3 MMRd (67%), 18 of 25 NSMP (72%), and 1 of 2 p53abn (50%) showed complete response. After complete response was achieved, 1 of 2 POLEmut (50%), 2 of 2 MMRd (100%), 14 of 18 NSMP (78%), and 0 of 1 p53abn (0%) had a recurrence.

CONCLUSION

Although the small number of patients limits our findings, a lower proportion of MMRd responded to progestins than of NSMP.

Clinicopathologic stratification demonstrates survival differences between endometrial carcinomas with mismatch repair deficiency and no specific molecular profile: a cohort study

OBJECTIVE

Endometrial carcinomas with mismatch repair deficiency (MMRd) and no specific molecular profile (NSMP) are considered to have intermediate prognoses. However, potential prognostic differences between these molecular subgroups remain unclear due to the lack of standardized control for clinicopathologic factors. This study aims to evaluate outcomes of MMRd and NSMP endometrial carcinomas across guideline-based clinicopathologic risk groups.

METHODS

This study analyzed patients treated at a single tertiary center. Immunohistochemistry and polymerase-ϵ sequencing were performed for molecular classification. MLH1-deficient tumors underwent methylation-specific multiplex ligation-dependent probe amplification. Carcinomas were classified into clinicopathologic risk groups according to European guidelines.

RESULTS

The analysis included 420 MMRd and 399 NSMP carcinomas. Among MMRd cases, 224 were subcategorized as MLH1-methylated or MLH1-non-methylated. Median follow-up was 71 months (range; 1-136). Survival differences were most notable in clinicopathologic medium-risk carcinomas, with the MMRd subgroup exhibiting poorer progression-free, disease-specific, and overall survival compared to NSMP. Adjusting for age and adjuvant therapy, MMRd still showed an association with progression-free survival. Both MLH1-methylated (n = 154) and MLH1-non-methylated tumors (n = 70) were associated with more aggressive clinicopathologic risk groups compared to NSMP, but only methylated tumors showed poorer outcomes.

CONCLUSION

The distinct outcomes for MMRd and NSMP in the clinicopathologic medium-risk group suggest that uterine risk factors may worsen the prognosis for MMRd endometrial carcinomas. Advanced stage may be the primary factor contributing to poor outcomes in high-risk-advanced metastatic carcinomas. Clinicopathologic factors may particularly worsen the prognosis of MLH1-methylated carcinomas.

Efficacy and safety of dostarlimab in combination with chemotherapy in patients with dMMR/MSI-H primary advanced or recurrent endometrial cancer in a phase 3, randomized, placebo-controlled trial (ENGOT-EN6-NSGO/GOG-3031/RUBY)

OBJECTIVES

Part 1 of the RUBY trial (NCT03981796) demonstrated improved survival in patients with primary advanced or recurrent endometrial cancer (EC) treated with dostarlimab plus carboplatin-paclitaxel versus placebo plus carboplatin-paclitaxel. Here, we examine additional efficacy and safety data from patients with mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) EC in the RUBY trial.

METHODS

Patients were randomized 1:1 to dostarlimab 500 mg or placebo plus carboplatin-paclitaxel every 3 weeks for 6 cycles followed by dostarlimab or placebo every 6 weeks for up to 3 years. In the dMMR/MSI-H population of RUBY Part 1, analysis of progression-free survival by investigator assessment compared with blinded independent central review, sensitivity analyses of the source-verified population compared with the randomized population, and analysis of safety in this population were completed.

RESULTS

In total, 118 patients with dMMR/MSI-H were enrolled in the RUBY trial (53, dostarlimab arm; 65, placebo arm). At the first interim analysis, a 72% reduction in the risk of progression or death (P < 0.0001) was seen with dostarlimab plus carboplatin-paclitaxel by investigator assessment per Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST v1.1), which was consistent with blinded independent central review per RECIST v1.1. Likewise, sensitivity analyses of the source-verified dMMR/MSI-H population compared with the randomized dMMR/MSI-H population were consistent for progression-free survival and overall survival. Safety results seen in the dMMR/MSI-H population were similar to those previously reported for the overall population.

CONCLUSIONS

All primary and secondary efficacy assessments demonstrate the consistent benefit of dostarlimab plus carboplatin-paclitaxel. The improvements seen in survival and the manageable safety profile support the favorable benefit-risk profile for dostarlimab plus carboplatin-paclitaxel in patients with dMMR/MSI-H primary advanced or recurrent EC.

Challenges in implementation of molecular classification in early stage endometrial cancer-An NRG Oncology cooperative group mixed-methods study

BACKGROUND

Professional guidelines recommend molecular profiling for mismatch repair (MMR), p53, and polymerase epsilon (POLE) status in endometrial cancer (EC). However, adoption in the United States has not been documented, and barriers to the implementation of testing have not been described.

METHODS

In this mixed-methods study, implementation science frameworks were used to develop a quantitative survey. Gynecologic oncologists, medical oncologists, radiation oncologists, and pathologists affiliated with NRG Oncology programs were contacted through snowball sampling and were surveyed during 2022-2023. A subset of respondents was interviewed. Statistical and thematic analyses were performed.

RESULTS

At least 403 NRG Oncology-affiliated providers were contacted for the survey, and 107 (26.6%) responded. Greater than 90% of respondents perceived POLE, MMR, and p53 status as important for clinical care. MMR and p53 tests were perceived as easy to obtain, but only 24.2% of respondents reported that POLE testing was moderately or very easy to obtain. Respondents from academic sites reported better access to molecular classification and perceived greater importance of molecular classification compared with respondents from community sites. In thematic analysis of 13 qualitative interviews, cost concerns were reported as large barriers to testing. Interviewees reported a desire for prospective data to guide treatment selection based on classification results.

CONCLUSIONS

Although integrating molecular classification into standard pathologic reporting is recommended, and clinicians perceive molecular profiling in early stage EC as important, survey respondents noted significant implementation barriers. Implementation challenges that differ between community oncology and academic practice settings were identified. Strategies to improve equitable access to molecular classification of early stage EC are needed.

Fertility Sparing in Endometrial Cancer: Where Are We Now?

Endometrial cancer is the most common gynecological neoplasm with an increased incidence in the premenopausal population in recent decades. This raises the problem of managing endometrial cancer in fertile women who have not yet achieved pregnancy. In these women, after careful selection, hysterectomy may be postponed in favor of conservative management if specific requirements are met. The latest evidence is focused on early endometrial carcinoma, endometrioid histotype, Grading 1, with no evidence of myometrial infiltration. Few clinical trials have opened this possibility also for women with an endometrial cancer Grading 2 diagnosis. There are still questions about the best medical therapy, dosage, route, and duration of treatment. Oral progestins or levonorgestrel-releasing intrauterine devices appear to be the options associated with the best outcome in terms of complete response and lower recurrence rates. Other options include the use of GnRH analogues, surgical hysteroscopy, or metformin, in a therapeutic approach that takes into account the characteristics of the patient. The pursuit of pregnancy should start as soon as two consecutive endometrial biopsies are obtained 3 months apart from each other; it is recommended to refer the patients to ART centers to maximize the success rate. After having reached the fulfillment of the reproductive desire, surgical radical treatment is still recommended.

FIGO 2023 staging system predicts not only survival outcome but also recurrence pattern in corpus-confined endometrial cancer patients

OBJECTIVE

Approximately 10-15 % of endometrial cancer patients with tumors confined to the uterus (FIGO 2009 stage I) demonstrate recurrence and the oncologic outcomes are highly related to recurrence patterns. This study aimed to verify whether the FIGO 2023 staging system could discriminate outcomes.

MATERIALS AND METHODS

Between January 2010 and March 2019, 536 FIGO 2009 stage I patients were eligible for this retrospective cohort study. Patient characteristics and clinicopathological data were retrieved from electronic medical records. The patients were reclassified according to the FIGO 2023 staging criteria. Oncological outcomes included the recurrence rate, recurrence pattern, and overall survival.

RESULTS

Among the 536 eligible patients, the (sub)stage migration rate was 23.5 % from the FIGO 2009 to the FIGO 2023 stage system. FIGO 2023 staging system resulted in (sub)stage up-migration, mostly owing to aggressive histological types. A higher recurrence rate was detected in the FIGO 2023 stage II patients (12.3 %) compared to the stage I patients (6.9 %). In comparison to the FIGO 2023 stage I patients, the stage II patients had a higher distant recurrence rate (8.8 % vs. 2.6 %) and poorer overall survival (38.0 vs 69.0 months, p = 0.02).

CONCLUSION

Patients who are upstaged are prone to worse oncological outcomes, including distant recurrence and mortality. Therefore, comprehensive adjuvant treatment strategies based on each FIGO 2023 substage are imperative.

Anaemia, blood transfusions and survival in high-grade endometrial cancer: retrospective study

OBJECTIVE

To determine if anaemia and blood transfusions in the perioperative, chemotherapy and radiation treatment periods are associated with overall survival (OS) and recurrence-free survival (RFS) in high-grade endometrial cancer.

METHODS

This retrospective cohort study examined patients at a single centre treated for high-grade endometrial cancer (2010-2023). This included International Federation of Gynecology and Obstetrics (FIGO) grade 3 endometrioid, serous, carcinosarcoma, mixed, clear cell, mucinous, dedifferentiated and undifferentiated histology. Primary outcomes were OS and RFS. Predictor variables were nadir haemoglobin and transfusion status. Multivariable Cox regression models for OS and RFS analysed the associations of treatment period-specific anaemia, overall transfusion status and confounder variables.

RESULTS

Two hundred twenty-seven cases were included; 64-86% of patients were anaemic during any treatment, with 0-10% having severe anaemia. Twenty-two patients (9.7%) had at least one blood transfusion. Transfusion in the perioperative and chemotherapy periods was associated with poorer survival, significant only for shorter RFS in the chemotherapy cohort (HR 3.22, p=0.04). There was no association between anaemia and survival.

CONCLUSION

This study is among the first to assess anaemia in treated patients with high-grade endometrial cancer and the associations of anaemia and blood transfusion with survival outcomes. Further larger studies are needed to strengthen evidence and guide transfusion policies.

Prognostic factors and survival outcomes of immunohistochemically detection based-molecular subtypes of endometrial cancer-analysis of 576 clinical cases

OBJECTIVE

The study aimed to identify distinct molecular subtypes of endometrial cancer (EC) by immunohistochemistry and to analyze their pathological characteristics, independent prognostic factors, and patient survival outcomes for potential clinical applications.

METHOD

576 patients with preoperative EC confined to the uterus were divided into three subgroups based on the immunohistochemical detection method: MMR-deficiency (MMRd), P53 wild type (P53wt) and P53 abnormal (P53abn). These subgroups were retrospectively analyzed, and their pathological characteristics, prognostic factors and survival outcomes were compared.

RESULTS

We identified 401 (69.6%), 123 (21.4%), and 52 (9%) cases of P53wt, MMRd, and P53abn subgroups, respectively. A significant difference was observed in the median age of onset, tumor stage, high-grade tumor differentiation, non-endometrioid carcinoma, myometrial invasion, lymphovascular invasion, the incidence of lymph node metastasis postoperative, and expression of ER and PR receptors among the three groups. Pathological type, lymphovascular invasion, ER and PR expression were identified as independent prognostic factors for disease-free survival (DFS). Additionally, pathological type, lymphovascular invasion, myometrial invasion, and PR expression were recognized as independent prognostic factors for overall survival (OS) in the study cohort. However, the survival outcome for P53abn was the worst, with lymphovascular invasion identified as an independent prognostic factor for DFS. Lymph node status, FIGO stage, and ER expression were identified as independent prognostic factors for OS.

CONCLUSION

The study concludes that immunohistochemical detection-based subtyping of EC holds clinical practicality and can be employed to explore both pathological and clinical prognoses for EC patients.

Implementation of the ProMisE classifier and validation of its prognostic impact in Brazilian endometrial carcinomas

Purpose

Molecular classification of endometrial cancer (EC) has emerged as a key approach to individualize therapy and define prognostic outcomes. This study aimed to implement the traditional ProMisE classification in a Brazilian population, compared with a molecular setting of ProMisE biomarkers, and evaluate its impact on patients' prognosis.

Patient and methods

A prospective cohort of 114 patients with primary EC treated at Barretos Cancer Hospital (BCH) between October 2020 and December 2022 was conducted. Pathology diagnosis, staging, treatment, and follow-up data were collected. The traditional ProMisE methodology was carried out by POLE hotspot sequencing and immunohistochemistry (IHC) for p53 and mismatch repair (MMR) proteins. We further evaluate the MMR and TP53 status by molecular approach, namely microsatellite instability (MSI) by PCR-based and TP53 mutation analysis by next-generation sequencing (NGS). The results of the 4 molecular groups in both methodologies were compared regarding agreement accuracy and survival outcomes.

Results

Among the 114 cases, the traditional ProMisE groups were: POLEmut 15.8%, MMRd 28.1%, p53abn 27.2%, and no specific molecular profile (NSMP) 28.9%. Considering the molecular classification approach, we observed a POLEmut group of 15.8%, MSI group of 23.7%, TP53 mutation of 27.2%, and NSMP of 33.3%. The concordance rate of both approaches was 86.8% (99/114 cases) with an overall accuracy of 0.87. Importantly, both traditional and molecular ProMisE approaches were associated with significant distinct overall survival (OS) and progression-free survival (PFS) outcomes, with POLEmut patients exhibiting a better prognosis (93.8% OS, at 24 months), whereas the p53abn having a worse survival time (68.9% of OS, at 24 months).

Conclusion

We reported for the first time the Brazilian profile of the ProMisE classification of endometrial cancer and demonstrated the prognostic impact of the traditional and molecular ProMisE classification on patient outcomes.

Impact of the FIGO2023 staging system on endometrial cancer in Japan: differences between next-generation sequencing and simplified surrogate marker analysis

BACKGROUND

The International Federation of Gynecology and Obstetrics (FIGO) revised the staging system of endometrial cancer in 2023. In this study, we aimed to determine stage transitions and prognosis of endometrial cancer using FIGO2008, FIGO2023 without molecular classification (FIGO2023), and FIGO2023 with molecular classification (FIGO2023m).

METHODS

Eighty-three patients diagnosed with endometrial cancer who underwent surgery and next-generation sequencing (NGS) molecular profiling as part of the Project HOPE cohort study were enrolled. Each case was staged according to the FIGO2008 and FIGO2023 criteria, and we evaluated changes in stage and disease-specific survival (DSS). Molecular classification based on NGS was performed to evaluate FIGO2023m, and the concordance rate with immunohistochemical marker analysis was assessed.

RESULTS

Transitioning from FIGO2008 to FIGO2023 resulted in the restaging of 18 cases. Conversely, transitioning from FIGO2008 to FIGO2023m led to the restaging of 15 cases. The concordance rate between FIGO2023 and FIGO2023m staging was 96.4%. With FIGO2023m, the 5-year DSS was 97.6% for stage I (95% confidence interval [CI] 83.9-99.7), 83.3% for stage II (95% CI 56.8-94.3), 100% for stage III (95% CI NA), and 25.0% for stage IV (95% CI 0.9-66.5). Discrepancies in disease staging due to discordance between simplified surrogate marker analysis and NGS evaluation occurred in two cases.

CONCLUSIONS

The revision of the staging system from FIGO2008 to FIGO2023 and FIGO2023m resulted in the restaging of several cases, with significant changes between stages I and II.

ZOOMit diffusion kurtosis imaging combined with diffusion weighted imaging for the assessment of microsatellite instability in endometrial cancer

PURPOSE

Detecting microsatellite instability (MSI) plays a key role in the management of endometrial cancer (EC), as it is a critical predictive biomarker for Lynch syndrome or immunotherapy response. A pressing need exists for cost-efficient, broadly accessible tools to aid patient for universal testing. Herein, we investigate the value of ZOOMit diffusion kurtosis imaging (DKI) and diffusion weighted imaging (DWI) based on preoperative pelvic magnetic resonance imaging (MRI) images in assessing MSI in EC.

METHODS

Preoperative MRI examination including ZOOMit DKI and DWI of 81 EC patients were retrospectively analyzed. The apparent diffusion coefficient (ADC), mean kurtosis (MK), mean diffusivity (MD) and the largest tumor size based on MRI images, as well as patients' clinicopathological features were compared and analyzed according to different microsatellite statuses.

RESULTS

Of the 81 patients, 59 (72.8%) who were microsatellite stability (MSS) and 22 (27.2%) who were MSI. Interobserver agreement for the quantitative parameter measurements was excellent (ICC 0.78-0.98). The ADC and MD values were significantly lower, while Ki-67 proliferation level and MK values were significantly higher in the MSI group compared to those of the MSS group. The parameters of MD and MK were independent predictors for determining MSI, and their combination showed better diagnostic efficacy with an area under the receiver operating characteristic curve (AUROC) of 0.860 (95% confidence interval, 0.765, 0.927), although there was no significant difference compared to each individual parameter.

CONCLUSION

The microstructural heterogeneity assessment of ZOOMit DKI allowed for characterizing MSI status in EC. Within the current universal MSI testing paradigm, DKI may provide added value as a potential noninvasive imaging biomarker for preoperative assessment of MSI tumors, thereby facilitating clinical decision-making.