Safety and antitumor activity of dostarlimab in patients with advanced or recurrent DNA mismatch repair deficient/microsatellite instability-high (dMMR/MSI-H) or proficient/stable (MMRp/MSS) endometrial cancer: interim results from GARNET—a phase I, single-arm study

Efficacy and safety of cadonilimab combined with chemotherapy as the first-line treatment for primary advanced or recurrent endometrial cancer: a prospective single-arm open-label phase II clinical trial

INTRODUCTION

Recently, immunotherapy has significantly transformed the treatment landscape of endometrial cancer (EC). Results from KEYNOTE-158, RUBY and AtTEnd showed programmed cell death 1 (PD-1) or programmed cell death-ligand 1 inhibitors with promising efficacy in primary advanced or recurrent EC. However, few studies focused on the role of dual immune checkpoints in primary advanced or recurrent EC. Cadonilimab is an immune checkpoint inhibitor targeting the PD-1 and T-lymphocyte antigen-4, which is expected to show substantial clinical efficacy in EC. Combining cadonilimab with standard chemotherapy may have synergistic effects, making this combination a promising first-line treatment for primary advanced or recurrent EC. Furthermore, incorporating molecular classification for guidance on the use of cadonilimab may hold valuable clinical benefits.

METHODS AND ANALYSIS

In this multicentre, open-label, phase II study, patients with histologically confirmed EC were eligible. Forty-five patients will be recruited. Seventeen patients will be enrolled in stage I, and at least seven cases of complete response (CR) and partial response (PR) should be observed before entering stage II. All patients will receive cadonilimab at a dosage of 10 mg/kg along with carboplatin (area under the curve (AUC)=4-5) plus paclitaxel (175 mg/m2) every 3 weeks (Q3W) for 6-8 cycles. Subsequently, patients with CR, PR or stable disease will receive maintenance of cadonilimab at 10 mg/kg Q3W for 24 months or until progressive disease or adverse events are reported. The objective response rate is the primary endpoint. The secondary endpoints include the disease control rate, duration of response, progression-free survival, overall survival and safety. Additionally, exploratory endpoints involve biomarkers that may predict the efficacy of cadonilimab and chemotherapy, as well as their relationship with molecular classifications. The interim analysis will be conducted after 17 patients have been enrolled.

ETHICS AND DISSEMINATION

The study protocol meets the approval of the ethical committee of Fujian Cancer Hospital (K2023-173-04) and all other participating hospitals. Study findings will be disseminated in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT06066216.

Research trends and hotspots of single nucleotide polymorphisms in endometrial cancer: a bibliometric analysis

BACKGROUND

Endometrial cancer (EC) is a common gynecological malignancy with increasing incidence, especially in developed nations. Understanding genetic variations, particularly single nucleotide polymorphisms (SNPs), is crucial for uncovering the disease's pathogenesis, progression, and treatment responses. This study explores the global research landscape of SNPs in EC, focusing on field evolution, key contributors, and emerging trends.

METHODS

A systematic search of the Web of Science Core Collection (WoSCC) retrieved 838 publications on SNPs in EC from 1991 to 2024. Bibliometric indicators, including publication volume, citation counts, and keyword occurrences, were analyzed using VOSviewer, CiteSpace, and the R package "bibliometrix" for visual mapping and trend analysis.

RESULTS

The United States (230 publications) and China (182 publications) were leaders in research output. Harvard University and the National Cancer Institute were prominent contributors. Key themes included "microsatellite instability" (a hallmark of DNA mismatch repair deficiency) and "genome-wide association studies" (GWAS), identifying susceptibility loci like HNF1B and CYP19A1. Recent trends, such as "Mendelian randomization," have enhanced causal inference in risk factor studies. SNP research has advanced risk prediction models and personalized therapeutic strategies, such as hormone therapy tailored to genetic profiles.

CONCLUSION

SNP research has deepened our understanding of EC's genetic basis, with a growing emphasis on Mendelian randomization and GWAS. These advancements have refined risk prediction and opened new avenues for personalized medicine. Integrating SNP data with environmental and hormonal factors remains crucial for advancing prevention, diagnosis, and treatment strategies in EC.

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.

Molecular mechanism of tumor-infiltrating immune cells regulating endometrial carcinoma

Endometrial carcinoma (EC) is a prevalent gynecological cancer, and its interaction with the immune system is pivotal in cancer progression. This comprehensive review explores the molecular mechanisms involved in the regulation of EC by tumor-infiltrating immune cells. This review discusses the composition and functions of various immune cell types within the tumor microenvironment, including T cells, B cells, macrophages, and natural killer cells, and elucidates their specific roles in cancer control. It also delves into the immune evasion strategies employed by EC cells, with a specific focus on immune checkpoint pathways and their influence on tumor development. Signaling pathways, cytokines, and chemokines mediating immune responses within the tumor microenvironment are also detailed. Furthermore, clinical implications and therapeutic strategies, such as immunotherapies, are also reviewed, and relevant clinical trials are discussed. Additionally, this review discusses the existing gaps in our knowledge, suggests potential avenues for future research, and emphasizes the significance of understanding these mechanisms for enhanced EC treatment. This review provides an exhaustive overview of the current knowledge, supporting the ongoing quest for more effective therapeutic interventions on EC.

Pembrolizumab in Patients of Chinese Descent with Microsatellite Instability-high/Mismatch Repair Deficient Advanced Solid Tumors: KEYNOTE-158 Final Analysis

INTRODUCTION

KEYNOTE-158 (NCT02628067) supported the US Food and Drug Administration approval of pembrolizumab for microsatellite instability-high (MSI-H)/mismatch repair deficient (dMMR) advanced solid tumors. Incidence of MSI-H/dMMR tumors in patients of Chinese descent is similar to that of Western populations. Cohort L of KEYNOTE-158 evaluated pembrolizumab in patients of Chinese descent with previously treated MSI-H/dMMR tumors. We previously reported an objective response rate (ORR) of 70% in 20 patients from cohort L which supported the approval in China of pembrolizumab in patients with MSI-H/dMMR solid tumors. Here we present results of the final analysis for 30 patients with median follow-up of 18 months.

METHODS

Eligible patients who had confirmed unresectable or metastatic MSI-H/dMMR tumors, and one or more prior lines of therapy, received 200 mg pembrolizumab Q3W (up to 35 cycles) until progression, toxicity, or withdrawal. Primary endpoint was ORR per RECIST 1.1 by central review. Secondary endpoints were duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

Thirty patients were enrolled; 7 (23%) were aged ≥ 65 years, and 20 (67%) were female. With median follow-up of 18 months, ORR was 66.7%. Median DOR was not reached (NR), with 12-month DOR rate of 85.9%. Median PFS was NR, with 18-month PFS rate of 63.0%. Median OS was NR, with 18-month OS rate of 78.8%. Treatment-related adverse events (AE) were reported in 22 (73%) patients. Grade 3-4 treatment-related AEs occurred in 7 (23%) patients. Immune-mediated AEs occurred in 11 (37%) patients of which 2 (7%) had grade 3 AEs. No grade ≥ 4 immune-mediated AEs occurred.

CONCLUSION

Pembrolizumab continues to provide clinically meaningful antitumor activity and durable responses with a manageable safety profile in patients of Chinese descent with MSI-H/dMMR advanced solid tumors. These results are consistent with those reported for patients in the global population and further support the use of pembrolizumab in patients of Chinese descent with MSI-H/dMMR tumors. TRIAL REGISTRATION NUMBER: NCT02628067.

An ambispective, real-world multi-center study of DOstarlimab in patients with Recurrent or Advanced DNA mismatch repair deficient/microsatellite instability-high endometrial cancer (GEICO 120-R/DORA study)

OBJECTIVE

Patients with advanced or recurrent endometrial cancer who experience progression following platinum-based chemotherapy have limited treatment options. The phase I GARNET trial showed the high efficacy of dostarlimab in treating mismatch repair deficient (dMMR) and/or microsatellite instability-high (MSI-H) endometrial cancer.

METHODS

DORA is a multi-center, ambispective, observational real-world study evaluating the efficacy and safety of dostarlimab. The study included patients with dMMR/MSI-H endometrial cancer who had experienced tumor progression on or after a platinum-based treatment and had received at least 1 cycle of dostarlimab within the Spanish Expanded Access Program. The primary endpoints were objective response rate and duration of response.

RESULTS

A total of 129 patients from 57 of the Spanish Research Group for Gynaecological Cancer (GEICO) affiliated hospitals were enrolled, with 125 evaluable for radiological response. The median duration of dostarlimab administration was 8.8 months (interquartile range; 13.2), and 73 patients (57%) remained on therapy at the data cutoff. With a median follow-up of 11.6 months (range; 0.8-30.1), the objective response rate was 53.6% (95% CI 44.4 to 62.5). Complete response was observed in 27 patients (21.6%), and partial response in 40 (32%), with a median time to response of 2.9 months (95% CI 2.6 to 3.6). The median duration of response was not reached. The probability of maintaining the response at 12 and 24 months was 84.98% (95% CI 70.8 to 92.5) and 73.39% (95% CI 50.5 to 86.9), respectively. Treatment was discontinued due to toxicity in 4.7% of patients.

CONCLUSIONS

Dostarlimab monotherapy in dMMR/MSI-H endometrial cancer patients shows similar efficacy in real-world practice to that observed in the GARNET trial.

Expanding horizons of cancer immunotherapy: hopes and hurdles

Background

Tumor displays various forms of tumor heterogeneity including immune heterogeneity that allow cancer cells to survive during conventional anticancer drug interventions. Thus, there is a strong rationale for overcoming anticancer drug resistance by employing the components of immune cells. Using the immune system to target tumor cells has revolutionized treatment. Recently, significant progress has been achieved at preclinical and clinical levels to benefit cancer patients.

Approach

A review of literature from the past ten years across PubMed, Scopus, and Web of Science focused on immunotherapy strategies. These include immune checkpoint inhibitors (ICIs), tumor-infiltrating lymphocyte therapy, antibody-drug conjugates (ADCs), cancer vaccines, CAR T-cell therapy, and the role of the gut microbiome.

Conclusion

While immunotherapy outcomes have improved, particularly for tumor types such as melanoma and non-small cell lung cancer (NSCLC), challenges persist regarding predictive biomarker identification and better management. Ongoing research on modifiers of immune function like gut microbiome-derived metabolites, next-generation ADCs, and new classes of biologics is warranted. Overall, continued investigation toward optimizing synergistic immunotherapeutic combinations through strategic drug delivery systems is imperative for preclinical and clinical success in cancer patients.

Immune microenvironment and molecular mechanisms in endometrial cancer: implications for resistance and innovative treatments

This review provides a systematic overview of the molecular mechanisms of endometrial cancer and its drug resistance, particularly involving the aberrant activation of some key signaling pathways. These molecular mechanisms significantly affect the therapeutic outcome of endometrial cancer by promoting tumor cell proliferation, anti-apoptosis, and drug resistance. The article also analyzes the critical role of the immune microenvironment in cancer drug resistance, focusing on the impact of immune cells, immune checkpoints, and hypoxic metabolic reprogramming on anticancer therapies. In recent years, immunotherapy and individualized therapy have shown promising clinical outcomes, especially in advanced endometrial cancer. This article summarizes recent advances in related therapeutic strategies and proposes emerging therapeutic strategies by targeting key pathways and modulating the immune microenvironment to overcome drug resistance and improve patient prognosis.

Diagnostic performance of radiomics models for preoperative prediction of microsatellite instability status in endometrial cancer: a systematic review and meta-analysis

PURPOSE

Microsatellite instability (MSI), caused by defects in mismatch repair (MMR) genes, serves as a critical molecular biomarker with therapeutic implications for endometrial cancer (EC). This study aims to assess the diagnostic performance of radiomics as a non-invasive approach for predicting MSI status in EC.

METHODS

A systematic search across PubMed, Scopus, Embase, Web of Science, Cochrane library and Clinical Trials was conducted. Quality assessment was performed using QUADAS-2 and METRICS. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and area under the curve (AUC) were computed using a bivariate model. Separate meta-analyses for radiomics and combined models were conducted. Subgroup analysis and sensitivity analysis were conducted to find potential sources of heterogeneity. Likelihood ratio scattergram was used to evaluate the clinical applicability.

RESULTS

A total of 9 studies (1650 patients) were included in the systematic review, with seven studies contributing to the meta-analysis of radiomics model and five for combined model. The pooled diagnostic performance of the radiomics model was as follows: sensitivity, 0.66; specificity, 0.89; PLR, 5.48; NLR, 0.43; DOR, 18.56; and AUC, 0.87. For combined model, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC were 0.58, 0.94, 7.37, 0.50, 16.43, and 0.85, respectively. Subgroup analysis of radiomics models revealed that studies employing non-linear classifiers achieved superior performance compared to those utilizing linear classifiers.

CONCLUSION

Radiomics showed promise as non-invasive tool for MSI prediction in EC, with potential clinical utility in guiding personalized treatments. However, further studies are required to validate these findings.

Docetaxel/Cisplatin Chemotherapy Followed by Pelvic Radiation Therapy in Patients With High-risk Endometrial Cancer After Staging Surgery: A Phase 2 Study

PURPOSE

To evaluate the efficacy and safety of docetaxel/cisplatin chemotherapy followed by pelvic radiation therapy after staging surgery in patients with high-risk endometrial cancer.

METHODS AND MATERIALS

In this open-label, single-arm, phase 2 trial conducted at 2 South Korean centers, we enrolled patients with histologically confirmed endometrial cancer who had undergone staging surgery. Inclusion criteria were based on International Federation of Gynecology and Obstetrics (FIGO) Staging 2009: stage I patients with ≥2 risk factors (grade 3, positive lymphovascular invasion, more than half of myometrium invasion); stage IB and II patients with clear cell or serous adenocarcinoma; stage II patients post-type 1 hysterectomy; and patients at stage III. Patients underwent 3 cycles of chemotherapy with docetaxel (70 mg/m2) and cisplatin (60 mg/m2) followed by pelvic radiation therapy ranging from 45 to 50.4 Gy. Disease status and adverse events were evaluated using RECIST 1.1 and Common Terminology Criteria for Adverse Events 4.0, respectively, with scheduled imaging and assessments throughout the study.

RESULTS

A total of 62 patients were included in this study and were followed for a median duration of 65 months (IQR, 48-86 months). The progression-free survival rates at 1, 3, and 5 years were 98.4%, 86.9%, and 79.1%, respectively. The overall survival rates at 1, 3, and 5 years were 98.4%, 96.4%, and 96.4%, respectively. After chemotherapy, 62.9% of patients experienced severe neutropenia, with 3.2% having grade 3 or 4 anemia. Common mild side effects included nausea (58.1%) and alopecia (38.7%). Postradiation, 16.7% experienced grade 3 neutropenia, and a few had grade 1 or 2 anemia (3.3%), with most other side effects being mild and no critical toxicities reported.

CONCLUSIONS

Patients with endometrial cancer with high-risk factors could benefit from adjuvant chemotherapy using docetaxel/cisplatin, followed by radiation therapy, with manageable toxicities.

DYNC2H1 mutation as a potential predictive biomarker for immune checkpoint inhibitor efficacy in NSCLC and melanoma

Dynein cytoplasmic 2 heavy chain 1 (DYNC2H1) is reported to play a potential role in cancer immunotherapy. However, the association between DYNC2H1 mutation and the clinical benefit of immunotherapy in non-small cell lung cancer (NSCLC) and melanoma remains to be elucidated. We collected data from three public immune checkpoint inhibitor (ICI)-treated NSCLC cohorts (n = 137 in total) and seven ICI-treated melanoma cohorts (n = 418 in total) to explore the potential of DYNC2H1 mutation as a predictive biomarker. The clinical outcomes, including the objective response rate (ORR) and progression-free survival (PFS), of patients with DYNC2H1 mutations are significantly better than those of patients with wild-type DYNC2H1. Multivariate Cox regression analysis confirmed that DYNC2H1 mutation was an independent predictive factor for ICI efficacy in NSCLC and melanoma. In addition, DYNC2H1 mutation exhibited no prognostic value for NSCLC or melanoma. Tumour mutational burden (TMB) and tumour neoantigen burden (TNB) were significantly higher in patients with DYNC2H1 mutation than in those with wild-type DYNC2H1 in both NSCLC and melanoma cohort. The analysis of immune-related genes and immune cell enrichment revealed an association between DYNC2H1 mutation and increased immune infiltration, revealing a potential mechanism underlying the predictive role of DYNC2H1 mutation in immunotherapy efficacy. In conclusion, DYNC2H1 mutation serves as a predictive biomarker of ICI efficacy in NSCLC and melanoma.

Phase 2b, open-label, single-arm, multicenter pilot study of the efficacy, safety, and tolerability of dostarlimab in women with early-stage mismatch repair-deficient endometrioid endometrial adenocarcinoma

BACKGROUND

The standard treatment for endometrial cancer is hysterectomy with or without bilateral salpingo-oophorectomy; however, this may not be an optimal choice for women who have not completed childbearing or who are at a high risk of surgical complications. Conservative treatment with levonorgestrel intrauterine devices appear to be effective in patients with early-stage endometrial cancer; however, patients with mismatch repair-deficient (dMMR) tumors have a low likelihood of responding to levonorgestrel intrauterine devices.

PRIMARY OBJECTIVE

To assess the efficacy of dostarlimab, an active immune checkpoint inhibitor that targets the programmed cell death protein-1 receptor, in patients with early-stage dMMR endometrioid endometrial adenocarcinoma.

STUDY HYPOTHESIS

Administration of 4 3-weekly cycles of 500 mg dostarlimab followed by a 3-week rest period and 3 6-weekly cycles of 1000 mg dostarlimab will be safe and efficacious in early-stage dMMR endometrial cancer patients.

TRIAL DESIGN

Non-randomized, open-label, pilot, multicenter phase2b study designed to evaluate the efficacy and safety of dostarlimab in 10 women aged ≥18 years with a clinically confirmed diagnosis of early-stage and dMMR endometrioid endometrial adenocarcinoma.

MAJOR INCLUSION/EXCLUSION CRITERIA

Eligible patients must have histologically proven stage I, International Federation of Gynecology and Obstetrics grade 1 or 2 dMMR endometrioid endometrial adenocarcinoma and desire for fertility preservation. Exclusions include, but are not limited to, patients with other high-risk endometrial cancer cell types, a poor medical risk due to uncontrolled medical conditions, or those who experienced grade 3 or higher immune-related adverse events from prior immunotherapy.

PRIMARY ENDPOINT(S)

The primary endpoint is the number of participants achieving investigator-assessed pathological complete response within 6 months of treatment.

SAMPLE SIZE

Ten (10) women ≥18 years of age will be enrolled.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

Accruals are expected to be completed by 2027, with the presentation of results by 2029.

TRIAL REGISTRATION

NCT06278857.

Impact of the FIGO 2023 Staging System on the Adjuvant Treatment of Endometrial Cancer: A Comparative Analysis with FIGO 2009

Background: ProMisE (Proactive Molecular Risk Classifier for Endometrial Cancer) has brought about the publication of the FIGO 2023 staging system with a significant impact in practice for endometrial cancer (EC). Methods: In this comparative study, we investigated the need for adjuvant treatment according to FIGO 2023, for each FIGO 2009 stage. We prospectively enrolled EC patients from June 2021 to June 2024, collected classical risk factors and classified according to FIGO 2009. Afterwards, we reclassified the same women according to FIGO 2023 and grouped them according to ESMO/ESTRO/ESGO risk factors. Results: We collected 211 eligible patients. We found 176 patients with FIGO 2009 I-II and 35 women with FIGO 2009 III-IV. Based on classic anatomopathological risk factors and FIGO 2009, adjuvant treatment was indicated in 124 (70.5%) patients with FIGO 2009 I-II (vaginal brachytherapy = 48; external beam radiotherapy with or without vaginal brachytherapy = 63; chemotherapy with external beam radiotherapy with or without vaginal brachytherapy = 13) and in 35 (100%) women with FIGO 2009 III-IV (all underwent chemotherapy). After FIGO 2023 re-staging, the women with early-stage EC, were more frequently candidates for no treatment, with a decreased relative risk (RR) for adjuvant treatment (RR 0.84; CI95% 0.74-0.95; p < 0.01) when compared to the previous FIGO classification. No significant risk (RR 1.01; CI95% 0.76-1.3; p = 0.08) for a more aggressive adjuvant treatment was noted after FIGO 2023 re-staging. In FIGO stage III-IV, no changes in the treatment modalities were observed. Conclusions: The re-staging according to FIGO 2023 of women previously staged to FIGO 2009 I-II, yields an RR of 0.84 to spare any type of adjuvant treatment.

Trends in FDA approvals of gynecologic oncology therapeutics from 2019 to 2024

OBJECTIVE

To quantify the impact of Food and Drug Administration (FDA) therapeutic approvals in gynecologic oncology from 2019 to 2024 and compare these approvals to other solid tumor disease sites.

METHODS

The FDA Approval Notifications was evaluated to assess drug approvals for solid tumors between August 15, 2019 and August 15, 2024. Drug approvals were evaluated to determine if they replaced the current standard of care (SOC), were used in combination with currently approved drugs, were used for adjuvant or maintenance therapy, or were approved for recurrence. Average therapeutic approval growth for each solid tumor category was calculated using the slope (b) from a simple linear regression model. Statistics were performed via Prism v10.1.1.

RESULTS

There were 150 drug approvals for solid tumors with gynecologic cancers representing 9.3 %. Gynecologic oncology had the second highest number of drug approvals compared to all other solid tumor disease sites. Of these, 8 were add on therapies (57.1 %) and 6 were later line therapies (42.9 %). Most disease sites (61.0 %) experienced an average decrease in FDA drug approvals during the study period. However, gynecologic oncology had the third largest approval growth (b = 0.17) compared to all other solid tumors.

CONCLUSION

While only representing 5 % of the oncology field, gynecologic oncology held the second highest number of FDA approvals by disease site in solid tumors (Ackroyd et al., 2021 [1]). The add on therapies provide a significant benefit in progression free and overall survival in the frontline setting and the later line therapies offer promising response rates in a heavily pre-treated population. This study highlights the promising future of gynecologic oncology therapeutics given the third largest relative growth in drug approvals compared to all other solid tumors.

[Endometrial cancer]

Novel developments in the diagnosis and treatment of endometrial cancer will likely improve the prognosis of early, advanced and recurrent tumors. Molecular pathology currently classifies endometrial carcinoma into 4 molecular subtypes with prognostic significance. POLE mutated tumors, amounting to about 7% of all endometrial cancer cases, dubbed "ultra-mutated", have an excellent prognosis in early stages - even without adjuvant therapy. Mismatch repair deficient (MMRd) tumors are called "hypermutated" and have an intermediate prognosis in early stages. In advanced stages, they are highly sensitive to immune checkpoint inhibitors which are an integral part of their treatment. The tumors with "no specific molecular profile" have a prognosis that is similar to MMRd endometrial cancers. Finally, TP53 mutated cancers have a dismal prognosis, and aggressive adjuvant therapy is indicated. The 2023 FIGO classification recognizes for the first time the prognostically favorable synchronous endometrial and ovarian carcinomas, the importance of lymph node metastases depending on size and pattern, and the relevance of peritoneal involvement inside versus outside the pelvis. In metastatic disease, in mismatch repair proficient cases, the combination of carboplatin and paclitaxel chemotherapy with durvalumab has been recently approved as first line therapy in the European Union, followed by maintenance therapy with the PARP inhibitor olaparib, in combination with durvalumab. For MMRd tumors, several immune checkpoint inhibitors in combination with chemotherapy or as monotherapy have been approved in recent years. Tumors that are overexpressing Her2/neu have an additional treatment option with trastuzumab.

Efficacy of PD-(L)1 inhibition in the treatment of endometrial cancer across molecular classes: a systematic review and meta-analysis

OBJECTIVE

PD-(L)1 inhibitors have shown benefit in mismatch repair-deficient (MMRd) endometrial cancer. However, their efficacy in mismatch repair-proficient endometrial cancer (comprising POLE-mutated (POLEmut), p53-abnormal (p53abn), and no-specific-molecular-profile (NSMP) molecular classes) remains unclear. This systematic review and meta-analysis evaluated the efficacy of PD-(L)1 inhibitors, as monotherapy or combined with chemotherapy, across the 4 molecular classes.

METHODS

Systematic searches were conducted across Embase, PubMed, Cochrane, and Web of Science, with manual searches of reference lists and conference websites. A total of 7 reports on 5 clinical trials were identified, with 3 included in the meta-analysis. Overall survival and progression-free survival were assessed.

RESULTS

In patients with primary advanced or recurrent MMRd endometrial cancer (n=215), adding a PD-(L)1 inhibitor to platinum-based chemotherapy significantly improved overall (HR 0.36, 95% CI 0.21 to 0.62) and progression-free survival (HR 0.35, 95% CI 0.23 to 0.53). In patients with p53abn endometrial cancer, no significant benefits in overall (HR 0.91, 95% CI 0.26 to 3.22; n=135) or progression-free survival (HR 0.84, 95% CI 0.41 to 1.70; n=326) were observed, but both were affected by significant heterogeneity. In patients with NSMP endometrial cancer, a significant benefit was observed for progression-free survival (HR 0.73, 95% CI 0.57 to 0.95; n=373), but no overall survival benefit (HR 0.93, 95% CI 0.63 to 1.39; n=242). Insufficient data were available for patients with POLEmut endometrial cancer (n=12), with no events reported in 2 of 3 clinical trials comprising the majority of patients (n=11).

CONCLUSIONS

PD-(L)1 inhibition demonstrated significant efficacy in patients with advanced or recurrent MMRd endometrial cancer. In NSMP endometrial cancer, adding a PD-(L)1 inhibitor to platinum-based chemotherapy showed potential benefit, whereas in p53abn endometrial cancer, such benefit was not found. POLEmut endometrial cancer, although rare in recurrent or metastatic settings, was associated with a favorable prognosis, regardless of treatment. These findings underscore the relevance of the molecular classification of endometrial cancer and highlight the importance of prioritizing molecular analyses in clinical trials to guide personalized PD-(L)1 inhibition strategies.

[Management of immune-related adverse events]

With the implementation of immunotherapy, a completely new, broad spectrum of side effects has emerged in oncology-the immune-related adverse events (irAEs). Their management differs greatly from that of classic cytotoxic side effects and is based primarily on corticosteroids, immunomodulatory agents, and treatment interruptions. Whereas some events are low grade and reversible, others can be severe and lead to permanent disorders or even death. Therefore, early recognition and treatment in the context of interdisciplinary side effects management is critical for patients' safety, prognosis, and quality of life.

Analytical and Clinical Validation of Solo-Test Driver: A Targeted Amplicon-Based NGS Test-System for FFPE and cfDNA Analysis in Clinical Oncology Setting

BACKGROUND

Next-generation sequencing (NGS) is increasingly integrated into cancer patient management, necessitating cost-effective, reliable tests for companion diagnostics. We present the validation of the Solo-test Driver panel, a custom NGS amplicon-based tool for DNA analysis of 34 oncogenes, addressing key clinical needs.

METHODS

The panel's performance was validated for detecting SNVs, CNVs, and MSI. Analytical validation used 182 samples, while clinical validation involved 130 samples, both encompassing diverse tumor types and specimen formats.

RESULTS

The Solo-test Driver panel has the potential to identify an additional 18.3%, 16.5%, and 8.7% of RAS+ colorectal, PIK3CA+ breast, and EGFR+ lung cancer patients, respectively, when compared to FDA-approved PCR tests. Analytical validation demonstrated high intra-lab robustness (coefficient of variation of coverage uniformity 6.4%) and high inter-lab robustness (PCC of per-amplicon coverage 0.82, 0.84, 0.9 for three different labs). Estimated in silico sensitivity was 100% for detecting clinically actionable SNVs at 250x, corresponding to only 60,000 read pairs per sample. In vitro mixing experiments determined LoD starting from 3.3% VAF. Estimated in silico LoD ranged from 0.5% to 5% at 1000× (1% to 5% at 650x). Clinical validation demonstrated PPA/NPA of 100%/80%, 95%/100%, and 100%/100% for detecting MSI, SNVs, and CNVs, respectively.

CONCLUSIONS

The Solo-test Driver panel offers a reliable, cost-effective solution for detecting somatic alterations and genomic signatures, making it suitable for routine companion diagnostics in solid tumors.

CD8+CD28+PD1- T Cells as a Prognostic Biomarker in Endometrial Cancer

Endometrial cancer (EC) is an immunogenic tumor, with CD8+ T cells playing a pivotal role in antitumor immunity. Overexpression of PD1 suppresses T cell function by inhibiting CD28, a critical co-stimulatory molecule. Classifying CD8+ T cells based on PD1 and CD28 expression provides valuable insights into the immune microenvironment of EC. Peripheral blood samples from 120 EC patients and tumor tissue samples from 81 EC patients were analyzed via flow cytometry. CD8+ T cells were categorized according to PD1 and CD28 expression, and their associations with clinical characteristics were systematically evaluated. Peripheral CD28-/CD8+ and PD1+/CD8+ T cell proportions were significantly associated with several high-risk factors, including deep myometrial invasion, and LVSI, as well as metabolic disorders such as dyslipidemia. Peripheral CD28+PD1-/CD8+ T cells were associated with stage, grade, and LVSI, inversely correlated with age, and elevated in patients with hypertension or dyslipidemia. Tumor-infiltrating CD28+PD1-/CD8+ T cells were associated with tumor grade and LVSI, with multivariate analysis identifying low proportions as an independent predictor of relapse. In summary, CD8+CD28- and CD8+PD1+ T cells are linked to high-risk clinical features in EC, while tumor-infiltrating CD8+CD28+PD1- T cells serve as a key independent prognostic marker for relapse. Additionally, CD8+CD28-, CD8+PD1+, and CD8+CD28+PD1- T cell proportions in PBMC are closely associated with metabolic disorders, emphasizing their potential as biomarkers for immune and metabolic interactions in EC.

Extracellular Vesicle-Based Strategies for Tumor Immunotherapy

Immunotherapy is one of the most promising approaches for cancer management, as it utilizes the intrinsic immune response to target cancer cells. Normally, the human body uses its immune system as a defense mechanism to detect and eliminate foreign objects, including cancer cells. However, cancers develop a 'switch off' mechanism, known as immune checkpoint proteins, to evade immune surveillance and suppress immune activation. Therefore, significant efforts have been made to develop the strategies for stimulating immune responses against cancers. Among these, the use of extracellular vesicles (EVs) to enhance the anti-tumor immune response has emerged as a particularly promising approach in cancer management. EVs possess several unique properties that elevate the potency in modulating immune responses. This review article provides a comprehensive overview of recent advances in this field, focusing on the strategic usage of EVs to overcome tumor-induced immune tolerance. We discuss the biogenesis and characteristics of EVs, as well as their potential applications in medical contexts. The immune mechanisms within the tumor microenvironment and the strategies employed by cancers to evade immune detection are explored. The roles of EVs in regulating the tumor microenvironment and enhancing immune responses for immunotherapy are also highlighted. Additionally, this article addresses the challenges and future directions for the development of EV-based nanomedicine approaches, aiming to improve cancer immunotherapy outcomes with greater precision and efficacy while minimizing off-target effects.

Obesity correlates to the microsatellite instability of endometrial cancer: A retrospective observational study

OBJECTIVE

To investigate the relationship between obesity and Microsatellite Instability (MSI) in endometrial cancer (EC), determine which mismatch repair (MMR) protein loss is influenced by obesity, and assess the correlation between BMI and MSI probability.

METHODS

This retrospective cohort study included 89 endometrial cancer patients treated at the Gynaecologic oncology unit of the University of Campania "Luigi Vanvitelli" from August 2023 to October 2024, and stratified by BMI: normal weight (n = 26), overweight (n = 31), obese (n = 26), and severely obese (n = 6). Microsatellite instability (MSI) was determined through immunohistochemical assessment of mismatch repair (MMR) protein expression: MLH1, PMS2, MSH2, and MSH6. Tumors were considered MSI if at least one of the four MMR proteins showed loss of expression. Univariate and multivariate logistic regression models were constructed to evaluate the correlation between BMI and MSI RESULTS: 89 patients were enrolled. Obese and severely obese groups showed significantly higher MSI rates (50 % each) compared to normoweight (12 %) and overweight (29 %) groups (P = .013). MLH1 and PMS2 loss of expression were significantly higher in obese and severely obese women (MLH1: P = .003; PMS2: P = .014). Univariate logistic regression showed a significant positive correlation between BMI and MSI (OR 1.02, 95 % CI 1.01-1.04, P = .007). In multivariate analysis, adjusting for grading, stage, histotype, and age, BMI maintained a significant positive correlation with MSI (OR 1.02, 95 % CI 1.01-1.04, P = .048).

CONCLUSIONS

This study demonstrates a significant association between obesity and MSI in EC, particularly affecting MLH1 and PMS2 expression. The findings suggest that obesity may contribute to EC development also through MMR deficiency.

Pembrolizumab in microsatellite instability-high/mismatch repair deficient (MSI-H/dMMR) and non-MSI-H/non-dMMR advanced endometrial cancer: Phase 2 KEYNOTE-158 study results

OBJECTIVE

We report updated results with longer follow-up in patients with MSI-H/dMMR endometrial cancer (EC) in cohort D (advanced EC of any MSI/dMMR status) and cohort K (any MSI-H/dMMR advanced solid tumor, except colorectal) of the phase 2 KEYNOTE-158 study (NCT02628067) and the first results from patients with non-MSI-H/non-dMMR advanced EC (cohort D).

METHODS

Patients received pembrolizumab 200 mg Q3W for ≥35 cycles. The primary endpoint was objective response rate (ORR) per RECIST v1.1 by central review. Secondary endpoints included duration of response (DOR), progression-free survival (PFS), overall survival (OS), and safety.

RESULTS

As of January 12, 2022, median (range) follow-up in the MSI-H/dMMR (n = 94) and non-MSI-H/non-dMMR (n = 96) groups was 54.5 (14.7-71.4) and 68.3 (64.3-71.9) months, respectively. The ORR (95 % CI) was 50 % (40 %-61 %) in the MSI-H/dMMR group; 15 patients (16 %) experienced a complete response, 32 (34 %) experienced a partial response. The ORR (95 % CI) in the non-MSI-H/non-dMMR group was 7 % (3 %-14 %); 7 patients (7 %) experienced a partial response, none experienced a complete response. The estimated 4-year DOR rates were 66 % and 56 %, respectively. Median PFS was 13.1 (95 % CI, 4.3-25.7) months in the MSI-H/dMMR group and 2.1 (95 % CI, 2.1-2.2) months in the non-MSI-H/non-dMMR group. Median OS was 65.4 (95 % CI, 29.5-not reached) and 11.1 (95 % CI, 8.1-15.3) months, respectively. Toxicity was manageable in both groups.

CONCLUSIONS

These results continue to support pembrolizumab as a standard-of-care option for MSI-H/dMMR advanced EC in patients with disease progression following prior systemic therapy who are not candidates for curative surgery or radiation.

First-line treatments for advanced or recurrent endometrial cancer: Systematic literature review of clinical evidence

Novel therapies are driving meaningful changes to the management of endometrial cancer (EC). Herein, a systematic literature review was conducted to evaluate the efficacy and safety of first-line treatments for advanced/recurrent EC. Searches were conducted using multiple databases through October 26, 2023. In total, 108 records of 57 unique trials (48 of first-line therapies) met the inclusion criteria. Baseline characteristics varied by study, and sample sizes ranged from 28 to 1328. Median progression-free survival was reported in 28 trials (range, 1.9-18.8 months), median overall survival in 26 trials with mature data (range, 6.9-41 months), and safety in 21 trials evaluating first-line systemic therapy ± maintenance. The potentially high risk of adverse events may outweigh the suboptimal efficacy benefits reported for conventional chemotherapy or hormonal therapies. The safety and efficacy of immunotherapies identified within are expected to contribute to a paradigm shift in the management of primary advanced/recurrent EC.

Pembrolizumab in microsatellite-instability-high and mismatch-repair-deficient advanced solid tumors: updated results of the KEYNOTE-158 trial

The phase 2 trial KEYNOTE-158 ( NCT02628067 ) evaluated pembrolizumab in microsatellite-instability-high and mismatch-repair-deficient (MSI-H/dMMR) noncolorectal tumors. With 373 participants (95% with baseline MSI/dMMR documentation) and 4.5 years of follow-up, the primary endpoint of overall response rate was 33.8%. Secondary endpoints of duration of response, overall survival and progression-free survival were 63.2, 19.8 and 4.0 months, respectively. Grade ≥3 treatment-related adverse events occurred in 50 (13%) participants. These results further support pembrolizumab use in MSI-H/dMMR tumors.

Efficacy and safety of PD-1/PD-L1 inhibitors in advanced or recurrent endometrial cancer: a meta-analysis with trial sequential analysis of randomized controlled trials

Background

The combination of programmed cell death 1 (PD-1)/programmed death ligand 1 (PD-L1) inhibitors with chemotherapy (CT) is currently under evaluation as a first-line treatment for advanced or recurrent endometrial cancer (EC). This study sought to assess the efficacy and safety of this therapeutic combination in patients with advanced or recurrent EC.

Methods

We performed an exhaustive review of randomized controlled trials (RCTs) up to September 25, 2024, examining the efficacy and safety of combining PD-1/PD-L1 inhibitors with CT versus CT alone (or plus placebo) in advanced or recurrent EC. Efficacy was measured by progression-free survival (PFS) and overall survival (OS), while safety was assessed by the incidence of any grade or grade ≥ 3 adverse events (AEs). We calculated hazard ratios (HRs) for PFS and OS, as well as risk ratios (RRs) for AEs, each accompanied by 95% confidence intervals (CIs). To evaluate heterogeneity, we employed Cochran's Q test, I2 statistics, and 95% prediction intervals (PIs). Trial sequential analysis (TSA) was conducted using R Version 4.3.1, STATA Version 12.0, and TSA Version 0.9.5.10 Beta software.

Results

Our analysis incorporated 6 studies, encompassing a total of 2,954 patients. The combination of PD-1/PD-L1 inhibitors with CT significantly improved PFS (HR = 0.617, 95% CI: 0.506-0.752; 95% PI: 0.334-1.140) and OS (HR = 0.774, 95% CI: 0.664-0.902; 95% PI: 0.553-1.083) compared to CT alone (or plus placebo) in the overall population. Subgroup analysis based on mismatch repair (MMR) status revealed pronounced benefits in PFS and OS for patients with deficient MMR (dMMR) (PFS: HR = 0.344, 95% CI: 0.269-0.438; 95% PI: 0.231-0.510; OS: HR = 0.371, 95% CI: 0.245-0.562; 95% PI: 0.025-5.461) compared to those with proficient MMR (pMMR) (PFS: HR = 0.772, 95% CI: 0.627-0.950; 95% PI: 0.394-1.512; OS: HR = 0.996, 95% CI: 0.692-1.435; 95% PI: 0.021-47.662). Although there was no observed difference in the incidence of any grades AEs (RR = 0.994, 95% CI: 0.982-1.006; 95% PI: 0.978-1.009), the risk of grade ≥ 3 AEs was elevated in the group receiving PD-1/PD-L1 inhibitors in combination with CT (RR = 1.132, 95% CI: 1.023-1.252; 95% PI: 0.836-1.532).

Conclusion

The combination of PD-1/PD-L1 inhibitors with CT significantly improved PFS and OS in advanced or recurrent EC patients, with particularly pronounced benefits observed in those with dMMR. Clinicians can tailor treatment strategies according to individual patient characteristics to optimize therapeutic outcomes, while remaining alert to the possibility of AEs in clinical practice.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024595455.

Brain Metastasis in Endometrial Cancer: A Systematic Review

BACKGROUND

Brain metastases (BMs) from endometrial cancer (EC) are rare and challenging to treat, with limited standardized guidelines. This systematic review aims to evaluate the incidence, therapeutic strategies, and outcomes associated with brain metastases in EC patients, offering insights for clinical practice and future research.

METHODS

A comprehensive literature search was conducted using PRISMA guidelines, including PUBMED up to October 2024. Reports reporting individual or aggregate data on EC brain metastases were included. Descriptive and quantitative analyses were performed on incidence, treatment modalities, and survival outcomes. Three reports that used data from the Surveillance, Epidemiology, and End Results and National Cancer Database were used only to assess the incidence of brain metastases from endometrial carcinoma.

RESULTS

From 911 reports identified, we included 99 reports, identifying 594 cases; these and the case of a patient with brain metastasis from endometrial carcinoma followed at our center were used for analysis of disease characteristics; incidence; and treatment modalities, such as surgery, radiotherapy, chemotherapy, and combinations. Survival outcomes were influenced by treatment type and disease characteristics, with multimodal approaches showing improved outcomes.

DISCUSSION

This review underscores the rarity of EC brain metastases and highlights the need for tailored, multimodal treatment strategies. Future research should focus on prospective trials and molecular profiling to optimize management.

From Genes to Clinical Practice: Exploring the Genomic Underpinnings of Endometrial Cancer

Endometrial cancer (EC), a prevalent gynecological malignancy, presents significant challenges due to its genetic complexity and heterogeneity. The genomic landscape of EC is underpinned by genetic alterations, such as mutations in PTEN, PIK3CA, and ARID1A, and chromosomal abnormalities. The identification of molecular subtypes-POLE ultramutated, microsatellite instability (MSI), copy number low, and copy number high-illustrates the diverse genetic profiles within EC and underscores the need for subtype-specific therapeutic strategies. The integration of multi-omics technologies such as single-cell genomics and spatial transcriptomics has revolutionized our understanding and approach to studying EC and offers a holistic perspective that enhances the ability to identify novel biomarkers and therapeutic targets. The translation of these multi-omics findings into personalized medicine and precision oncology is increasingly feasible in clinical practice. Targeted therapies such as PI3K/AKT/mTOR inhibitors have demonstrated the potential for improved treatment efficacy tailored to specific genetic alterations. Despite these advancements, challenges persist in terms of variability in patient responses, the integration of genomic data into clinical workflows, and ethical considerations. This review explores the genomic underpinnings of EC, from genes to clinical practice. It highlights the ongoing need for multidisciplinary research and collaboration to address the complexities of EC and improve diagnosis, treatment, and patient outcomes.

PD-1 and PD-L1 Expression in Endometrial Cancer: A Systematic Review of the Literature

Background/Objectives: Cancer immunotherapy through the use of PD-1/PD-L1 inhibitors have shown significant promise in endometrial carcinoma (EC), particularly in tumors with microsatellite instability (MSI) or mismatch repair deficiency (dMMR), present in approximately 30% of cases. This review evaluated PD-L1 and PD-1 expression as potential biomarkers for immunotherapy response in EC, focusing on their relationship with MSI status. Methods: A systematic review, adhering to PRISMA guidelines, analyzed studies from MEDLINE and Embase until February 2023 on PD-1/PD-L1 expression in EC stratified by MSI status, including diverse study designs but excluding conference abstracts, with independent screening, data extraction, and additional reference checks to ensure comprehensive coverage. Results: A systematic analysis of 10 studies found that PD-L1 expression was more frequently expressed in MSI tumors (49%) compared to microsatellite-stable tumors (MSS) (33.5%), while PD-1 was expressed in 58% of MSI cases and 48% of MSS cases. Despite these findings, the prognostic value of PD-L1/PD-1 remains uncertain, with conflicting results regarding their association with survival outcomes. PD-L1 expression varied across molecular subtypes, being highest in POLE-mutated tumors (76.56%) and serous carcinomas (73%). Differences in PD-L1 expression between primary and metastatic sites were also noted, complicating its use as a biomarker. Conclusions: The assessment of PD-L1 expression in EC could represent a valuable option for selecting patients who may benefit from immune checkpoint inhibitors (ICI), including those in the MSS cohort, thereby ensuring a more tailored and personalized treatment strategy.

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.

Immunotherapy plus chemotherapy in patients with advanced endometrial cancer: a cost-effectiveness analysis

OBJECTIVE

Pembrolizumab and dostarlimab are immune checkpoint inhibitors that target programmed death receptor 1 (PD-1). Combination anti-PD-1 regimens have been shown to exhibit favorable survival benefits when treating advanced endometrial cancer (EC). Which treatment was preferable will need to be confirmed by a cost-effectiveness comparison between them.

METHODS

Based on patient and clinical parameters from RUBY and NRG-GY018 phase III randomized controlled trials, the Markov model with a 20-year time horizon was established to evaluate the cost-effectiveness of dostarlimab plus chemotherapy (DC), pembrolizumab plus chemotherapy (PC), and chemotherapy alone (C) treatment for patients with mismatch repair-proficient microsatellite-stable (pMMR-MSS) and mismatch repair-deficient microsatellite instability-high (dMMR-MSI-H) advanced EC from the American payers' perspective. The main results include total cost, life-years (LYs), quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER) at a $150,000/QALY of willingness-to-pay.

RESULTS

In the pMMR-MSS population, DC, PC, and C produced costs (QALYs) of $99,205 (3.02), $322,530 (3.25), and $421,923 (4.40), resulting in corresponding ICERs of $974,177/QALY (PC vs. C), $234,527/QALY (DC vs. C), $86,671/QALY (DC vs. PC), respectively; In the dMMR-MSI-H population, DC, PC, and C obtained costs (QALYs) of $120,177 (5.73), $691,399 (8.43), and $708,787 (11.26), yielding ICERs of $266,423/QALY (PC vs. C), $135,165/QALY (DC vs. C), $7,866/QALY (DC vs. PC), respectively.

CONCLUSION

In the US, DC was a more cost-effective treatment than PC for patients with advanced EC irrespective of MMR status. However, compared to C, DC was associated with more cost-effectiveness in the dMMR-MSI-H population.

Immune checkpoint inhibitors in gynecological cancers: a narrative review on the practice-changing trials

During the last decades, the introduction of immune checkpoint inhibitors has radically changed the treatment landscape of several cancer types, improving the prognosis and the quality of life of cancer patients. Even for gynecological cancers, where the prognosis has historically been poor despite advancements in surgery, radiotherapy and oncological treatment, immunotherapy has represented a significant leap forward. In cervical and endometrial cancer, the introduction of immunotherapy has radically changed the treatment algorithm, especially for advanced disease. However, the scenario remains less promising for ovarian cancer, where, despite extensive research efforts, no consistent positive results have been achieved with immune checkpoint inhibitors, except for a few cases in rarer histological subtypes Here, we present a narrative review summarizing the most important practice-changing studies involving immune checkpoint inhibitors in gynecological cancers, particularly in cervical, endometrial, ovarian and vulvar cancer.

Immune checkpoint inhibitors for patients with mismatch repair deficient or microsatellite instability-high advanced cancers: a meta-analysis of phase I-III clinical trials

BACKGROUND

Mismatch repair deficient (dMMR) and microsatellite instability-high (MSI-H) cancers are associated with an increased number of somatic mutations, which can render tumors more susceptible to immune checkpoint blockade. However, a comprehensive evaluation of the efficacy profile of immune checkpoint inhibitors in this patient population across multiple cancer types is lacking. This study aims to address this knowledge gap by synthesizing data from phase I-III clinical trials.

METHODS

A systematic search was conducted in PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Google Scholar from inception until June 2024. Eligible studies included randomized controlled trials (RCTs), nonrandomized comparative studies, and single-arm trials investigating immune checkpoint inhibitors in patients with dMMR/MSI-H advanced cancers. The primary outcome was objective response rate (ORR), and the secondary outcomes included disease control rate (DCR), 1-year, 2-year, and 3-year overall survival (OS) and progression-free survival (PFS) rates. Subgroup analyses were conducted for the primary outcome stratified by major study characteristics.

RESULTS

Of the 10 802 identified studies, 19 trials in 25 studies totaling 2052 participants met the inclusion criteria and were included in the meta-analysis. The pooled ORR was 41.7% (95% CI, 35.7-47.7%). The pooled DCR was 68.9% (95% CI, 62.2-75.7%). The pooled 12-month, 24-month, and 36-month OS rates were 29.1% (95% CI, 19.9-38.3%), 35.8% (95% CI, 23.6-48.0%), and 35.8% (95% CI, 23.6-48.0%), respectively. The pooled 12-month, 24-month, and 36-month PFS rates were 46.4% (95% CI, 39.1-53.8%), 67.0% (95% CI, 55.2-78.8%), and 63.1% (95% CI, 37.3-88.9%), respectively.

CONCLUSIONS

The study establishes the therapeutic potential of immune checkpoint inhibitors in dMMR/MSI-H advanced cancers, highlighting the importance of MSI status in this context. Further, head-to-head comparisons are needed to conclusively determine MSI's predictive power relative to proficient mismatch repair/microsatellite stable (pMMR/MSS) tumors.

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.

Palbociclib plus letrozole in estrogen receptor-positive advanced/recurrent endometrial cancer: Double-blind placebo-controlled randomized phase II ENGOT-EN3/PALEO trial

PURPOSE

The CDK4/6 inhibitor palbociclib inhibits cyclin A, which is overexpressed in endometrial cancer. Combining palbociclib with endocrine therapy improves efficacy in hormone receptor-positive breast cancer. We investigated palbociclib combined with endocrine therapy for estrogen receptor-positive advanced/recurrent endometrial cancer.

PATIENTS AND METHODS

This placebo-controlled double-blind, randomized phase II screening trial (NCT02730429) enrolled women with measurable/evaluable estrogen receptor-positive endometrioid endometrial cancer that was primary metastatic or had relapsed after ≥1 prior systemic therapy. Patients were randomized in a 1:1 ratio, stratified by number of prior chemotherapy lines, measurable versus evaluable non-measurable disease, and prior medroxyprogesterone/megestrol acetate treatment, to receive oral letrozole 2.5 mg on days 1-28 plus either oral palbociclib 125 mg or placebo on days 1-21, repeated every 28 days until disease progression or unacceptable toxicity. The primary end point was investigator-assessed progression-free survival (PFS).

RESULTS

Among 77 patients randomized between February 16, 2017, and December 21, 2018, 73 were treated (36 with palbociclib-letrozole, 37 with placebo-letrozole). Median follow-up was 21.9 (95 % CI, 16.7 to 22.3) months. Median PFS was 8.3 (95 % CI, 4.6 to 11.2) versus 3.1 (95 % CI, 2.7 to 6.8) months, respectively. In a landmark analysis at 12 months the PFS hazard ratio was 0.57 (95 % CI, 0.32 to 0.99; P = .044). Grade ≥ 3 adverse events were more common with palbociclib-letrozole (67 %) than placebo-letrozole (30 %), most commonly neutropenia (44 % v 0 %, respectively).

CONCLUSION

These results support a potential role of the palbociclib-letrozole combination as treatment for hormone receptor-positive advanced/recurrent endometrial cancer. Based on these encouraging results, phase III evaluation of letrozole combined with a CDK4/6 inhibitor is planned.

CLINICAL TRIAL INFORMATION

NCT02730429.

Dostarlimab: A promising new PD-1 inhibitor for cancer immunotherapy

OBJECTIVE

Dostarlimab, a humanized monoclonal PD-1 blocking antibody, is being tested as a cancer therapy in this review. Specifically, it addresses mismatch repair failure in endometrial cancer and locally progressed rectal cancer patients.

DATA SOURCES

A thorough database search found Dostarlimab clinical trials and studies. Published publications and ongoing clinical trials on Dostarlimab's efficacy as a single therapy and in conjunction with other medicines across cancer types were searched.

DATA SUMMARY

The review recommends Dostarlimab for endometrial cancer mismatch repair failure, as supported by GARNET studies. The analysis also highlights locally advanced rectal cancer findings. In the evolving area of cancer therapy, immune checkpoint inhibitors including pembrolizumab, avelumab, atezolizumab, nivolumab, and durvalumab were discussed.

CONCLUSIONS

Locally advanced rectal cancer patients responded 100% to Dostarlimab. Many clinical trials, including ROSCAN, AMBER, IOLite, CITRINO, JASPER, OPAL, PRIME, PERLA, and others, are investigating Dostarlimab in combination treatment. This research sheds light on Dostarlimab's current and future possibilities, in improving cancer immunotherapy understanding.

Endometrial cancer in the elderly: Characteristics, prognostic and risk factors, and treatment options

Endometrial cancer incidence and related mortality are on the rise due to aging demographics. This population often presents with unfavorable features, such as myometrial invasion, non-endometrioid histology, high-grade tumors, worse prognosis, etc. The role of age as an independent prognostic factor is still debated, and screening tools addressing frailty emerge as pivotal in guiding treatment decisions; however, they are still underutilized. Treatment disparities are evident in the case of older patients with endometrial cancer, who frequently receive suboptimal care, hindering their survival. Radiotherapy and minimally invasive surgical approaches could be performed in older patients. Data on chemotherapy and immunotherapy are scarce, but their potential remains promising and data are being gathered by recent trials, contingent on optimal patient selection through geriatric assessments. Overall, we recommend personalized, screening tool-guided approaches, adherence to guideline-recommended treatments, and inclusion of older people in clinical trials to help identify the best course of treatment.

Potential predictive biomarkers in antitumor immunotherapy: navigating the future of antitumor treatment and immune checkpoint inhibitor efficacy

Immune checkpoint inhibitors (ICIs) have revolutionized cancer treatment modality, offering promising outcomes for various malignancies. However, the efficacy of ICIs varies among patients, highlighting the essential need of accurate predictive biomarkers. This review synthesizes the current understanding of biomarkers for ICI therapy, and discusses the clinical utility and limitations of these biomarkers in predicting treatment outcomes. It discusses three US Food and Drug Administration (FDA)-approved biomarkers, programmed cell death ligand 1 (PD-L1) expression, tumor mutational burden (TMB), and microsatellite instability (MSI), and explores other potential biomarkers, including tumor immune microenvironment (TIME)-related signatures, human leukocyte antigen (HLA) diversity, non-invasive biomarkers such as circulating tumor DNA (ctDNA), and combination biomarker strategies. The review also addresses multivariable predictive models integrating multiple features of patients, tumors, and TIME, which could be a promising approach to enhance predictive accuracy. The existing challenges are also pointed out, such as the tumor heterogeneity, the inconstant nature of TIME, nonuniformed thresholds and standardization approaches. The review concludes by emphasizing the importance of biomarker research in realizing the potential of personalized immunotherapy, with the goal of improving patient selection, treatment strategies, and overall outcomes in cancer treatment.

The value of a multimodal approach combining radical surgery and intraoperative radiotherapy in the recurrence treatment of gynecological malignancies - analysis of a large patient cohort in a tertiary care center

BACKGROUND

Recurrent and locally advanced gynecological malignancies have a poor prognosis. In particularly, pelvic local recurrence after previous radiotherapy and/or positive resection margins during surgical treatment for recurrent disease result in low survival rates. Consequently, locoregional control is of utmost importance in this cohort of patients. The aim of this study was to analyze treatment outcomes and determine prognostic factors for patients treated with surgery and intraoperative radiotherapy (IORT) for recurrent and locally advanced gynecological malignancies.

METHODS

40 patients who underwent surgical treatment and IORT between 2010 and 2022 were eligible for inclusion. The median follow-up time was 22 months. The outcomes measured were locoregional control (LRC), overall survival (OS), and survival without distant metastases (DMFS). The Cox proportional hazards model was used for univariate and multivariate analysis to assess the impact of patient variables and treatment factors on the endpoints mentioned. The following variables were analyzed: age at surgical treatment and IORT and initial diagnosis (< 65 vs. ≥65 years, each), disease-free interval (DFI) between initial diagnosis and first recurrence, DFI to surgical treatment and IORT, grading, histology, IORT dose (≤ 13 vs. >13 Gy) and technique (high dose radiotherapy (HDR) vs. IORT using electrons, (IOERT)). Survival curves were generated using the Kaplan-Meier method.

RESULTS

The mean IORT dose was 13.8 Gy (range 10-18 Gy). Cervical carcinoma was most frequently found in 27.5% of patients followed by endometrial carcinoma and vulvar carcinoma in 25% respectively. The final histopathologic results after surgery with IORT showed no residual tumour in 24 patients (60%), microscopic residual disease in 5 patients (12.5%), resection status could not be evaluated in three patients (7.5%) and the resection status was unknown in eight patients (20%). Subsequently, 27.5% of patients also received adjuvant radiotherapy of the local recurrence bed. However, after IORT, 65% of the women suffered a recurrence. Of these, the recurrences were localized: in-field 32.5%, out-of-field 22.5% and margin-of-field 12.5%. The 3- and 5-year OS was 69% and 55% respectively. The 3- and 5-year LRC was 56% respectively. The 3- and 5-year DMFS was 66% and 49%. Whereas the comparison between groups by IORT dose level (≤ 13 vs. >13 Gy) showed a non-significant trend in favor of the higher dose only for OS (p = 0.094), but not in LRC and DMFS (p > 0.05). OS and DMFS, but not LRC, differed significantly between the HDR-IORT and IOERT groups (p = 0.06 and p = 0.03,) in favor of the HDR-IORT technique. For HDR-IORT technique a trend towards superior OS and LRC was observed in the univariate analysis: HR 3.76, CI 95%: 0.95-14.881, p = 0.059 and HR 2.165 CI 95%: 0.916-5.114, p = 0.078 CONCLUSIONS: The survival rate for pelvic recurrence in gynecological malignancies remains poor and comparable with historical data from the last two decades. Particularly HDR-IORT, appears to provide a long-term oncological benefit in carefully selected patients.

Treatment Strategies for Advanced Endometrial Cancer According to Molecular Classification

The management of advanced endometrial cancer (EC) has changed in the last few years due to the introduction of a new molecular classification and the approval of immunotherapy. For a long time, carboplatin plus paclitaxel was considered the standard treatment for first-line advanced EC, since the approval of the combination of chemotherapy plus immunotherapy. For patients with recurrent EC, with previous platinum-based chemotherapy, single-agent immunotherapy or in combination with tyrosine-kinase inhibitor (TKI) has been approved according to mismatch repair status. Ongoing trials are exploring the possibility of a chemo-free future for mismatch repair-deficient (dMMR) EC and new molecular targets are under investigation. The treatment paradigm for advanced EC has shifted from standard chemotherapy for all to a more personalized approach. The aim of this review is to provide an updated therapeutic landscape for the management of patients with advanced/metastatic EC according to their disease history and molecular biology.

Efficacy and safety of immune checkpoint inhibitors for advanced or recurrent endometrial cancer: a systematic review and network meta-analysis

BACKGROUND

Currently, several randomized controlled trials (RCTs) have been conducted to investigate the efficacy of combining immune checkpoint inhibitors (ICIs) with chemotherapy as a first-line treatment for advanced or recurrent endometrial cancer; however, the optimal treatment strategy remains undetermined.

METHODS

A comprehensive search of online databases was conducted to identify RCTs published until December 31, 2023. Network meta-analysis was performed to evaluate PFS, OS, TRAEs, irAEs, and the ranking of different treatment regimens.

RESULTS

A total of 2702 patients from five RCTs (six reports) were included in the analysis. The combination therapy of ICIs significantly prolonged PFS (HR = 0.69, 95%CI 0.63-0.76, p < 0.0001) and OS (HR = 0.73, 95%CI 0.63-0.85, p < 0.0001) in the overall population. Among the different ICIs combinations evaluated, Durva-Olap-CP exhibited superior efficacy for both PFS and OS outcomes. In the pMMR population, both Durva-Olap-CP and Pembro-CP significantly reduced the risk of disease progression or death compared to Avelu-CP and Atezo-CP treatments; however, no significant differences were observed among various ICI combination therapies in patients with dMMR. In the dMMR population, Dostar-CP demonstrates a 42.2% probability of achieving first rank in terms of PFS, whereas in the pMMR population, Pembro-CP exhibits a 60% likelihood of securing the top position. Importantly, the toxicity associated with ICIs combination therapy was manageable and well-tolerated.

CONCLUSIONS

The combination of ICIs and chemotherapy as first-line treatment for advanced or recurrent endometrial cancer has demonstrated superior survival outcomes compared to chemotherapy alone. Durva-Olap-CP exhibited the most favorable PFS and OS benefits in the overall population. In patients with dMMR, Dostar-CP showed the greatest improvement in PFS, while Pembro-CP demonstrated the most pronounced PFS benefit in patients with pMMR.

Unraveling the Heterogeneity of Deficiency of Mismatch Repair Proteins in Endometrial Cancer: Predictive Biomarkers and Assessment Challenges

Endometrial cancer (EC) poses a significant global health challenge, with increasing prevalence in 26 of 43 countries and over 13,000 deaths projected in the United States by 2024. This rise correlates with aging populations, the obesity epidemic, and changing reproductive patterns, including delayed childbearing. Despite the early diagnosis in 67% of cases, approximately 30% of cases present with regional or distant spread, leading to nearly 20% mortality rates. Unlike many cancers, EC mortality rates are escalating, outpacing therapeutic advancements until recently. One of the reasons for this was the lack of effective therapeutic options for advanced disease until recently. The introduction of immunotherapy has marked a turning point in EC treatment, particularly benefiting patients with defects in mismatch repair proteins (dMMRs). However, dMMR status alone does not ensure a favorable response, underscoring the need for precise patient selection. This review explores the pivotal role of mismatch repair proteins in EC, emphasizing their heterogeneity, the challenges in their assessment, and their potential as predictive biomarkers.

Identification of molecular subtypes for endometrial carcinoma using a 46-gene next-generation sequencing panel: a retrospective study on a consecutive cohort

BACKGROUND

Traditional classification tools for endometrial carcinoma (EC), such as DNA sequencing, immunohistochemistry (IHC), or PCR, are cumbersome and time-consuming. Large next-generation sequencing (NGS) panels have simplified testing but are expensive. In this study, we propose a concise NGS panel as an effectively viable approach for classifying EC.

MATERIALS AND METHODS

We retrospectively enrolled a consecutive EC cohort of hysterectomy with bilateral salpingo-oophorectomy from Fudan University Shanghai Cancer Center between 2020 and 2022. A 46-gene NGS panel was utilized to identify POLE exonuclease domain mutations, microsatellite instability-high (MSI-H), TP53 mutations, and other clinically relevant targets.

RESULTS

Tumor tissue samples from 331 EC patients were evaluated, with 284 (85.8%) cases classified as endometrioid endometrial carcinoma. The median follow-up time was 32.6 months (n = 303), during which 23 patients experienced recurrence or disease progression. Using the concise NGS panel, patients were stratified into four molecular subgroups according to the World Health Organization classification criteria: POLE mut (n = 47; 14.2%), mismatch repair deficiency (dMMR) (n = 79; 23.9%), non-specific molecular profile (n = 148; 44.7%), and abnormal p53 expression (p53 abn) (n = 57; 17.2%). POLE mut displayed the most favorable prognosis, while p53 abn had the worst prognosis (P < 0.001). The concordance between NGS and IHC was 91.8% (269/293) for detecting MMR status and 65.3% (201/308) for detecting p53 status. Patients detected solely by NGS had significantly worse prognosis than those detected solely by IHC, indicating higher accuracy of the NGS panel. With the molecular subtyping information, adjuvant treatment plans for 19.6% of patients could potentially be altered, mainly concentrated in the POLE mut and p53 abn subtypes. This panel also aids targeted therapy and poly (ADP-ribose) polymerase (PARP) inhibitor-related gene mutation detection, as well as auxiliary genetic screening.

CONCLUSION

Our study demonstrates that the concise NGS panel is an effective 'one-stop' strategy for precisely classifying EC with high clinical availability.

Safety of dostarlimab in combination with chemotherapy in patients with primary advanced or recurrent endometrial cancer in a phase III, randomized, placebo-controlled trial (ENGOT-EN6-NSGO/GOG-3031/RUBY)

Background

In Part 1 of the phase III RUBY trial (NCT03981796) in patients with primary advanced or recurrent endometrial cancer (EC), dostarlimab plus carboplatin-paclitaxel (CP) significantly improved progression-free survival and overall survival compared with CP alone. Limited safety data have been reported for the combination of immunotherapies plus chemotherapy in this setting.

Objectives

The objective of this analysis was to identify the occurrence of treatment-related adverse events (TRAEs) and immune-related adverse events (irAEs) and to describe irAE management in Part 1 of the RUBY trial.

Design

RUBY is a phase III, randomized, double-blind, multicenter study of dostarlimab plus CP compared with CP alone in patients with primary advanced or recurrent EC.

Methods

Patients were randomized 1:1 to dostarlimab 500 mg, or placebo, plus CP every 3 weeks for 6 cycles, followed by dostarlimab 1000 mg, or placebo, every 6 weeks for up to 3 years. Adverse events (AEs) were assessed according to Common Terminology Criteria for Adverse Events, version 4.03.

Results

The safety population included 487 patients who received ⩾1 dose of treatment (241 dostarlimab plus CP; 246 placebo plus CP). Treatment-emergent AEs were experienced by 100% of patients in both arms. TRAEs occurred in 97.9% of the dostarlimab arm and 98.8% of the placebo arm.The most common TRAEs occurred at similar rates between arms and were mostly low grade. IrAEs occurred in 58.5% of patients in the dostarlimab arm and 37.0% of patients in the placebo arm. Dostarlimab- or placebo-related irAEs were reported in 40.7% of patients in the dostarlimab arm and 16.3% of the placebo arm.

Conclusion

The safety profile of dostarlimab plus CP was generally consistent with that of the individual components. Dostarlimab plus CP has a favorable benefit-risk profile and is a new standard of care for patients with primary advanced or recurrent EC.

Trial registration

NCT03981796.

DNA damage response in breast cancer and its significant role in guiding novel precise therapies

DNA damage response (DDR) deficiency has been one of the emerging targets in treating breast cancer in recent years. On the one hand, DDR coordinates cell cycle and signal transduction, whose dysfunction may lead to cell apoptosis, genomic instability, and tumor development. Conversely, DDR deficiency is an intrinsic feature of tumors that underlies their response to treatments that inflict DNA damage. In this review, we systematically explore various mechanisms of DDR, the rationale and research advances in DDR-targeted drugs in breast cancer, and discuss the challenges in its clinical applications. Notably, poly (ADP-ribose) polymerase (PARP) inhibitors have demonstrated favorable efficacy and safety in breast cancer with high homogenous recombination deficiency (HRD) status in a series of clinical trials. Moreover, several studies on novel DDR-related molecules are actively exploring to target tumors that become resistant to PARP inhibition. Before further clinical application of new regimens or drugs, novel and standardized biomarkers are needed to develop for accurately characterizing the benefit population and predicting efficacy. Despite the promising efficacy of DDR-related treatments, challenges of off-target toxicity and drug resistance need to be addressed. Strategies to overcome drug resistance await further exploration on DDR mechanisms, and combined targeted drugs or immunotherapy will hopefully provide more precise or combined strategies and expand potential responsive populations.

[Association Between the Protein Expressions of MutS Homologs and Villin and the Clinicopathological Characteristics in 310 Colon Cancer Patients]

Objective

To examine the relationship between the expressions of mismatch repair proteins, MutS homolog 2 (MSH2) and MutS homolog 6 (MSH6), and villin and the pathological features in patients with colon cancer.

Methods

A total of 310 cases of colon cancer patients who were treated at our hospital between January 2017 and September 2021 were selected. The diagnosis of colon cancer of all patients was verified by pathological evaluation. Immunohistochemistry was used to determine the protein expressions of MSH2, MSH6, and villin. The correlation between the expressions of MSH2, MSH6, and villin and the clinicopathological parameters in patients with colon cancer was analyzed accordingly. Multivariate logistic regression was used to analyze the correlation between the expressions of MSH2, MSH6, and villin and the clinicopathological parameters of colon cancer. Kaplan-Meier survival curve was used to compare the 2-year survival rates of colon cancer patients with different expression levels of the proteins.

Results

Among the 310 patients with colon cancer, the negative expression rates of MSH2, MSH6, and villin proteins in cancer tissues were 8.71% (27/310), 9.35% (29/310), and 46.13% (143/310), respectively. The negative expression rates of the three proteins in tissues adjacent to cancer were 3.23% (10/310), 4.19% (13/310), and 9.68% (30/310), respectively. The negative expression rates of the three proteins in cancer tissues were all higher than those in adjacent tissues (P<0.05). Regression analysis showed that the expression of MSH2 and MSH6 in cancer tissues was correlated with the age, the location of tumor lesions, tumor differentiation degree, and lymph node metastasis in colon cancer patients (P<0.05). The expression of villin in the cancer tissue is correlated with the depth of tumor infiltration, lymph node metastasis, distant metastasis, and clinical staging status in colon cancer patients (P<0.05). The 2-year survival rates of patients with negative expressions of MSH2 and MSH6 were 51.85% and 44.83%, respectively, which were lower than those of patients with positive expression of MSH2 and MSH6 (79.51% and 80.43%, P<0.05). Thirteen patients (4.1%) had negative expression of MSH2, MSH6, and villin (referred to as "triple negative expressions") in the cancer tissues, and their 2-year survival rate was 30.77%, which was lower than that of colon cancer patients who did not meet the criteria for triple negative expressions (79.12% [235/297], P<0.05).

Conclusion

The expressions of MSH2, MSH6, and villin are closely correlated with the pathological features of colon cancer patients. Evaluating the expression of the three proteins may assist in the clinical diagnosis, treatment, and prognosis evaluation of colon cancer.

Clinical research in endometrial cancer: consensus recommendations from the Gynecologic Cancer InterGroup

The Gynecologic Cancer InterGroup (GCIG) Endometrial Cancer Consensus Conference on Clinical Research (ECCC) was held in Incheon, South Korea, Nov 2-3, 2023. The aims were to develop consensus statements for future trials in endometrial cancer to achieve harmonisation on design elements, select important questions, and identify unmet needs. All 33 GCIG member groups participated in the development, refinement, and finalisation of 18 statements within four topic groups, addressing adjuvant treatment in high-risk disease; treatment for metastatic and recurrent disease; trial designs for rare endometrial cancer subgroups and special circumstances; and specific methodology and adaptation for trials in low-resource settings. In addition, eight areas of unmet need were identified. This was the first GCIG Consensus Conference to include patient advocates and an expert on inclusion, diversity, equity, and access to take part in all aspects of the process and output. Four early-career investigators were also selected for participation, ensuring that they represented different GCIG member groups and regions. Unanimous consensus was obtained for 16 of the 18 statements, with 97% concordance for the remaining two. Using the described methodology from previous Ovarian Cancer Consensus Conferences, this conference did not require even one minority statement. The high acceptance rate following active involvement in the preparation, discussion, and refinement of the statements by all representatives confirmed the consensus progress within a global academic setting, and the expectation that the ECCC will lead to greater harmonisation, actualisation, inclusion, and resolution of unmet needs in clinical research for individuals living with and beyond endometrial cancer worldwide.

Locally advanced and metastatic endometrial cancer: Current and emerging therapies

Until recently, patients diagnosed with locally advanced and metastatic endometrial cancer faced significant challenges in their treatment due to limited options and poor prognostic outcomes. The sequencing of tumors has been a major advancement in its management. It has led to The Cancer Genome Atlas classification currently used in clinical practice and the initiation of several clinical trials for innovative treatments targeting principally signaling pathways, immune checkpoints, DNA integrity, growth factors, hormonal signaling, and metabolism. Numerous clinical trials are investigating a combinatorial approach of these targeted therapies to counter tumoral resistance, cellular compensatory mechanisms, and tumor polyclonality. This review provides a comprehensive overview of historical, current, and promising therapies in advanced and metastatic endometrial cancer. It particularly highlights clinical research on targeted and hormonal therapies, but also immunotherapy, reflecting the evolving landscape of treatment modalities for this disease.

Atezolizumab and chemotherapy for advanced or recurrent endometrial cancer (AtTEnd): a randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

At the time of AtTEnd trial design, standard treatment for advanced or recurrent endometrial cancer included carboplatin and paclitaxel chemotherapy. This trial assessed whether combining atezolizumab with chemotherapy might improve outcomes in this population.

METHODS

AtTEnd was a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial done in 89 hospitals in 11 countries across Europe, Australia, New Zealand, and Asia. Enrolled patients were aged 18 years or older, and had advanced or recurrent endometrial carcinoma or carcinosarcoma, an Eastern Cooperative Oncology Group performance status of 0-2, and received no previous systemic chemotherapy for recurrence. Patients were randomly assigned (2:1) using an interactive web response system (block size of six) to either atezolizumab 1200 mg or placebo given intravenously with chemotherapy (carboplatin at area under the curve of 5 or 6 and paclitaxel 175 mg/m2 intravenously on day 1 every 21 days) for 6-8 cycles, then continued until progression. Stratification factors were country, histological subtype, advanced or recurrent status, and mismatch repair (MMR) status. Participants and treating clinicians were masked to group allocation. The hierarchically tested co-primary endpoints were progression-free survival (in patients with MMR-deficient [dMMR] tumours, and in the overall population) and overall survival (in the overall population). Primary analyses were done in the intention-to-treat population, defined as all randomly assigned patients who gave their full consent to participation in the study and data processing. Safety was assessed in all patients included in the intention-to-treat population who received at least one dose of study treatment. Here, we report the primary progression-free survival and the interim overall survival results. This study is ongoing and is registered with ClinicalTrials.gov, NCT03603184.

FINDINGS

Between Oct 3, 2018, and Jan 7, 2022, 551 patients were randomly assigned to atezolizumab (n=362) or placebo (n=189). Two patients in the atezolizumab group were excluded from all analyses due to lack of consent. Median follow-up was 28·3 months (IQR 21·2-37·6). 81 (23%) patients in the atezolizumab group and 44 (23%) patients in the placebo group had dMMR disease by central assessment. In the dMMR population, median progression-free survival was not estimable (95% CI 12·4 months-not estimable [NE]) in the atezolizumab group and 6·9 months (6·3-10·1) in the placebo group (hazard ratio [HR] 0·36, 95% CI 0·23-0·57; p=0·0005). In the overall population, median progression-free survival was 10·1 months (95% CI 9·5-12·3) in the atezolizumab group and 8·9 months (8·1-9·6) in the placebo group (HR 0·74, 95% CI 0·61-0·91; p=0·022). Median overall survival was 38·7 months (95% CI 30·6-NE) in the atezolizumab group and 30·2 months (25·0-37·2) in the placebo group (HR 0·82, 95% CI 0·63-1·07; log-rank p=0·048). The p value for the interim analysis of overall survival did not cross the stopping boundary; therefore, the trial will continue until the required number of events are recorded. The most common grade 3-4 adverse events were neutropenia (97 [27%] of 356 patients in the atezolizumab group vs 51 [28%] of 185 in the placebo group) and anaemia (49 [14%] vs 24 [13%]). Treatment-related serious adverse events occurred in 46 (13%) patients in the atezolizumab group and six (3%) patients in the placebo group. Treatment-related deaths occurred in two patients (pneumonia in one patient in each group).

INTERPRETATION

Atezolizumab plus chemotherapy increased progression-free survival in patients with advanced or recurrent endometrial carcinoma, particularly in those with dMMR carcinomas, suggesting the addition of atezolizumab to standard chemotherapy as first-line treatment in this specific subgroup.

FUNDING

F Hoffmann-La Roche.

The Clinicopathological Features and Prognoses of Lower Uterine Segment Cancer: A Retrospective, Single-Center Cohort Study

Introduction

This study used single-center data to analyze the clinicopathological features of site-specific endometrial cancer.

Methods

Patients with endometrial carcinoma who had undergone surgery at Peking Union Medical College Hospital, China, between March 2016 and January 2022 were enrolled. Clinical information and pathological characteristics were summarized, and microsatellite status was analyzed using the immunohistochemical method. Patient prognoses were measured in terms of the rates of overall survival and progression-free survival.

Results

The mean patient age was 49 years (ranging: from 25 to 76 years old), and there was no difference in clinicopathological features between endometrioid and type II endometrial carcinoma in LUSC. The ER and PR expression ratios were 80.4% and 64.3%, respectively, in this LUSC cohort, and the MMR deficiency ratio was 33.9%, including 39.6% in endometrioid carcinoma and 15.4% in type II endometrial carcinoma. Combined MSH2&MSH6 loss was more common than combined MLH1&PMS2 being unexpressed (16.1% vs 12.5%), and dMMR patients differed significantly from the pMMR group in terms of vascular invasion (P=0.003). The combination of chemotherapy and radiotherapy did not provide a statistically significant improvement in prognosis compared to chemotherapy alone.

Conclusion

The results of this study showed that LUSC patients tended to be younger and their tumors had less expression of hormone markers. The biological behavior of both endometrioid cancer and type II EC may be similar when EC occurs in this area. Furthermore, this type of tumor also showed a higher incidence of vascular invasion, and the combination of chemotherapy and radiotherapy did not provide significant improvement. Thus, successful treatment of LUSC tumors requires aggressive surgical intervention and a more effective postoperative treatment approach.