Molecular Classification of the PORTEC-3 Trial for High-Risk Endometrial Cancer: Impact on Prognosis and Benefit From Adjuvant Therapy

Rare Uterine Tumors: What to Do?

Rare uterine malignancies present treatment challenges because of their clinical and biological heterogeneity. Among the rarest of the uterine cancers are leiomyosarcomas, uterine stromal tumors, and the mesonephric-like and serous carcinomas. In this article, we review recent advancements in diagnostic precision, risk stratification, and identification of biomarker-guided therapeutic options for these rare subtypes of uterine tumors. The improved understanding of the molecular profile of these tumors has led to the development of targeted treatment approaches. Further progress will depend on a coordinated, global effort to further characterize these diseases and enroll patients on biomarker-driven clinical trials.

Prognostic significance of estrogen receptor expression and estrogen signaling in endometrial carcinomas of no specific molecular profile: A comprehensive molecular and pathologic analysis

INTRODUCTION

Copy number-low (CNL) endometrial cancer (EC), also known as no specific molecular profile (NSMP), is the most heterogeneous molecular subtype. In this study, we evaluated the prognostic significance of estrogen receptor (ER) and PTEN expression in primary untreated CNL/NSMP ECs across all histologic subtypes to further refine risk stratification within this heterogeneous group.

METHODS

We identified a total of 1835 CNL/NSMP ECs that underwent clinical sequencing of 410-468 cancer-related genes. Of these, we randomly selected 100 CNL/NSMP ECs and evaluated ER and PTEN expression by immunohistochemistry. We recorded clinicopathological data regarding tumor histology and estrogen signaling sources, including ovarian volume, menopausal status, body mass index, exogenous sources of estrogen, and hotspot mutations in ESR1. We used Cox regression models to evaluate the prognostic value of these variables.

RESULTS

We observed ER positivity in 85 % of CNL/NSMP ECs, with absence of ER expression significantly associated with adverse progression-free (HR, 3.75; 95 % CI, 1.78-7.9) and overall survival (HR, 6; 95 % CI, 2.39-15.1). We observed PTEN loss of expression in 59 % of CNL/NSMP ECs, but it was not associated with survival outcomes. Multivariate analysis identified high-grade histology (HR, 6.75; 95 % CI, 2.5-17.9), lack of ER expression (HR, 3.46; 95 % CI, 1.2-9.7), and absence of any estrogen signaling sources (HR, 3.87; 95 % CI, 1.4-10.7) as significant prognostic factors for poor overall survival.

CONCLUSION

ER positivity is associated with more favorable survival outcomes in CNL/NSMP EC. These data support dividing patients with CNL/NSMP EC into two distinct prognostic subgroups based on ER immunohistochemistry.

The Role of Surgery in Management of Primary Metastatic Endometrial Cancer

For the majority of patients with endometrial cancer who are diagnosed at an early stage, high-quality evidence directs mainstay initial surgical treatment, which confers excellent long-term survival. Conversely, the 8%-15% of endometrial cancers diagnosed at a clinically advanced stage with primary metastatic disease have a significantly worse prognosis and a 5-year relative survival rate of 15%-20%. The management of primary advanced endometrial cancer is understudied with the majority of relevant evidence being retrospective, single institution, and in heterogenous populations (combined with management of recurrent endometrial cancer), and there are few prospective studies that focus solely on primary advanced disease. It appears that hysterectomy and surgical cytoreduction may improve long-term survival in metastatic endometrial cancer; however, it remains unclear which patients are most likely to benefit. Furthermore, the new integration of molecular classifications to the management of endometrial cancer has opened up new prognosis and treatment perspectives; however, the majority of current trials investigating new management paradigms based on molecular features exclude advanced-stage disease, so the implications for practice regarding this patient group are understudied. This review analyzes the current available evidence regarding surgical management of primary metastatic endometrial cancer, including current international guideline recommendations, evidence for primary cytoreductive surgery and neoadjuvant systemic treatment followed by surgery, surgical resection of distant metastases, and lymph node management.

Pragmatic preoperative molecular classification of endometrial cancers; Replacing POLE sequencing with hormone receptor staining

OBJECTIVE

Molecular classification including POLE sequencing is encouraged for all endometrial cancer (EC) patients, although the relevance of POLE sequencing has been questioned. We aimed to determine whether POLE sequencing can be omitted when introducing hormone receptor (HR) immunohistochemical staining.

METHODS

Preoperative EC biopsies were molecularly classified according to two different algorithms: a pragmatic approach including staining of HRs, p53 and mismatch repair (MMR) proteins but omitting POLE sequencing (n = 534), and the conventional algorithm including POLE sequencing and with patients completely overlapping with the pragmatic cohort (n = 505). The two algorithms were tested by Cox proportional hazard analysis calculating the probability of disease-specific survival (DSS) (hazard ratios) with 95 % confidence intervals.

RESULTS

Both classifiers identified four patient groups with significantly different prognosis (p < 0.001). However, with the pragmatic approach, the group with lowest risk included 44 % of the patients, as compared to 7 % using the conventional algorithm. In the preoperative setting, Cox proportional hazard analysis demonstrated that the pragmatic algorithm was stronger to predict DSS than the conventional algorithm. Only 1.4 % (7/498) of patients failed to be identified for potential POLE-driven de-escalation of treatment using the pragmatic algorithm.

CONCLUSIONS

Preoperative evaluation of ER, PR, MMR and p53 identifies four molecular and prognostic groups. This pragmatic classification allows POLE sequencing to be omitted. Our proposed algorithm saves time and resources and is a valuable alternative to full molecular classification.

MMRNet: Ensemble deep learning models for predicting mismatch repair deficiency in endometrial cancer from histopathological images

Combining molecular classification with clinicopathologic methods improves risk assessment and chooses therapies for endometrial cancer (EC). Detecting mismatch repair (MMR) deficiencies in EC is crucial for screening Lynch syndrome and identifying immunotherapy candidates. An affordable and accessible tool is urgently needed to determine MMR status in EC patients. We introduce MMRNet, a deep convolutional neural network designed to predict MMR-deficient EC from whole-slide images stained with hematoxylin and eosin. MMRNet demonstrates strong performance, achieving an average area under the receiver operating characteristic curve (AUROC) of 0.897, with a sensitivity of 0.628 and a specificity of 0.949 in internal cross-validation. External validation using three additional datasets results in AUROCs of 0.790, 0.807, and 0.863. Employing a human-machine fusion approach notably improves diagnostic accuracy. MMRNet presents an effective method for identifying EC cases for confirmatory MMR testing and may assist in selecting candidates for immunotherapy.

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.

Patterns of primary metastasis and recurrence in mismatch repair deficiency and p53 abnormal endometrial carcinoma

OBJECTIVES

Molecular classification of endometrial carcinoma(EC) provides relevant prognostication and is now being utilized to determine adjuvant therapy. It is currently unclear how molecular classification relates to disease dissemination and recurrence patterns in EC. The objective of this study was to characterize patterns of disease in mismatch repair-deficient (MMRd) and p53 abnormal (p53abn) carcinomas.

METHODS

Immunohistochemistry molecular classification was performed to relate patterns of disease spread among EC patients undergoing surgical staging/cytoreduction. Dissemination patterns were assigned according to the most distant site of disease and subdivided as carcinomatosis, visceral organ, or lymphatic locations. Standard statistical methods were employed for comparisons, including multivariate logistic regression.

RESULTS

Of 380 cases, 127 had advanced disease at presentation: 43.4 % pelvic, 44.8 % lower abdominal, 7.1 % upper abdominal and 4.7 % extra-abdominal. P53abn carcinomas were more likely to present with peritoneal-based disease compared to MMRd and p53wt tumors(30.8 %, 11.7 %, and 9.7 %, p < 0.0001). Among 128 patients with recurrence, upper abdominal spread and carcinomatosis were more common with p53abn than MMRd or p53wt tumors(49.2 %, 10 %, 8.2 %, p < 0.0001 and 60.8 %, 7.5 %, 18.9 %, p < 0.0001). MMRd tumors were associated with lymphatic recurrences compared to p53abn or p53wt(55 %, 19.6 %, 35.1 %, p = 0.001). These associations remained significant in multivariate analysis.

CONCLUSIONS

EC recurrence patterns differ based on molecular classification. Patients with p53abn cancers are more likely to present with peritoneal-based disease and experience peritoneal recurrence. Patients with MMRd cancers are more likely to experience lymphatic-based recurrences. This information provides a model of biologic behavior of molecular subtypes that can inform prospective surgical and therapeutic trials.

Frequency of microsatellite instability in gynecologic cancers and the efficacy of immune checkpoint inhibitors treated: real-world data from a single gynecologic center

Objective

This study evaluated the incidence of Microsatellite Instability-High (MSI-H) in patients with gynecologic cancers in a single gynecologic center and investigated the effect of immune checkpoint inhibitors (ICIs) in treating MSI-H in advanced or recurrent gynecologic cancers.

Methods

We conducted a retrospective study of patients diagnosed with gynecological cancers between June 2021 and May 2024. We investigated their clinicopathological information, the results of microsatellite instability (MSI), the immunohistochemistry staining PD-L1 analyses, the molecular classification testing, and the tumor response to treatment with ICIs.

Results

Among 1333 patients included in the analysis, the frequency of MSI-H was 1.3% (3/223) in cervical cancer, 25.7% (280/1091) in endometrial cancer, and 10.5% (2/19) in ovarian or tubal and peritoneal cancer. When the patients were evaluated by histologic type, the frequency of MSI-H was 26.1% (241/921) in endometrioid adenocarcinoma and 35.1% (20/57) in mixed adenocarcinoma. Molecular classification results for the 1020 cases that successfully underwent the tests were 71 for the POLE mutation (POLEmut) subtype, 271 for MMR-deficiency (MMRd) subtype, 571 for the non-specific molecular profile (NSMP) subtype, and 107 for the p53 abnormality (p53abn) subtype. Thirty-five patients were treated with ICIs for at least one cycle. The objective response rate (ORR) was 34.3% (95% CI, 19.1% to 52.2%). Among the patients who achieved an objective response, the median time to respond was 2.65 months, and the median duration of response had not been reached. The median progression-free survival (PFS) was 9 months (95% CI, 4 to 10), and the median overall survival (OS) had not been reached. Additionally, in the patients with endometrial cancer, the median PFS in MSI-H patients was 5 months versus 3 months in microsatellite stable (MSS) patients (Δ = 2 months; p=0.92), and the median OS in both MSI-H and MSS patients had not been reached (p=0.89).

Conclusion

This study had shown the MSI-H frequencies for the three major types of gynecological tumors and demonstrated the clinical benefit of treatment with ICIs in patients with advanced or recurrent gynecologic cancer. Among endometrial cancer patients, the effects of immunotherapy may be consistent regardless of MSI status.

Association of endometrial cancer epigenetic mismatch repair deficiency with clinicopathologic factors and survival in a large, diverse community-based cohort

OBJECTIVES

To evaluate associations between epigenetic mismatch repair deficiency (MMRd), clinicopathologic factors and overall survival in a diverse endometrial cancer cohort.

METHODS

Retrospective analysis of patients with endometrioid cancer whose tumor mismatch repair status was classified by a universal screening program. Associations between epigenetic MMRd, race, other patient characteristics, tumor grade, and stage were assessed using multivariate regression. The Kaplan-Meier method and Cox regression were used to evaluate the association between epigenetic MMRd and overall survival, stratified by receipt of adjuvant therapy.

RESULTS

Among 6477 patients, 14.3 % were found to have MMRd tumors due to epigenetic promoter hypermethylation. Compared to MMR proficient (MMRp) tumors, epigenetic MMRd was associated with age ≥ 70 (P < 0.001) and obesity (P = 0.03) but not smoking or comorbidity burden and were less common in Hispanic patients (P < 0.01) and individuals of lower socioeconomic status (P < 0.001). Epigenetic MMRd was associated with non-localized stage independent of tumor grade (aOR 1.28, 95 % CI 1.05-1.55, P = 0.01) and lower survival among the 4754 (73 %) patients not treated with any adjuvant therapy (HR 1.44, 95 % CI 1.09-2.01, P = 0.02) but not among 1723 (27 %) who received adjuvant chemotherapy, radiotherapy and/or immunotherapy (HR 0.89, 95 % CI 0.60-1.33, P = 0.56).

CONCLUSION

In a diverse community-based cohort, epigenetic MMRd characterized 14.3 % of endometrioid endometrial cancers and was associated with older age, obesity, and higher socioeconomic status. Controlling for these factors, epigenetic MMRd tumors were less common among Hispanic patients. Epigenetic MMRd was associated with non-localized stage independent of tumor grade and lower survival among patients who did not receive adjuvant therapy.

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.

Exploring endometrial cancer risk stratification by copy number assessment

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Prognostic Value of Tumor Cell Clusters in the Fallopian Tube Lumen in Stage I Endometrioid Carcinoma

The aim of this study was to investigate the pathologic prognostic factors such as tumor cell clusters (TCCs) in the fallopian tube lumen, myometrial invasion patterns, and positive peritoneal cytology (PPC) in women with Stage I endometrial endometrioid carcinoma (EEC). From 2009 to 2020, consecutive patients with Stage I EEC who underwent hysterectomy and bilateral salpingectomy were included. The primary outcome was the recurrence-free survival (RFS) rate, and the clinicopathological factors affecting RFS were analyzed. A total of 765 patients were enrolled. Seventeen patients (2.2%) had TCC in the fallopian tube lumen, and 58 patients showed a microcystic elongated and fragmented pattern (7.6%). PPC was found in 19 patients (2.5%). The median follow-up period was 61.0 months (range: 2.0-149.7). The majority (88.6%) of patients had Stage IA EEC. The 5-year RFS and overall survival rates were 97.5% and 98.5%, respectively. In multivariate analysis for RFS, the significant prognostic factors were lymphovascular invasion (hazard ratio = 4.604; 95% CI: 1.387-15.288; P = 0.013) and grade (grade 2; hazard ratio = 4.949; 95% CI: 1.035-23.654; P = 0.045, and grade 3; hazard ratio = 5.469; 95% CI: 1.435-20.848; P = 0.013). Other pathologic factors including TCC in the fallopian tube lumen, myometrial invasion patterns, PPC, and hormonal status had no prognostic significance. TCC in the fallopian tube lumen, myometrial invasion pattern, PPC, and estrogen and progesterone receptor positivity were not significant prognostic factors in Stage I EEC. In contrast, lymphovascular invasion and grade were significant prognostic factors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adjuvant treatment in stage I clear cell endometrial carcinoma: A population-based study of survival outcomes

OBJECTIVE

Uterine clear cell carcinoma (UCCC) is a rare but aggressive histologic type of endometrial cancer. Recommendations for adjuvant treatment of early-stage UCCC remain vague. The objective of this study is to assess the impact of adjuvant treatment on survival outcomes of patients with stage I UCCC.

METHODS

Using the Surveillance, Epidemiology and End Results database (SEER), patients with stage I UCCC were identified. Disease-specific survival (DSS) as well as overall survival (OS) for patients who underwent observation alone versus adjuvant treatment with either chemotherapy alone, radiotherapy (RT) alone, or chemotherapy plus RT, were analyzed by Kaplan-Meier (K-M) survival estimates and multivariate Cox proportion hazards model.

RESULTS

The study included 881 patients with stage I UCCC. Kaplan-Meier estimates showed no difference in DSS among those who underwent observation versus adjuvant treatment. In the multivariate model for DSS, tumor size ≥40 mm was associated with an increased risk of death (HR 2.02, p = 0.0267) while living in a metropolitan county decreased the risk of death (HR 0.46, p = 0.009). The K-M curve for OS showed a significant difference among the four treatment groups (p = 0.0475), with a 10-year OS of 61 % for patients who received no adjuvant treatment versus 74 % for those receiving chemotherapy plus radiation. However, this difference was not significant in the multivariate analysis.

CONCLUSIONS

In this study of stage I UCCC, the use of adjuvant treatment did not confer a survival advantage. Observation may be considered an acceptable option although prospective research is needed.

Recent advances in gynecologic radiation oncology

Significant advances have been made in the treatment of patients with gynecologic malignancies in the past few years. Integration of molecular testing in endometrial cancer now allows for more accurate risk stratification and personalized treatment recommendations for patients, with PORTEC-4a investigating outcomes after treatment de-escalation based on molecular subgroup. In several clinical trials, mismatch repair-deficiency (MMR-d) status has been proven to be a strong predictor for response to immunotherapy in the advanced/metastatic setting, and the role of immunotherapy in early-stage endometrial cancer is now being investigated. For patients with locally advanced cervical cancer, results from INTERLACE demonstrate that induction chemotherapy is now a viable treatment option, and KEYNOTE A-18 shows promise for the addition of concurrent and maintenance pembrolizumab to chemoradiation. Meanwhile, EMBRACE 1 and 2 have demonstrated the benefits of high-quality image guided brachytherapy, providing patients with locally advanced cervical cancer excellent control with improved toxicity. For patients with vulvar cancer, GOG279 demonstrated that addition of multi-agent chemotherapy with intensity modulated radiation therapy resulted in high rates of complete pathologic response, and GROINS-V III is currently investigating the role of chemotherapy and nodal radiation for patients with macrometastases on sentinel lymph node biopsy. This work summarizes the findings of recent landmark trials in endometrial, cervical, and vulvar cancer and their implications for the radiation oncologist.

Molecular subgroup-specific prognostic value of semiquantitative lymphovascular space invasion in early-stage endometrioid endometrial cancer

OBJECTIVE

Molecular subgroups of endometrial carcinoma represent distinct disease entities, prompting subgroup-specific stratification. Recognizing lymphovascular space invasion (LVSI) as a key parameter in risk assessment, this study evaluates 3-tiered LVSI as a molecular subgroup-specific prognostic factor in stage I-II endometrioid endometrial cancer.

METHODS

This retrospective study included patients treated at a single tertiary center. Immunohistochemistry and polymerase-ϵ (POLE) sequencing were conducted for molecular classification and determination of estrogen receptor and L1 cell adhesion molecule (L1CAM) expression.

RESULTS

Among 843 eligible patients (median follow-up: 70 months), survival outcomes differed by molecular subgroup (P < 0.001 for progression-free survival and disease-specific survival). In MMRd carcinomas (n = 364), both focal (P < 0.001) and substantial (P < 0.001) LVSI were associated with poor progression-free survival. In NSMP carcinomas (n = 359), only substantial LVSI (P < 0.001) was prognostic (focal: P = 0.480). In p53abn carcinomas (n = 62), neither focal (P = 0.248) nor substantial (P = 0.484) LVSI showed prognostic significance. These findings remained after bivariate adjustments for stage (IA vs. IB vs. II), grade (low vs. high), estrogen receptor expression (3-tiered scale), L1CAM expression, age, and adjuvant therapy. Analysis was unfeasible for POLE ultramutated tumors (n = 58) due to a single progression.

CONCLUSION

The prognostic impact of 3-tiered LVSI varied by molecular subgroup in stage I-II endometrioid endometrial cancer, highlighting the need for subgroup-specific risk assessment to improve individualized counceling on treatment decisions and risk of progression.

Integrative analysis of DNA methylation, RNA sequencing, and genomic variants in the cancer genome atlas (TCGA) to predict endometrial cancer recurrence

Introduction

The prognosis within each subtype varies due to histological and molecular factors. This study leverages omics datasets and machine learning to identify biomarkers associated with EC recurrence in different molecular subtypes.

Methods

Utilizing DNA methylation, RNA-sequencing, and common variant data from 116 EC samples in The Cancer Genome Atlas (TCGA), differentially expressed genes (DEGs) and differentially methylated regions (DMRs) were identified using t-tests between recurrence and non-recurrence groups. These were visualized through volcano plots and heat maps, while decision trees and random forests classified and stratified the samples.

Results

A machine learning analysis combined with box plots showed that in the copy number-high (CN-H) recurrence group, PARD6G-AS1 had decreased methylation, CSMD1 had increased methylation, and TESC expression was higher than the non-recurrence group. In the copy number-low (CN-L) recurrence group, CD44 expression was elevated. Further validation using TCGA clinical data confirmed PARD6G-AS1 hypomethylation and CD44 overexpression as significant indicators of recurrence (p=0.006 and p=0.02, respectively), and both were linked to advanced stage and lymph node metastasis.

Conclusion

The study concludes that PARD6G-AS1 hypomethylation and CD44 overexpression are potential predictors of recurrence in CN-H and CN-L EC patients, respectively.

Present progress in biomarker discovery of endometrial cancer by multi-omics approaches

Endometrial cancer (EC), a prevalent and intricate disease, is associated with a poor prognosis among gynecological malignancies. Its incidence rising globally underscores the urgent need for biomarkers detection in both research and clinical settings. Over the past decade, we've witnessed rapid advancements in biological methodologies and techniques. A multitude of omics technologies, encompassing genomic/transcriptomic sequencing and proteomic/metabolomic mass spectrometry, have been extensively employed to analyze both tissue and liquid samples derived from EC patients. The integration of multi-omics data has not only broadened our understanding of the disease but also unearthed valuable biomarkers specific to EC. This review encapsulates the recent progress and future prospects in the application of multi-omics technologies in EC research, emphasizing the potential of multi-omics in uncovering novel biomarkers and enhancing clinical assessments.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The value of multi-sequence magnetic resonance imaging and whole-tumor apparent diffusion coefficient histogram analysis in differentiating p53 abnormal from non-p53 abnormal endometrial carcinoma

Objective

To investigate the utility of multi-sequence magnetic resonance imaging (MRI) and whole-tumor apparent diffusion coefficient (ADC) histogram metrics in preoperatively differentiating p53 abnormal (p53abn) from non-p53abn endometrial carcinoma (EC).

Methods

This retrospective study included 146 EC patients (29 p53abn cases and 117 non-p53abn cases) who underwent preoperative MRI scans. MRI features were analyzed. Whole-tumor ADC histogram analysis was conducted by delineating regions of interest (ROIs) on diffusion-weighted imaging (DWI) scans. Receiver operating characteristic (ROC) curve analysis with the area under the curve (AUC) was used for diagnostic performance evaluation.

Results

Extrauterine extension (p=0.004) and lymphadenopathy (p=0.005) were more frequently observed in p53abn EC compared to non-p53abn EC. p53abn EC exhibited significantly lower value of minADC (p=0.001), meanADC (p=0.005), P10 (p=0.009), P50 (p=0.007), and P90 (p=0.013) ADC and higher value of kurtosis (p=0.008), compared to non-p53abn EC. MinADC demonstrated the highest discrimination ability in differentiating p53abn from non-p53abn EC [AUC 0.70(0.60;0.80)].

Conclusion

Preoperative multi-sequence MRI findings and whole-tumor ADC histogram metrics are conducive to differentiating p53abn from non-p53abn EC.

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

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

The past, present, and future of FIGO staging of endometrial cancer

The International Federation of Gynecology and Obstetrics (FIGO) staging of endometrial cancer (EC) is regarded as a crucial tool for guiding treatment, evaluating prognosis, and advancing clinical research. It is a concept of shared importance among gynecologic oncologists, pathologists, and patients with EC. In June 2023, the International Federation of Gynecology and Obstetrics released a new staging system for EC. This review aims to discuss comprehensively the developmental trajectory of FIGO staging for EC, focusing on the differences between the 2023 FIGO and earlier staging systems, and delineating the advantages and disadvantages of incorporating various pathological factors and molecular subtypes into staging. The article emphasizes the progress made with the updated 2023 FIGO version in improving prognostic prediction accuracy for patients with EC. However, as the staging categories expand, their complexity becomes increasingly apparent, potentially impacting health care professionals' accurate understanding and application of staging. Moreover, unresolved issues persist regarding histological types and grading, lymphovascular space invasion, and molecular subtypes, as well as distinguishing between low-grade endometrioid carcinomas confined to the uterus and ovaries, which may affect the personalized management of patients with EC. In the future, these issues still require extensive clinical research and specific data for validation or confirmation, presenting a challenge shared by gynecologic oncologists and pathologists.

The new 2023 endometrial cancer FIGO staging system: balancing innovation with complexity

In August 2023, the International Federation of Gynecology and Obstetrics introduced an updated staging system for endometrial cancer that integrates histopathologic and molecular characteristics (optional) of the tumor alongside with anatomic extent of the disease. This innovative approach aims to improve the prognostication of the system and the identification of treatment-relevant patient populations by more accurately stratifying patients based on tumor biology, representing a significant advancement toward personalized medicine. However, its implementation poses challenges, including the heterogeneous availability of molecular testing worldwide, and the need for further standardization and prospective validation of some of the newly introduced histopathological parameters. To address these innovations and related controversies, a meeting of physicians, including gynecologic oncologists and pathologists, was held. This article summarizes the reflections that emerged from this meeting, focusing on key elements such as the integration of histopathologic features (eg, "high-grade, aggressive histologic types," "substantial lymphovascular space invasion"), molecular classification, and the implications for global reproducibility and applicability. It also addresses the basic approach toward staging: should it offer integrated, patient-relevant information to enable accurate prognostication and inform treatment decisions or should a staging system simply provide a common language to communicate disease extent? The meeting provided an opportunity for a group of physicians to share considerations on this evolving topic. Our article highlights focal points of change in the new staging system and identifies key areas for future research, advocating for collaborative efforts to generate more robust evidence on some variables introduced in the staging system through prospective studies. By addressing these challenges, we aim to improve the applicability and effectiveness of the new International Federation of Gynecology and Obstetrics staging system in real-world scenarios and identify elements that may require further refinement, ultimately advancing precision medicine in endometrial cancer care.

Analysis of fertility-preserving treatment outcomes in patients with POLE-mutated endometrioid carcinoma

To explore the clinical outcomes of fertility-sparing treatment (FST) in patients with POLE-mutated endometrioid carcinoma (EEC). A total of 9 EEC patients who received FST and were classified to the POLE-mutated subtype in Peking University People's Hospital from April 2020 to October 2023, were retrospectively collected. Clinical and pathological data were analyzed to describe the outcomes of FST in patients with POLE-mutated EEC. A total of 9 patients with EEC including 6 cases with well-differentiated (G1) and 3 cases with moderately-differentiated (G2). The average age was 34.8±2.1 years. POLE mutation sites were P286R (5 cases), V411L (2 cases), L424I (1 cases), and S459F (1 cases), respectively. The median follow-up time was 16 months (9-41 months). The complete response (CR) rate was 88.9% (8/9), with a median time to CR of 5.5 months (3-18 months). The partial response (PR) rate was 11.1% (1/9). The relapse rate was 50.0% (4/8), with a median recurrence time of 9.5 months (5-25 months). Of these, 75% (3/4) underwent secondary FST, with all achieving CR again (3/3). Three of 5 who were out-of-indication patients achieved CR by individual therapy. FST in patients with POLE-mutated EEC achieve a CR rate of 88.9% in this study, the largest number of retrievable reports. In certain patients who are out-of-indication, individualized treatment may also result in remission. However, unlike surgical patients, some patients experience disease recurrence and whether POLE-mutated EEC is sensitive to conventional therapy in FST is controversial given its pathogenesis.

Global research trends and focus on immunotherapy for endometrial cancer: a comprehensive bibliometric insight and visualization analysis (2012-2024)

Background

This study conducted a novel systematic bibliometric and visualization analysis of global literature on immunotherapy for endometrial cancer (EC) to explore dynamic trends, research hotspots, and emerging topics, providing valuable references for future research.

Methods

Articles and reviews on EC immunotherapy published between 2012 and August 2024 were retrieved from the Web of Science Core Collection (WoSCC). Bibliometric tools, CiteSpace and VOSviewer, were used to analyze clustering patterns and research dynamics.

Results

A total of 861 articles were contributed by 5,331 authors from 1,392 institutions across 58 countries or regions, involving 1,823 keywords. China demonstrated outstanding performance in this field, contributing over 40% of the total publications and ranking first in publication volume. However, the total citation counts for publications from China lags that of the United States, highlighting the latter's leading position and areas for further improvement in China's research efforts. The University of Texas Medical Anderson Cancer Center and Nanjing Medical University were the two institutions with the highest number of publications. In terms of authorship, research teams led by Bosse, Tjalling, and Creutzberg, Carien L made significant contributions to advancing the field. Among individual publications, the work by Talhouk et al. achieved the highest average annual citation count of 70.88, demonstrating its profound impact. In terms of journals, Gynecologic Oncology emerged as a pivotal academic platform, publishing numerous articles and achieving the highest co-citation frequency. Additionally, Frontiers in Oncology, Frontiers in Immunology, and Frontiers in Genetics have become some of the most active and rapidly developing journals in recent years. Research hotspots are concentrated on themes such as the "Tumor Immune Microenvironment", "Immune Checkpoint Inhibitors", and "Targeted Therapy". Recent trends and frontier research focus on the combined application of immune checkpoint inhibitors with other therapies, research on the application of nanotechnology in immunotherapy, and the integration of artificial intelligence to enhance precision medicine. Additionally, efforts are increasingly directed toward advancing various immunotherapy strategies from basic research to clinical applications.

Conclusions

This comprehensive analysis reveals rapid advancements and significant potential in EC immunotherapy. Strengthening international collaboration and addressing barriers in the translation of research to clinical practice will drive further progress in this promising field.

The genomic landscape of distant metastatic endometrial cancer

OBJECTIVE

The molecular underpinnings of primary treatment-naïve endometrial carcinoma (EC) are well described. Here we sought to characterize the genomic landscape of distant metastatic EC.

METHODS

Distant metastatic ECs from a total of 1888 cases subjected to a clinical panel sequencing between 4/2015 and 6/2020 were identified, and their genomic profiles, affected pathways and actionable alterations were compared to those of 711 primary ECs. Wilcoxon and Fisher's exact tests were used for continuous and categorical variables, respectively, and p-values adjusted for multiple hypothesis-testing.

RESULTS

Distant EC metastases (n = 137) of the lung (n = 66, 48 %), liver (n = 21, 15 %), soft tissue (n = 15, 11 %), distant lymph nodes (n = 15, 11 %), gastrointestinal tract (n = 10, 7 %), central nervous system (n = 5, 4 %), bone (n = 4, 3 %), and renal system (n = 1, 1 %) were included. Distant EC metastases were most commonly of copy number (CN)-high/TP53 abnormal (42 %) or CN-low/no specific molecular profile (NSMP) (39 %) molecular subtype; 18 % were microsatellite instability (MSI)-high/mismatch repair (MMR)-deficient and 1 % were of POLE molecular subtype. Distant EC metastases were significantly more chromosomally unstable compared to primary ECs across molecular subtypes (p < 0.0001). CTNNB1 mutations were more prevalent in distant CN-low/NSMP and MSI-high/MMR-deficient metastases compared to primary ECs (q < 0.1). Clinically actionable alterations were significantly less common in metastatic ECs (27 % vs 37 % primary; p = 0.025). PI3K, p53 and epigenetic pathways were the most altered pathways among all anatomic sites.

CONCLUSIONS

Distant metastatic ECs are more frequently chromosomally unstable but less commonly exhibit hypermutator phenotypes. Exploitation of genetic differences of metastatic EC is warranted for targeted treatment strategy development.

Global practice patterns of sentinel lymph node biopsy in endometrial cancer: a survey from the European Network of Young Gynecologic Oncologists (ENYGO)

OBJECTIVE

This survey aimed to evaluate trends in sentinel lymph node (SLN) biopsy for endometrial cancer among members of the European Society of Gynecologic Oncology (ESGO) and the International Gynecologic Cancer Society (IGCS).

METHODS

We conducted an online cross-sectional survey among gynecologic oncologists over 40 years of age consisting of 30 questions. It was distributed to ESGO and IGCS members via Survey Monkey and Qualtrics between September and December 2022. Surveys were excluded in the analysis if >50% of questions were incomplete. Statistical analysis, performed with SPSS version 27.0.

RESULTS

A total of 302 (70.2%) of 430 participants completed the survey, with 159 (52.6%) affiliated with ESGO and 143 (47.4%) with IGCS. The majority were male 206 (68.2%), and 170 (56.3%) were based in Europe. Most respondents (n = 261, 86.4%) were certified gynecologic oncologists. Indocyanine green was the most common tracer used (n = 234, 77.5%), with higher rates of blue dye injections among IGCS respondents (p = .002). The predominant injection volume was 4 cm3 (51%, n = 154). Most respondents (n = 232, 76.8%) used a combined superficial and deep ectocervical injection technique, with a higher proportion of superficial injections alone in the IGCS respondents (25.9% vs 11.9%, p = .003). Nearly half of the respondents (44.4%, n = 134) started SLN mapping at the uterine artery and continued dissecting laterally. In cases of mapping failure, 77.5% (n = 234) opted for side-specific lymphadenectomy. The Memorial Sloan Kettering Cancer Center algorithm was followed by 69.5% (n = 210), with 45.7% (n = 138) routinely using ex-vivo green fluorescence or gamma counter measurements. Finally, there was a higher adoption of immunohistochemistry for SLN ultra-staging in ESGO (n = 116, 73%) compared to the IGCS respondents (n = 94, 65.7%), (p = .047).

CONCLUSIONS

This study showed significant variations in SLN biopsy practices for endometrial cancer, underscoring the need for global standardization through harmonized guidelines, consistent training, and international collaboration to improve staging accuracy and patient outcomes.

Circulating tumor DNA in endometrial cancer: clinical significance and implications

Circulating tumor DNA (ctDNA) is a promising non-invasive tool that has been demonstrated to be a clinically useful biomarker in several tumor types for risk stratification, prognosis, and early detection of recurrence. However, there are limited data on the clinical utility of ctDNA in endometrial cancer (EC) compared with other solid tumors. The evolution of EC management through the integration of molecular characterization into the treatment algorithm has intensified the need to develop more effective predictive biomarkers to optimize treatment and reduce clinical toxicities. Given its non-invasive nature and its ability to represent and complement tumor multiclonal spatial and temporal heterogeneity, ctDNA could act as a valid surrogate for tissue sampling. In addition to plasma ctDNA detection being associated with clinicopathologic features of tumor aggressiveness at pre-operative assessment, an association with reduced disease-free survival and overall survival has been observed in patients with detectable ctDNA. Moreover, the half-life of ctDNA is significantly shorter than CA125, and plasma levels are reported to be completely cleared from the blood within 1 week from surgical debulking. Therefore, ctDNA may serve as a dynamic biomarker for occult microscopic residual disease when assessed within the first 4 to 8 weeks after eradicative surgery. Few studies have reported high sensitivity of ctDNA in detecting disease recurrence at longitudinal follow-up, although there are limited data comparing ctDNA and traditional serum biomarkers (CA125 and HE4) in identifying recurrence. In the perspective of personalized oncology, ctDNA may potentially help improve adjuvant therapeutic management by escalating/de-escalating treatment based on ctDNA detection after surgery, during maintenance, or in the recurrent/metastatic setting, in addition to acting as a sensitive biomarker for early detection of recurrence. Several challenges hinder the use of ctDNA in EC, including the lack of standardized protocols, the low mutational burden, tumor heterogeneity, and background normal DNA, which limit assay sensitivity and specificity. In addition, the high cost of ctDNA analysis, particularly, next-generation sequencing, restricts its accessibility. Future trials should focus on cost-effective approaches to ensure sustainability and efficient resource allocation.

New FIGO 2023 Staging System of Endometrial Cancer: An Updated Review on a Current Hot Topic

The International Federation of Gynaecology and Obstetrics (FIGO) introduced a new staging system for endometrial carcinoma FIGO 2023 in June 2023. The new staging system differs significantly from previous versions by incorporating other non-anatomical parameters (histological type of tumour, tumour grade and the presence of massive lymphovascular space involvement as well as the molecular classification of the tumour). The FIGO 2023 staging system enhances the accuracy of prognostic assessments for patients at a specific stage with better options for targeted treatment. Another objective was to synchronise staging as much as possible with the European oncogynaecological ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma established in 2021. However, several changes are controversial. Routine molecular classification of endometrial carcinomas is not yet commonly available in most countries of the world. Another limitation of the FIGO 2023 staging system of endometrial cancer is the inclusion of variables whose definitions are still evolving, as well as variables that are subject to considerable interobserver variability in their assessment. Advantages, controversies, and limitations for clinical practice of the new FIGO 2023 endometrial cancer staging system are discussed.

Clinicopathological and Molecular Characterization of Non-Endometrioid Endometrial Carcinoma

Objective: Molecular classification has become an essential tool in endometrial carcinoma; however, its application in non-endometrioid carcinoma (NEEC), particularly rare histological subtypes, remains relatively unexplored. This study aims to investigate the potential utility of molecular classification in NEEC. Methods: A retrospective analysis was conducted on 167 NEEC cases diagnosed at the Women's Hospital of Zhejiang University from 2013 to 2020. The cases were categorized into four molecular subtypes: POLE ultra-mutated (POLEmut), mismatch repair-deficient (MMRd), p53-abnormal (p53abn), and no specific molecular profile (NSMP) molecular subgroups. Statistical significance was set at P<0.05. Results: Among the cases, 13 (7.8%) patients were classified as POLEmut, 25 (15.0%) as MMRd, 84 (50.3%) as p53abn, and 45 (27.0%) as NSMP. Most POLEmut cases were at early stages (11/13, 84.6% at stages I-II), whereas p53abn cases were predominantly at advanced stages (32/49, 65.3% at stages III-IV). Additionally, p53abn was the most common subtype in serous carcinoma (41/45, 91.1%) and mixed adenocarcinoma (24/57, 42.1%). The 3-year recurrence-free survival (RFS) rates for POLEmut, MMRd, NSMP, and p53abn were 100.0%, 88.0%, 73.3%, and 71.4% , respectively. The 3-year overall survival (OS) rates were 100.0%, 88.0%, 82.2%, and 73.8%, respectively. Univariate analysis revealed significant associations of age ≥60 years (P=0.01), hypertension (P=0.03), FIGO stage (P<0.001), lymphovascular space invasion (P=0.01), lymph node metastasis (P<0.001), myometrial invasion (P<0.001), and postoperative adjuvant therapy (P=0.01) with 3-year RFS. Multivariate analysis identified age ≥60 years (P=0.03), myometrial invasion (P=0.01), and FIGO stage (P=0.046) as independent risk factors for 3-year OS. Conclusion: Molecular classification is crucial for accurately predicting the prognosis of NEEC, enabling more tailored treatment approaches in clinical practice. Furthermore, patient age may have a significant influence on NEEC classification and progression.

Uterine Carcinosarcoma: Adaptation to New FIGO 2023 Staging System Through Clinical Profile and Oncologic Outcomes

Objective: We aimed to analyze the impact of stage shifts on disease-free survival and overall survival in patients with uterine carcinosarcoma stratified based on FIGO 2009 and 2023 staging systems. Materials and Methods: A total of forty-five patients diagnosed with uterine carcinosarcoma between 2010 and 2024 were included in the study. Patients were classified and analyzed according to both the 2009 and the revised 2023 FIGO staging systems to evaluate the impact of the updated staging criteria on oncologic outcomes. The median disease-free (DFS) and overall survival (OS) rates were calculated and compared when stage shifts occurred. Results: A total of 17 upstage shifts (37.7%) occurred between the 2009 and 2023 FIGO staging system. All patients with upstage shifts were stage I patients categorized according to the FIGO 2009 classification. Restaging from the FIGO 2009 to the FIGO 2023 criteria resulted in a reduction in the number of stage I cases and an increase in the number of stage II cases. The two main factors leading to upstage were serous histology and LVSI positivity. The 5-year DFS and OS rates for stage I disease were 80% and 75%, respectively, according to the 2009 FIGO staging system, whereas the 2023 FIGO staging system demonstrated significantly higher rates of 100% for both DFS and OS. In stage II patients, the 5-year DFS and OS rates were 33.5% and 33.7%, respectively, according to the 2009 FIGO staging system, while the 2023 FIGO staging system demonstrated higher rates of 58.8% for DFS and 65% for OS. Conclusions: The revised FIGO 2023 staging system has better performance in predicting disease prognosis than the previous version.

Long-Term Follow-Up and Overall Survival in NRG258, a Randomized Phase III Trial of Chemoradiation Versus Chemotherapy for Locally Advanced Endometrial Carcinoma

This randomized phase III trial aimed to determine whether treatment with cisplatin and volume-directed radiation followed by carboplatin and paclitaxel for four cycles (chemoradiotherapy [C-RT]) increased recurrence-free survival (RFS) and overall survival (OS) when compared with carboplatin and paclitaxel for six cycles (chemotherapy [CT]) in locally advanced endometrial cancer (UC). Previously reported results showed that C-RT did not improve RFS compared with CT. Here we report the final OS analysis. Patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage III-IVA UC or stage I/II serous or clear cell UC and positive cytology were enrolled. The primary objective was RFS. Secondary objectives were OS, toxicity, and quality of life. Cumulative probabilities of OS were estimated using the Kaplan-Meier method. Subgroup analyses of treatment effect for FIGO stage, age, race, gross residual disease, histology, lymph-vascular space invasion, and body mass index were performed. In total, 813 patients were randomly assigned (407 C-RT and 406 CT). The median follow-up was 112 months. Median OS was not achieved in either arm. The stratified hazard ratio for death comparing C-RT versus CT was 1.05 (95% CI, 0.82 to 1.34, log-rank two-sided P value = .72). None of the factors analyzed predicted OS benefit from C-RT. Although C-RT reduced the rate of local recurrence compared with CT, it did not increase OS or RFS in stage III/IVA UC.

The Prognostic Significance and Co-Expression of Fibroblast Growth Factor Receptor 2 and c-Met in Endometrial Cancer

Objective

We sought to study the expression of FGFR2 and c-Met and evaluate the correlation between the two proteins in a series of endometrial cancer patients as well as the prognostic significance of the two markers in endometrium carcinoma.

Methods

Patients who were diagnosed with endometrial cancer and had undergone surgical treatment in Beijing Chao-Yang Hospital, Capital Medical University from November 2004 to June 2011 were included in this study. Tissue microarray construction, immunohistochemical staining and scoring were employed to study the expression of FGFR2 and c-Met. SPSS version 22.0 was used to evaluate the correlation between FGFR2 and c-Met expression and the prognosis prediction value of the two markers.

Results

In total, 109 patients were included in this study. The median age was 56 years (ranges, 30-79). The most common histologic tumor subtype was adenocarcinoma (86.2%). The five-year survival rate was 87.2%. Significantly different FGFR2 expression was observed among patients with different disease stages (p < 0.001), depths of myometrial invasion (p = 0.001) and lymph node status (p < 0.001). C-Met expression was also increased in tissues from patients with advanced stage disease, deep myometrial invasion and lymph node metastasis (p < 0.001, p = 0.031 and p < 0.001, respectively). The expression of FGFR2 and c-Met was increased in the group with poorer prognosis (overall survival < 5 years) (p = 0.002 and p = 0.023, respectively). Moreover, a strong positive correlation was observed between FGFR2 and c-Met expression (p < 0.01, r = 0.656). FGFR2 was a significant factor that influence the FIGO stage.

Conclusion

Higher expression of FGFR2 and c-Met is associated with more advanced stage, deeper myometrial invasion and lymph node metastasis in endometrial cancer and poorer prognosis. In addition, high expression of FGFR2 is correlated with high c-Met expression.

International Federation of Gynecology and Obstetrics 2023 stage IIIB2 endometrial cancer with pelvic peritoneal metastasis: assessment of adjuvant therapy effect on survival

The 2023 International Federation of Gynecology and Obstetrics (FIGO) endometrial cancer staging schema classifies pelvic peritoneum only metastasis as stage IIIB2 disease. In this retrospective cohort study of 193 patients with FIGO 2023 stage IIIB2 endometrial cancer who underwent primary hysterectomy from 2006 to 2015 identified in the Commission-on-Cancer's National Cancer Database, systemic chemotherapy without external beam radiotherapy was the most frequent adjuvant therapy type (48.7%), followed by combination systemic chemotherapy and external beam radiotherapy (42.0%) and external beam radiotherapy without systemic chemotherapy (9.3%). After controlling for patient age, race and ethnicity, co-morbidity, and histology, combination systemic chemotherapy and external beam radiotherapy was associated with 40% reduction of all-cause mortality compared with systemic chemotherapy without external beam radiotherapy (5-year rates: 63.1% vs 45.7%, adjusted-hazard ratio 0.60, 95% confidence interval 0.40-0.92). This reduction of all-cause mortality for combination systemic chemotherapy and external beam radiotherapy compared with systemic chemotherapy without external beam radiotherapy increased to 55% among non-endometrioid histology (5-year overall survival rates: 52.0% vs 33.4%, adjusted-hazard ratio 0.45, 95% confidence interval 0.23-0.88). In conclusion, the results of this investigation suggest that, despite peritoneal disease spread, multi-modal treatment with combination systemic and local therapies may improve survival in FIGO 2023 stage IIIB2 endometrial cancer, especially in non-endometrioid histology.

Advances in the management of endometrial cancer

Endometrial cancer is now the most lethal gynecologic malignancy, with incidence rates rising globally. Treatment strategies have historically been focused on a combination of surgery, radiation, and/or chemotherapy based primarily on histology and extent of tumor. Advances in the evaluation and treatment of endometrial cancers are occurring at a rapid pace, with a new focus on genomic profiling and targeted therapies. Surgical removal of the tumor remains the mainstay of therapy, but adjuvant treatments are a shifting paradigm. In the realm of gynecologic malignancies, endometrial cancer leads in the evolution of precision medicine. The ability to analyze patients, tumors, and therapy has increased over the past 10 years. Gaps in knowledge about racial and ethnic disparities, as well as pre-invasive disease prevention, are closing. This review describes the advances in endometrial cancer with a focus on people at risk, molecular classification, and modern therapeutic strategies.

Controversies in the management of clear cell carcinoma of the uterus and ovary

Clear cell ovarian and endometrial carcinomas are rare and aggressive gynecologic malignancies that present unique challenges owing to their underrepresentation in clinical trials and limited prospective data. In this report, we aimed to explore 3 major controversies in the management of clear cell ovarian and endometrial carcinomas, highlighting areas that require further investigation. First, we addressed the unique phenotypic characteristics of clear cell ovarian carcinoma and clear cell endometrial carcinoma and whether they should be considered a unified disease entity or a distinct disease. Recent trials grouped these carcinomas, potentially expanding their therapeutic options. However, emerging molecular data underscores the significant differences between clear cell ovarian carcinoma and clear cell endometrial carcinoma, raising questions regarding this combined approach. This distinction is critical in guiding tailored treatment strategies. Second, we examined the management of localized diseases. Although early-stage diagnoses are common in clear cell carcinomas, optimal surgical and adjuvant treatment strategies remain uncertain. Current practice often relies on data from broader studies with limited inclusion of clear cell histology. This review underscores the need for more specific evidence to refine treatment protocols and balance efficacy with the minimization of treatment-related morbidity. Third, we explored novel therapeutic strategies for the treatment of recurrent diseases. Advances in the understanding of the biology of clear cell carcinomas have identified potential targets in the immune microenvironment, cellular processes, and metabolism. Ongoing clinical trials are investigating these approaches, which hold promise in transforming the treatment landscape and outcomes. In conclusion, this review emphasizes the necessity for international collaboration and the inclusion of diverse patient populations to address the challenges posed by cell carcinomas. By focusing on these controversies, we aim to stimulate further research and support more evidence-based personalized approaches for the management of these rare but challenging cancers.

[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.

Practice guideline for management of endometrial cancer in Thailand: a Thai Gynecologic Cancer Society consensus statement

The Thai Gynecologic Cancer Society (TGCS) continues its efforts to elevate the standard of practice of gynecologic oncologists across all regions of Thailand. A key initiative involves collaborating with the Royal Thai College of Obstetricians and Gynaecologists and the National Cancer Institute, Thailand to regularly update and release clinical practice guidelines (CPGs) for gynecologic cancer. The TGCS released the first CPG for endometrial cancer (EMC) in 2011. Following significant advancements in disease understanding and the major revision of EMC staging by the International Federation of Gynecology and Obstetrics in 2023, national experts collaborated to update the guideline for EMC. The key components of the CPG for EMC covered screening, diagnostic indications and methods, primary treatment including surgical approaches and procedures, pathological processes, adjuvant therapies, and the management of recurrent and advanced diseases through medical or surgical means. The guideline was based on scientific evidence, recommendations from international organizations, and the unique healthcare context of Thailand. The final version reflects a consensus reached through extensive discussions among TGCS members. To share our work with international organizations and healthcare professionals, an English version of the CPG was developed. While it mirrors the content of the Thai version, it differs in length and level of detail. The English version additionally included the level of evidence and a recommendation summary for each section, reflecting common domestic practices, available resources, and coverage under health reimbursement systems.

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

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

Comprehensive Molecular and Genomic Analysis of NCI-MATCH Subprotocol Y: Capivasertib in Patients With an AKT1 E17K-Mutated Tumor

PURPOSE

NCI-MATCH (EAY131) is a precision medicine trial using genomic testing to allocate patients with advanced malignancies to targeted treatments. Arm Y evaluated capivasertib, a pan AKT inhibitor, in patients with an AKT1 E17K-mutated tumor. Here, we report on the translational objectives of the study, a molecular and genomic analysis of specimens to identify potential biomarkers of response or resistance to capivasertib.

METHODS

Eligible patients had AKT1 E17K-mutated metastatic tumors that progressed with standard treatment and received capivasertib 480 mg orally twice daily for 4 days on and 3 days off weekly in 28-day cycles. The primary end point was objective response rate (ORR). We performed whole-exome sequencing, RNA sequencing, and gene set and pathway enrichment analysis on 25 pretreatment tissue samples and evaluated findings in responders (complete response [CR], n = 0, and partial response, n = 9) and nonresponders (stable disease, n = 13, and progressive disease, n = 3).

RESULTS

The ORR was 28.6% (10 of 35) in the reported primary trial and 36% (9 of 25) in this translational cohort. Mutations in the TP53 gene were more frequent in responders, whereas the PI3K/AKT/mTOR pathway genes TYRO3, SYNJ1, and CDIPT were significantly altered in nonresponders. DNA repair, p53, E2F, and Wnt-beta catenin pathways were enriched in the responder group. Unsupervised clustering of gene expression identified five genes, ANKRD30A, SUSD4, TTC6, POTEJ, and POTEI, that were significantly higher in responders and lower in nonresponders. In addition, EGFR expression was significantly increased in nonresponders.

CONCLUSION

In patients with AKT1 E17K-mutated tumors, capivasertib achieved a clinically significant ORR. TP53 mutations appear to be associated with response, whereas certain additional PI3K/AKT/mTOR pathway mutations and EGFR overexpression appear to be associated with nonresponse to capivasertib. Further investigation of predictive biomarkers is warranted.

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.

Retinoblastoma Protein Loss in p53 Abnormal Endometrial Carcinoma: Histologic and Clinicopathological Correlates

Of the 4 molecular subtypes of endometrial cancer (EC), p53-abnormal (p53abn) EC is associated with abundant copy number alterations and the worst clinical outcome. Patients with p53abn EC have the highest risk of disease recurrence and death, independent of tumor grade and histologic subtype. Currently, all invasive p53abn ECs are considered high risk, and no prognostic biomarkers have yet been found that can aid in clinical management. Here, we aimed to test whether loss of retinoblastoma (RB) protein expression using immunohistochemistry has the potential for prognostic refinement of p53abn EC. A large cohort of 227 p53abn ECs collected from the PORTEC-1/2/3 clinical trials and the Medisch Spectrum Twente cohort study was investigated, and RB loss was identified in 7.0% (n = 16/227). RB-lost p53abn ECs were predominantly high-grade endometrioid ECs (n = 6, 37.5%) and carcinosarcomas with endometrioid-type epithelial component (n = 5, 31.3%). Histologically, RB-lost p53abn ECs were typified by high-grade nuclear atypia (n = 16, 100%), predominantly solid growth pattern (n = 15/16, 93.8%), and polypoid growth (n = 9/16, 56.3%). Copy number loss involving the RB1 locus was identified in the majority of RB-lost p53abn EC (n = 13/14, 92.9%), explaining the loss of RB expression. Comparative analysis also showed that RB-lost p53abn ECs were diagnosed at earlier stages than RB-retained p53abn EC (P = .014). Interestingly, RB-lost p53abn EC showed prolonged time to overall recurrence (P = .038), even within stage I alone (P = .040). These findings highlight distinct morphomolecular features in RB-lost p53abn ECs and confirm the utility of RB immunohistochemistry as a surrogate for underlying molecular RB1 alterations. To our knowledge, this is the first study to show the potential use of RB in prognostic refinement of p53abn EC, although validation is warranted.

Prognosis conferred by molecular features of appendix-derived Pseudomyxoma Peritonei

INTRODUCTION

Pseudomyxoma Peritonei (PMP) is an extremely rare disease characterized by progressive accumulation of mucinous ascites and implants in the peritoneum. We investigated the prognostic value for response to cytoreductive surgery (CRS) or hyperthermic intraperitoneal chemotherapy (HIPEC) and dissected potential beneficial targeted therapy utilizing genomic characteristics.

METHODS

Whole-exome sequencing (WES) was performed on tissue specimens and matched white blood cells from 81 patients with PMP. The study investigated mutational signatures, profiling, and their correlation with progression-free survival (PFS) and overall survival (OS).

RESULTS

Signature 3 (HRD) and signature 15 (dMMR) were dominant. NMF cluster 1, characterized by signature 4, exhibited a worse prognosis. The p53 and TGF-β signaling pathways may contribute as risk factors for worse OS and PFS, respectively. MUC16-mutated patients had worse PFS (P = 0.016) and OS (P = 0.004) compared to wild-type patients. Patients with tumor mutational burden (TMB) > 1(P = 0.026) or alterations in TP53 (P = 0.006) or SMAD4 (P = 0.013) had significantly worse OS compared to those with a TMB < 1 or normal genes. Patients with homologous recombination deficiency (HRD) positivity (P = 0.003) or alterations in TGFBR2 (P = 0.037) experienced worse PFS compared to their respective control groups. Furthermore, NMF cluster1 (P = 0.020), TP53 (P = 0.004), and MUC16 (P = 0.013) were identified as independent prognostic factors for OS, while HRD status (P = 0.003) was independent predictors for PFS in PMP.

CONCLUSIONS

The study reveals that genomic profiling can serve as a robust tool for identifying prognostic markers in PMP. The identified genomic mutations and signaling pathway offer new avenues for targeted therapies.

Histology-specific prognostic significance of isolated tumor cells, micrometastases, and macrometastases in endometrial cancer

OBJECTIVE

To examine the association between regional lymph node status based on metastatic size and anatomical location and survival per histology in endometrial cancer.

METHODS

This retrospective study queried the Commission-on-Cancer's National Cancer Database. Study population included 87,904 patients with stage I-III endometrial cancer from 2018 to 2021. Multivariable Cox proportional hazard regression models were created to assess overall survival per histology (non-endometrioid / high-grade endometrioid or low-grade endometrioid).

RESULTS

In both histology groups, comparing to pelvic micro-metastasis, macro-metastasis regardless of anatomical location (pelvic / para-aortic) was associated with decreased overall survival (non-endometrioid / high-grade endometrioid histology, adjusted-hazard ratio [aHR] 1.31, 95% confidence interval [CI] 1.08-1.59/aHR 1.39, 95%CI 1.13-1.72; and low-grade endometrioid histology, aHR 1.68, 95%CI 1.19-2.36 / aHR 1.78, 95%CI 1.10-2.88) while para-aortic micro-metastases had overall survival similar to pelvic micro-metastasis. Survival effects of macro-metastasis were larger in low-grade endometrioid compared to non-endometrioid / high-grade endometrioid histology (aHR range, 1.68-1.78 vs 1.31-1.39). For non-endometrioid / high-grade endometrioid histology, isolated tumor cells were associated with better overall survival compared to pelvic micro-metastasis (aHR 0.62, 95%CI 0.45-0.85); isolated tumor cells and negative nodal metastasis had similar overall survival (aHR 1.05, 95%CI 0.80-1.38). Contrary, in low-grade endometrioid histology, isolated tumor cells were associated with decreased overall survival compared to negative-node (aHR 1.55, 95%CI 1.18-2.04); isolated tumor cells had overall survival similar to pelvic micro-metastasis (aHR 0.83, 95%CI 0.56-1.24).

CONCLUSION

The results of this cohort study suggest that tumor metastatic size may be more prognostic than anatomical location in endometrial cancer. Histology-specific interaction of isolated tumor cells warrants further investigation, especially in low-grade endometrioid histology.

Molecular Classification of Endometrial Cancers Using an Integrative DNA Sequencing Panel

BACKGROUND AND OBJECTIVES

Adoption of molecular classification in endometrial cancer (EC) into clinical practice remains challenging due to complexity in coordination of multiple assays. We aimed to develop a simple molecular technique to classify ECs into four subgroups using our custom-designed targeted sequencing panel.

METHODS

Patients with newly diagnosed ECs were prospectively recruited from three cancer centres in Ontario, Canada. Using our panel, 181 ECs were sequenced. Variants were analysed for pathogenicity and clinicopathologic information was collected through medical records retrospectively.

RESULTS

Of 181, 86 (48%) were mismatch repair deficient (MMRd), of which 62 (72%) harboured MLH1 promoter methylation and 24 (28%) had pathogenic variants in MMR genes. Of single classifiers, three (1.8%) had pathogenic POLE (POLEmut), 15 (9%) had TP53 mutations (p53abn) and 61 (37%) had no specific molecular profile subtype (NSMP). Sixteen (9%) had more than one molecular classifying feature, with eight (4%) MMRd-p53abn, six (3%) POLEmut-MMRd, one (0.5%) POLEmut-MMRd-p53abn and one (0.5%) POLEmut-p53abn. When MMRd group was further subclassified according to mechanism of MMR loss, MLH1 promoter methylated group had worse outcomes than those with somatic MMR pathogenic variants.

CONCLUSIONS

Our panel can classify ECs into four subgroups through a simplified process and can be implemented reflexively in clinical practice.

Perspectives, Challenges, and Advances in Therapeutic Strategies for Gynecological Malignant Tumors

For years, treatment options for advanced gynecological malignancies have been limited, with the combination of carboplatin and paclitaxel being the preferred first-line therapeutic approach, regardless of disease type [...].

Comprehensive Review of Endometrial Cancer: New Molecular and FIGO Classification and Recent Treatment Changes

Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries, with rising incidence due to aging populations and obesity-related factors. This review explores the evolving molecular and FIGO classifications of EC, highlighting their significance in diagnosis, prognosis, and personalized treatment strategies. Molecular subtyping based on The Cancer Genome Atlas (TCGA) classification offers a more precise understanding of EC, dividing it into POLE ultramutated, microsatellite instability-high (MSI-H), copy-number low (CNL), and copy-number high (CNH) subtypes. Each subgroup has distinct genetic, histological, and prognostic characteristics. Recent updates to the FIGO staging system incorporate molecular features, allowing for more tailored treatment approaches. Advances in immunotherapy, targeted therapies, and novel therapeutic combinations have reshaped clinical management. This review emphasizes the integration of molecular diagnostics into routine practice, outlining challenges and future perspectives in managing EC for improved patient outcomes.