Molecular Classification Predicts Response to Radiotherapy in the Randomized PORTEC-1 and PORTEC-2 Trials for Early-Stage Endometrioid Endometrial Cancer

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.

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.

Development and validation of clinical-radiomics deep learning model based on MRI for endometrial cancer molecular subtypes classification

OBJECTIVES

This study aimed to develop and validate a clinical-radiomics deep learning (DL) model based on MRI for endometrial cancer (EC) molecular subtypes classification.

METHODS

This multicenter retrospective study included EC patients undergoing surgery, MRI, and molecular pathology diagnosis across three institutions from January 2020 to March 2024. Patients were divided into training, internal, and external validation cohorts. A total of 386 handcrafted radiomics features were extracted from each MR sequence, and MoCo-v2 was employed for contrastive self-supervised learning to extract 2048 DL features per patient. Feature selection integrated selected features into 12 machine learning methods. Model performance was evaluated with the AUC.

RESULTS

A total of 526 patients were included (mean age, 55.01 ± 11.07). The radiomics model and clinical model demonstrated comparable performance across the internal and external validation cohorts, with macro-average AUCs of 0.70 vs 0.69 and 0.70 vs 0.67 (p = 0.51), respectively. The radiomics DL model, compared to the radiomics model, improved AUCs for POLEmut (0.68 vs 0.79), NSMP (0.71 vs 0.74), and p53abn (0.76 vs 0.78) in the internal validation (p = 0.08). The clinical-radiomics DL Model outperformed both the clinical model and radiomics DL model (macro-average AUC = 0.79 vs 0.69 and 0.73, in the internal validation [p = 0.02], 0.74 vs 0.67 and 0.69 in the external validation [p = 0.04]).

CONCLUSIONS

The clinical-radiomics DL model based on MRI effectively distinguished EC molecular subtypes and demonstrated strong potential, with robust validation across multiple centers. Future research should explore larger datasets to further uncover DL's potential.

CRITICAL RELEVANCE STATEMENT

Our clinical-radiomics DL model based on MRI has the potential to distinguish EC molecular subtypes. This insight aids in guiding clinicians in tailoring individualized treatments for EC patients.

KEY POINTS

Accurate classification of EC molecular subtypes is crucial for prognostic risk assessment. The clinical-radiomics DL model outperformed both the clinical model and the radiomics DL model. The MRI features exhibited better diagnostic performance for POLEmut and p53abn.

The prognostic impact of MLH1 promoter hypermethylation in stage I-II endometrial cancer treated with adjuvant radiotherapy: a multi-institutional retrospective study: MLH1ph status in stage I-II endometrial cancer

PURPOSE

To assess the impact of MLH1 promoter hypermethylation (MLH1ph) on prognosis and define the patterns of recurrence in stage I-II endometroid endometrial cancer (EEC) treated with adjuvant radiotherapy.

MATERIALS AND METHODS

In a retrospective, IRB-approved, multi-institutional cohort study, 814 patients with stage I-II EEC with known mismatch repair (MMR) status were included. Tumors with MSH2, MSH6, MLH1 or PMS2 mutations were classified as somatic dMMR (sdMMR), while tumors with epigenetic silencing of the MLH1 promoter were classified as MLH1ph. Recurrence-free survival (RFS) was calculated by the Kaplan Meier method. Univariate and multivariate analyses (UVA/MVA) were performed via Cox proportional hazards. Statistical analyses were conducted using SPSS version 27.

RESULTS

The median age at diagnosis was 65 (IQR 58-71) and most patients had grade 2-3 disease (59.2%), ≥50% myometrial invasion (56.0%) and absence of lymphovascular space invasion (58%). Vaginal brachytherapy was delivered to 643 (78.1%) patients, while 180 (21.9%) patients received external beam radiation (EBRT) ± VBT. MMR was proficient in 550 (67.6%) patients and deficient in 264 (32.4%) patients. Of the patients with dMMR, most patients harbored MLH1ph (n=171, 66%), while 93 patients (35.2%) had somatic dMMR. Tumor size ≥ 3.8cm (HR 2.2, p=0.003), MMR deficient vs proficient (HR 2.7, p<0.001) and EBRT±VBT vs VBT alone (HR 1.9, p=0.032) were associated with decreased RFS on MVA. On subgroup analysis including patients with dMMR only, patients with MLH1ph had worse RFS compared to patients with sdMMR (HR 1.9 (95% CI1.1-3.6), p=0.025). Distant recurrence was the most common recurrence site, regardless of MMR status. Patients with MLH1ph had significantly higher proportion of vaginal (5% vs 0% vs 2%) and pelvic (5.3% vs 3.2% vs 0.5%) recurrences compared with sdMMR and pMMR, respectively (p=0.038).

CONCLUSION

Patients with MLH1ph had worse RFS, which may be attributed in part to a higher proportion of locoregional recurrences compared to the pMMR and sdMMR patients.

Integration of sentinel node mapping and molecular classification in endometrial cancer staging

Sentinel node mapping has gained popularity in surgical staging of endometrial cancer, providing a less invasive alternative to lymphadenectomy for staging purpose. Recent advances in molecular classification have deepened our understanding of endometrial cancer, leading to more personalized approaches in diagnosis and treatment. This review examined the interaction between sentinel node mapping and molecular classification in endometrial cancer, emphasizing the clinical implications. Surrogate molecular classification identified four distinct subtypes, each with different patterns of lymphatic spread and metastatic potential, overcoming the Bokhman's historic dualistic classification in type I (endometrioid) and type II (non-endometrioid) endometrial cancer. Accumulating evidence supported that integrating molecular subtypes with sentinel node mapping, would improve the accuracy of lymph node staging, allowing for more tailored therapeutic strategies. The potential for artificial intelligence and machine learning to analyze molecular signatures in real-time may further refine mapping accuracy and enable more individualized treatment plans. The development of novel molecular tracers and targeted therapies for sentinel node biopsy promises to enhance precision and minimize unnecessary lymphadenectomy. The aim of this review was to explore current methodologies, challenges, and future directions, highlighting the increasing role of molecular tools in sentinel node mapping and the personalized management of endometrial cancer.

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.

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.

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 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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

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.

Preclinical research models for endometrial cancer: development and selection of animal models

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, with rising incidence in recent years. Experimental animal models are crucial for studying the pathogenesis, advancing diagnostic methods, and developing new treatments. We review five main EC animal models. The use of spontaneous and chemically-induced models has decreased, with transgenic mouse and xenograft models becoming the most widely used. These models better simulate tumor molecular mechanisms and treatments, with the organoid-based patient-derived xenograft model (O-PDX) showing great promise in drug screening and personalized therapy. The application of humanized models remains limited due to technical challenges and high costs. In this review, we highlight the strengths and limitations of each model to guide researchers in their selection.

Patterns of Care in Adjuvant Radiation Therapy for Stage II Endometrioid Endometrial Adenocarcinoma: A National Cancer Database Analysis

Purpose

Treating stage II endometrial cancer involves total hysterectomy, bilateral salpingo-oophorectomy, and risk-adapted adjuvant therapy. Professional guidelines support various adjuvant treatments, but high-level data supporting specific options are conflicting. We sought to evaluate adjuvant radiation therapy (RT) trends for these patients, hypothesizing increased utilization of pelvic external beam RT (EBRT) over time.

Methods and Materials

Patients diagnosed in 2004-2019 with stage II endometrioid endometrial cancer who underwent total hysterectomy, bilateral salpingo-oophorectomy, and surgical staging were identified in the National Cancer Database. Patient characteristics per adjuvant RT received were compared using Wilcoxon rank sum and analysis of variance testing. Multivariable regression analysis (MVA) identified variables associated with EBRT, vaginal brachytherapy (VBT), or RT omission. A P value < .05 was significant, except in MVA, where Bonferroni correction was employed (p value < .017).

Results

Patients meeting criteria totaled 18,798; 19% received adjuvant EBRT alone, 25% VBT alone, 24% EBRT + VBT, and 32% no RT. Adjuvant RT use increased from 2004 to 2019, particularly EBRT + VBT (p < .05). In MVA, community hospital treatment (odds ratio [OR], 1.8; p < .001), Midwest location (OR, 1.2; p = .02), single-agent chemotherapy receipt (OR, 6.9; p < .001), lymphovascular space invasion (OR, 1.4; p < .001), and positive surgical margins (OR, 1.8; p < .001) were positively associated with EBRT. No variables were positively associated with VBT. Black race (OR, 1.2; p = .03), community hospital treatment (OR, 1.4; p = .04), South (OR, 2.2; p < .001) or West (OR, 2.1; p < .001) location, distance >50 miles from the treatment center (OR, 1.5; p < .001), and grade 2 (OR, 1.2; p < .001) or 3 (OR, 1.3; p = .01) disease were associated with RT omission.

Conclusions

Adjuvant RT for stage II endometrial cancer increased over time, particularly EBRT + VBT. Patient-related factors such as race, region, and distance from the treatment center were associated with RT omission, suggesting sociodemographic barriers to care. Tumor-related factors such as positive surgical margins and lymphovascular space invasion were associated with EBRT receipt, suggesting consideration of high-risk factors for locoregional recurrence in adjuvant RT approaches.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes of endometrial cancer prevention strategies in patients with Lynch syndrome: a nationwide cohort study in the Netherlands

Background

Female Lynch syndrome carriers have an increased risk of developing endometrial cancer. Regardless, research on endometrial carcinoma tumorigenesis is scarce and no uniform, evidence-based gynaecological management guidelines exist. We therefore described gynaecological surveillance and surgery outcomes in a nation-wide Lynch syndrome cohort.

Methods

For this retrospective cohort study, female Lynch syndrome carriers, prospectively registered in the Dutch Lynch syndrome database (StOET), were included up to February 28th 2022. Carriers were linked to the Dutch national pathology (PALGA) database. The number of carriers with/without gynaecological surveillance, number of index carriers with endometrial carcinoma before Lynch syndrome diagnosis were assessed, as well as uptake of risk-reducing surgery and characteristics of endometrial carcinomas including the requisite for adjuvant therapy according to current guidelines. Overall survival after endometrial carcinoma diagnosis was analyzed using Kaplan Meier time to event analyses, cumulative incidence was calculated after adjusting for competing risks (death and prophylactic hysterectomy).

Findings

In total, 1046 registered female Lynch syndrome carriers were eligible for surveillance, of whom 313 (30.0%) did not have surveillance and 21.4% (n = 224 of 1046) opted for prophylactic hysterectomy. In carriers with surveillance, more cases of endometrial carcinoma and hyperplasia were found than in those without (37 endometrial carcinomas (7.3%) and 28 hyperplasias (5.5%) in 506 carriers with surveillance versus 14 (2.6%) and 4 (0.7%) in 540 carriers without surveillance, respectively); carriers with surveillance were generally younger than those without (median 56 years [IQR 48-65] versus median 65 years [IQR 49-75] at database assembly, respectively; p < 0.0001). Endometrial carcinomas were predominantly of endometrioid type and FIGO stage IA, regardless of surveillance. Adjuvant external beam radiotherapy was required in one patient in both groups. Overall survival after endometrial carcinoma diagnosis did not differ between carriers with or without surveillance or carriers with endometrial carcinoma before LS diagnosis (p = 0.51). For all endometrial carcinomas together, including index carriers, cumulative incidence was 22.7% at age 70.

Interpretation

In a nation-wide cohort of Lynch syndrome carriers, nearly one-third of eligible carriers did not undergo gynaecological surveillance. Endometrial carcinomas diagnosed during surveillance were slightly more often stage FIGO IA, but this did not seem to substantially decrease the requisite for adjuvant therapy or affect overall survival, questioning effectiveness of current gynaecological management. Prospective research should further assess this, as well as patient preferences.

Funding

None.

Transformative clinical trials in gynaecologic radiation oncology in 2023-2024: Shaping modern treatment practices

The field of gynaecologic oncology has evolved rapidly in recent years, largely driven by advances in both radiotherapy and systemic therapies. These innovations have reshaped the management of key gynaecologic cancers, including cervical, endometrial, vaginal, and vulvar cancers, leading to more personalized and effective treatment approaches. This review explores pivotal clinical trials conducted between 2023 and 2024 that have potentially modified current practices. Through an extensive analysis of randomized controlled trials and meta-analyses, we examine the evolving role of radiotherapy, the integration and sequencing of immunotherapy, and the refinement of neoadjuvant and adjuvant treatments based on molecular classifications. The combination of immunotherapy with chemoradiotherapy has shown promising outcomes, particularly in patients with locally advanced cervical cancer. For endometrial cancer, molecular profiling has enabled a more precise classification of tumour subtypes, leading to better-targeted adjuvant therapies that reduce unnecessary interventions and increase treatment efficacy. In parallel, radiotherapy has advanced with the increasing use of modern techniques such as intensity-modulated radiotherapy and more recently the developments of adaptive treatments in order to minimize exposure to healthy tissue, thereby reducing toxicity and enhancing patient quality of life. Integration of image-guided brachytherapy and expansion of capabilities with newer generation of brachytherapy applicators have also increased possibilities to achieve efficient local treatments, including in very advanced cases. However, despite progress in common gynaecologic cancers, the management of rare cancers such as vulvar and vaginal cancers continues to face challenges due to limited clinical research and treatment data. This review highlights the transformative potential of these innovations and emphasizes the need for continued research and personalized treatment strategies to optimize patient outcomes in gynaecologic oncology.

International Federation of Gynecology and Obstetrics Endometrial 2023 Is Better For Radiation Oncology Patients

The International Federation of Gynecology and Obstetrics (FIGO) 2023 staging system for endometrial cancer has marked changes from the previous staging system instituted 14 years prior in 2009. The new staging system includes nonanatomic factors for the first time (lymphovascular space invasion and histology) and molecular classification, which impacts the stage in early-stage disease (IAmPOLEmut and IICmp53abn). The purpose of these changes was to provide (1) high accuracy in the predictive prognosis for patients and (2) identification of distinct treatment-relevant subgroups. Our understanding of the biology and natural history of endometrial cancer has undergone a radical transformation since the Cancer Genome Atlas results in 2013. The 2023 FIGO staging system harmonizes and integrates old and new knowledge on anatomic, histopathologic, and molecular features. Moreover, FIGO 2023 has distinct substages that improve adjuvant treatment decision making. Although the practicality of the new staging system has been debated, we postulate that FIGO 2023 is more useful for radiation oncologists aiming to provide personalized care recommendations. FIGO 2023 requires a change in our perception of a staging system, from a traditional anatomic borders-based system to a staging system integrating anatomy and tumor biology as pivotal prognostic factors for patients while providing important information for treatment decision making.

Prognostic performance of FIGO 2023 endometrial carcinoma staging: a comparison to FIGO 2009 staging in the setting of known and unknown molecular classification

AIMS

The 2023 FIGO staging criteria for endometrial cancer (EC) introduced marked changes from the 2009 version. The full implication of these changes for patient diagnosis and treatment is unknown. We evaluate the differences in staging and prognostication between the two systems, with and without inclusion of molecular classification.

METHODS AND RESULTS

We assigned (1) FIGO 2009, (2) 2023 molecular-agnostic and (3) 2023 molecular-informed stages to 404 fully staged and molecularly classified patients with EC. Disease-specific and progression/relapse-free survival were analysed via the Kaplan-Meier method and compared with log-rank testing; 118 of 252 (47%) FIGO 2009 stage I patients were upstaged based on histopathological findings alone. Stage I/II subgroup survival distribution analysis showed a worse prognosis in FIGO 2023 IIB and IIC patients. In the molecular-informed FIGO 2023 system, three of 15 (20%) POLE-mutated stage I/II cases were downstaged from FIGO 2009 and eight (53%) were downstaged from molecular-agnostic FIGO 2023. Fifty-one of 60 (85%) p53-abnormal tumours were upstaged from the FIGO 2009, whereas 13 of 60 (22%) were upstaged from the 2023 molecular-agnostic stage. Molecular classification improved prognostic stratification for both 2009 and 2023 FIGO systems.

CONCLUSIONS

Downstaging based on POLE mutation more accurately represents patient outcomes. However, in the absence of known POLE status, applying molecular-agnostic FIGO 2023 criteria for stage I/II disease should be conducted with caution. For aggressive histotypes, additionally reporting FIGO 2009 stage should be considered. Upstaging based on substantial lymphovascular space invasion, aggressive histotype with any myometrial invasion and abnormal p53 improves prognostic discernment. Further subdivisions within stage I/II provide minimal additional prognostic information.

Translating biological insights into improved management of endometrial cancer

Endometrial cancer (EC) is the most common gynaecological cancer among women in high-income countries, with both incidence and mortality continuing to increase. The complexity of the management of patients with EC has evolved with greater comprehension of the underlying biology and heterogeneity of this disease. With a growing number of novel therapeutic agents available, emerging treatment regimens seem to have the potential to help to address the concerning trends in EC-related mortality. In this Review, we describe the epidemiology, histopathology and molecular classification of EC as well as the role of the new (2023) International Federation of Gynecologists and Obstetricians (FIGO) staging model. Furthermore, we provide an overview of disease management in the first-line and recurrent disease settings. With increasing use of molecular profiling and updates in treatment paradigms, we also summarize new developments in this rapidly changing treatment landscape.

Survival benefit of cytoreductive surgery in patients with primary stage IV endometrial cancer: a systematic review & meta-analysis

BACKGROUND

This systematic review and meta-analysis aimed to investigate the survival outcomes following cytoreductive surgery (CRS) in patients with primary stage IV endometrial cancer (EC).

METHODS

We systematically searched the Cochrane Library, Embase, MEDLINE/PubMed, and Web of Science for original studies reporting survival outcomes of primary stage IV EC after complete, optimal, and incomplete CRS. Pooled hazard ratios (HRs) for overall survival (OS) comparing optimal CRS with incomplete CRS were calculated using a random-effects model. Heterogeneity was assessed using the I2 and the Q-test.

RESULTS

Twelve studies, including 748 patients, were analysed. 187 patients underwent complete CRS, and 146 patients optimal CRS. Ten studies reported a significant OS benefit after complete (18-48 months) and optimal CRS (13-34 months) compared to incomplete CRS (7-19 months). A benefit was also observed in patients with serous EC or extra- abdominal metastasis. Meta-analysis showed improved OS after complete/optimal vs. incomplete CRS (HR = 0.38, 95% CI 0.21-0.69, p = 0.0016). Heterogeneity was substantial between studies (I2 = 76.7%, p < 0.0001).

CONCLUSION

Our study supports considering CRS in all patients with primary stage IV EC if complete resection is deemed feasible, while also emphasizing the importance of weighing the harms and benefits of this extensive treatment and adopting shared decision-making.

PROSPERO REGISTRATION

CRD42022302968 on May 10th, 2022.

The impact of estrogen receptor and L1 cell adhesion molecule expression on endometrial cancer outcome correlates with clinicopathological risk group and molecular subgroup

OBJECTIVE

To assess the risk stratification of clinicopathologically and molecularly classified endometrial cancer based on estrogen receptor (ER) and L1 cell adhesion molecule (L1CAM) expression.

METHODS

This was a retrospective study of patients who underwent primary treatment at a single tertiary center. Carcinomas were classified into 5 clinicopathological risk groups, as per European guidelines. Immunohistochemistry and polymerase-ϵ sequencing were conducted for molecular classification and determination of ER and L1CAM expression.

RESULTS

Data from 1044 patients were analyzed. The median follow-up was 67.5 months. In univariable analyses, ER expression correlated with improved disease-specific survival (DSS) in the "no specific molecular profile" (NSMP) (P < 0.001) and mismatch repair deficient (MMRd) (P = 0.002) subgroups. Negative L1CAM expression was associated with enhanced DSS in the NSMP subgroup alone (P < 0.001). ER (hazard ratio [HR] 0.18), but not L1CAM, exhibited prognostic significance within NSMP when controlling for parameters available at the time of diagnosis (tumor histotype, grade, age). ER and L1CAM were not independently associated with DSS within NSMP when controlling for parameters available after surgery (clinicopathological risk groups, age, adjuvant therapy). However, in high-risk-advanced-metastatic cases, both ER (HR 0.26) and L1CAM (HR 3.9) independently correlated with DSS. Similarly, within MMRd, ER was associated with improved DSS in high-risk-advanced-metastatic carcinomas (HR 0.42).

CONCLUSION

The prognostic significance of ER and L1CAM varies across clinicopathological risk groups and molecular subgroups of endometrial cancer. Notably, risk assessment for high-risk-advanced-metastatic NSMP and MMRd subtype carcinomas can be refined by ER status.

Neoadjuvant immune checkpoint blockade in women with mismatch repair deficient endometrial cancer: a phase I study

Neoadjuvant immune checkpoint blockade (ICB) has shown unprecedented activity in mismatch repair deficient (MMRd) colorectal cancers, but its effectiveness in MMRd endometrial cancer (EC) remains unknown. In this investigator-driven, phase I, feasibility study (NCT04262089), 10 women with MMRd EC of any grade, planned for primary surgery, received two cycles of neoadjuvant pembrolizumab (200 mg IV) every three weeks. A pathologic response (primary objective) was observed in 5/10 patients, with 2 patients showing a major pathologic response. No patient achieved a complete pathologic response. A partial radiologic response (secondary objective) was observed in 3/10 patients, 5/10 patients had stable disease and 2/10 patients were non-evaluable on magnetic resonance imaging. All patients completed treatment without severe toxicity (exploratory objective). At median duration of follow-up of 22.5 months, two non-responders experienced disease recurrence. In-depth analysis of the loco-regional and systemic immune response (predefined exploratory objective) showed that monoclonal T cell expansion significantly correlated with treatment response. Tumour-draining lymph nodes displayed clonal overlap with intra-tumoural T cell expansion. All pre-specified endpoints, efficacy in terms of pathologic response as primary endpoint, radiologic response as secondary outcome and safety and tolerability as exploratory endpoint, were reached. Neoadjuvant ICB with pembrolizumab proved safe and induced pathologic, radiologic, and immunologic responses in MMRd EC, warranting further exploration of extended neoadjuvant treatment.

High-Grade Endometrial Cancer: Molecular Subtypes, Current Challenges, and Treatment Options

Although many recent advancements have been made in women's health, perhaps one of the most neglected areas of research is the diagnosis and treatment of high-grade endometrial cancer (EnCa). The molecular classification of EnCa in concert with histology was a major step forward. The integration of profiling for mismatch repair deficiency and Human Epidermal Growth Factor 2 (HER2) overexpression, can further inform treatment options, especially for drug resistant recurrent disease. Recent early phase trials suggest that regardless of subtype, combination therapy with agents that have distinct mechanisms of action is a fruitful approach to the treatment of high-grade EnCa. Unfortunately, although the importance of diagnosis and treatment of high-grade EnCa is well recognized, it is understudied compared to other gynecologic and breast cancers. There remains a tremendous need to couple molecular profiling and biomarker development with promising treatment options to inform new treatment strategies with higher efficacy and safety for all who suffer from high-grade recurrent EnCa.

The Effects of Gynecological Tumor Irradiation on the Immune System

Radiobiology has evolved from a mechanistic model based on DNA damage and response factors into a more complex model that includes effects on the immune system and the tumor microenvironment (TME). Irradiation has an immunomodulatory effect that can manifest as increased anti-tumor immunity or immunosuppression. Irradiation promotes an inflammatory microenvironment through the release of pro-inflammatory cytokines and endothelial damage, which recruit immune system cells to the irradiated area. Radiation-induced immunogenic cell death (ICD), characterized by the release of damage-associated molecular patterns (DAMPs) and tumor antigens, triggers an anti-tumor immune response of both innate and adaptive immunity. Anti-tumor immunity can manifest at a distance from the irradiated area, a phenomenon known as the abscopal effect (AE), which involves dendritic cells and CD8+ T cells. Irradiation also produces an immunosuppressive effect mediated by tumor-associated macrophages (TAMs) and regulatory T lymphocytes (Tregs), which counterbalances the immunostimulatory effect. In this work, we review the mechanisms involved in the radiation-induced immune response, which support the combined treatment of RT and immunotherapy, focusing, where possible, on gynecologic cancer.

Molecular classification of endometrial carcinoma on endometrial biopsy: an early prognostic value to guide personalized treatment

OBJECTIVE

Molecular features are essential for estimating the risk of recurrence and impacting overall survival in patients with endometrial cancer. Additionally, the surgical procedure itself could be personalized based on the molecular characteristics of the tumor. This study aims to assess the feasibility of obtaining reliable molecular classification status from biopsy specimens collected during hysteroscopy to better modulate the appropriate surgical treatment.

METHODS

This monocentric, retrospective, observational study was conducted on 106 patients who underwent a biopsy procedure followed by radical surgery for endometrial cancer, with concurrent molecular investigation. The molecular classification was determined through immunohistochemical staining for p53 and mismatch repair proteins, along with gene sequencing for POLE.

RESULTS

Overall, 106 patients underwent molecular investigation, which was finally achieved on 99 patients (93.4%). Among these, the molecular analysis was conducted in 71 patients (67%) on the pre-operative endometrial biopsy and on the final uterine specimen in 28 patients (26.4%). Most of the endometrial biopsies were performed using Bettocchi hysteroscopy (66%). Molecular analysis was not possible in seven patients (6.6%), with six cases due to sample inadequacy and one case attributed to intra-mucosal carcinoma. The molecular results showed that the copy number low sub-group was the most common, and five cases of 'multiple classifiers' were observed in the low-risk category.

CONCLUSION

Our experience in obtaining molecular information from biopsy samples underscores the feasibility and efficacy of this technique, even in small tissue samples. This capability helps define the prognostic group of patients, facilitates timely decision-making, and develops a personalized strategy for each patient.

Tailoring Endometrial Cancer Treatment Based on Molecular Pathology: Current Status and Possible Impacts on Systemic and Local Treatment

Endometrial cancer (EC) is a heterogeneous disease with a rising incidence worldwide. The understanding of its molecular pathways has evolved substantially since The Cancer Genome Atlas (TCGA) stratified endometrial cancer into four subgroups regarding molecular features: POLE ultra-mutated, microsatellite instability (MSI) hypermutated, copy-number high with TP53 mutations, and copy-number low with microsatellite stability, also known as nonspecific molecular subtype (NSMP). More recently, the International Federation of Gynecology and Obstetrics (FIGO) updated their staging classification to include information about POLE mutation and p53 status, as the prognosis differs according to these characteristics. Other biomarkers are being identified and their prognostic and predictive role in response to therapies are being evaluated. However, the incorporation of molecular aspects into treatment decision-making is challenging. This review explores the available data and future directions on tailoring treatment based on molecular subtypes, alongside the challenges associated with their testing.

Prognostic Effect of Mismatch Repair Status in Early-Stage Endometrial Cancer Treated With Adjuvant Radiation: A Multi-institutional Analysis

PURPOSE

The aim of this work was to report the effect of mismatch repair (MMR) status on outcomes of patients with stage I-II endometrioid endometrial adenocarcinoma (EEC) who receive adjuvant radiation therapy.

METHODS AND MATERIALS

This is a multi-institutional retrospective cohort study across 11 institutions in North America. Patients with known MMR status and stage I-II EEC status postsurgical staging were included. Overall survival (OS) and recurrence-free survival (RFS) rates were estimated via the Kaplan-Meier method. Univariable and multivariable analyses were performed via Cox proportional hazard models for RFS and OS. Statistical analyses were conducted using SPSS version 27.

RESULTS

In total, 744 patients with a median age at diagnosis of 65 years (IQR, 58-71) were included. Most patients were White (69.4%) and had Federation of Obstetrics and Gynecology 2009 stage I (84%) and Federation of Obstetrics and Gynecology grade 1 to 2 (73%). MMR deficiency was reported in 234 patients (31.5%), whereas 510 patients (68.5%) had preserved MMR. External beam radiation therapy with or without vaginal brachytherapy was delivered to 186 patients (25%), whereas 558 patients (75%) received vaginal brachytherapy alone. At a median follow-up of 43.5 months, the estimated crude OS and RFS rates for the entire cohort were 92.5% and 84%, respectively. MMR status was significantly correlated with RFS. RFS was inferior for MMR deficiency compared with preserved MMR (74.3% vs 88.6%, P < .001). However, no difference in OS was seen (90.8% vs 93.2%, P = .5). On multivariable analysis, MMR deficiency status was associated with worse RFS (hazard ratio, 1.86; P = .001) but not OS.

CONCLUSIONS

MMR status was independently associated with RFS but not OS in patients with early-stage EEC who were treated with adjuvant radiation therapy. These findings suggest that differential approaches to surveillance and/or treatment based on MMR status could be warranted.

Prognostic value of molecular classification in stage IV endometrial cancer

OBJECTIVES

Multiple studies have proven the prognostic value of molecular classification for stage I-III endometrial cancer patients. However, studies on the relevance of molecular classification for stage IV endometrial cancer patients are lacking. Hypothetically, poor prognostic molecular subtypes are more common in higher stages of endometrial cancer. Considering the poor prognosis of stage IV endometrial cancer patients, it is questionable whether molecular classification has additional prognostic value. Therefore, we determined which molecular subclasses are found in stage IV endometrial cancer and if there is a correlation with progression-free and overall survival.

METHODS

A retrospective multicenter cohort study was conducted using data from five Dutch hospitals. Patients with stage IV endometrial cancer at diagnosis who were treated with primary cytoreductive surgery or cytoreductive surgery after induction chemotherapy between January 2000 and December 2018 were included. Exclusion criteria were age <18 years or recurrent disease. The molecular classification was performed centrally on all tumor samples according to the World Health Organization 2020 classification (including POLE and estrogen receptor status). The Kaplan-Meier method was used to calculate progression free and overall survival in the molecular subclasses, for the different histological subtypes and for estrogen receptor positive versus estrogen receptor negative tumors. Groups were compared using the log-rank test.

RESULTS

164 stage IV endometrial cancer patients were molecularly classified. Median age of the patients was 67 years (range 33-86). Most patients presented with a non-endometrioid histological subtype (58%). Intra-abdominal complete cytoreductive surgery was achieved in 60.4% of the patients. 101 tumors (61.6%) were classified as p53 abnormal, 35 (21.3%) as no specific molecular profile, 21 (12.8%) as mismatch repair deficient, and 6 (3%) as POLE mutated. Molecular classification had no significant impact on progression free (p=0.056) or overall survival (p=0.12) after cytoreductive surgery. Overall survival was affected by histologic subtype (p<0.0001) and estrogen receptor status (p=0.013).

CONCLUSION

The distribution of the molecular subclasses in stage IV endometrial cancer patients differed substantially from the distribution in stage I-III endometrial cancer patients, with the unfavorable subclasses being more frequently present. Although the molecular classification was not prognostic in stage IV endometrial cancer, it could guide adjuvant treatment decisions.

Prognostic impact and causality of age on oncological outcomes in women with endometrial cancer: a multimethod analysis of the randomised PORTEC-1, PORTEC-2, and PORTEC-3 trials

BACKGROUND

Numerous studies have shown that older women with endometrial cancer have a higher risk of recurrence and cancer-related death. However, it remains unclear whether older age is a causal prognostic factor, or whether other risk factors become increasingly common with age. We aimed to address this question with a unique multimethod study design using state-of-the-art statistical and causal inference techniques on datasets of three large, randomised trials.

METHODS

In this multimethod analysis, data from 1801 women participating in the randomised PORTEC-1, PORTEC-2, and PORTEC-3 trials were used for statistical analyses and causal inference. The cohort included 714 patients with intermediate-risk endometrial cancer, 427 patients with high-intermediate risk endometrial cancer, and 660 patients with high-risk endometrial cancer. Associations of age with clinicopathological and molecular features were analysed using non-parametric tests. Multivariable competing risk analyses were performed to determine the independent prognostic value of age. To analyse age as a causal prognostic variable, a deep learning causal inference model called AutoCI was used.

FINDINGS

Median follow-up as estimated using the reversed Kaplan-Meier method was 12·3 years (95% CI 11·9-12·6) for PORTEC-1, 10·5 years (10·2-10·7) for PORTEC-2, and 6·1 years (5·9-6·3) for PORTEC-3. Both overall recurrence and endometrial cancer-specific death significantly increased with age. Moreover, older women had a higher frequency of deep myometrial invasion, serous tumour histology, and p53-abnormal tumours. Age was an independent risk factor for both overall recurrence (hazard ratio [HR] 1·02 per year, 95% CI 1·01-1·04; p=0·0012) and endometrial cancer-specific death (HR 1·03 per year, 1·01-1·05; p=0·0012) and was identified as a significant causal variable.

INTERPRETATION

This study showed that advanced age was associated with more aggressive tumour features in women with endometrial cancer, and was independently and causally related to worse oncological outcomes. Therefore, our findings suggest that older women with endometrial cancer should not be excluded from diagnostic assessments, molecular testing, and adjuvant therapy based on their age alone.

FUNDING

None.

Aspiring toward equitable benefits from genomic advances to individuals of ancestrally diverse backgrounds

Advancements in genomic technologies have shown remarkable promise for improving health trajectories. The Human Genome Project has catalyzed the integration of genomic tools into clinical practice, such as disease risk assessment, prenatal testing and reproductive genomics, cancer diagnostics and prognostication, and therapeutic decision making. Despite the promise of genomic technologies, their full potential remains untapped without including individuals of diverse ancestries and integrating social determinants of health (SDOHs). The NHGRI launched the 2020 Strategic Vision with ten bold predictions by 2030, including "individuals from ancestrally diverse backgrounds will benefit equitably from advances in human genomics." Meeting this goal requires a holistic approach that brings together genomic advancements with careful consideration to healthcare access as well as SDOHs to ensure that translation of genetics research is inclusive, affordable, and accessible and ultimately narrows rather than widens health disparities. With this prediction in mind, this review delves into the two paramount applications of genetic testing-reproductive genomics and precision oncology. When discussing these applications of genomic advancements, we evaluate current accessibility limitations, highlight challenges in achieving representativeness, and propose paths forward to realize the ultimate goal of their equitable applications.

Patterns of Undertreatment and Overtreatment in Adjuvant Radiotherapy for Early-Stage Endometrial Cancer Based on Molecular Classification

The quality improvement study examines the use of risk-adaptive adjuvant radiotherapy in women with non–mismatch repair deficiency endometrial cancer.

2023 FIGO staging system for endometrial cancer: The evolution of the revolution

INTRODUCTION

Embracing the complex and diverse nature of the heterogenous group of malignancies that are included under the umbrella of "endometrial cancer" (EC) to better align prognosis with treatment recommendations, requires a more comprehensive staging system. Our goal at the development of the new FIGO staging was to provide 1) high accuracy in the predictive prognosis for a patient with EC, which is the genuine purpose of a staging system, and 2) identification of distinct treatment relevant subgroups. Since the publication of the 2009 staging system by the International Federation of Gynecology and Obstetrics (FIGO) 14  years ago (1, 2), our understanding of the biology and natural history of EC has undergone a radical transformation. The TGCA results in 2013 (3), and the many validation reports published since then (4-9), have taught us that "EC" is composed of at least four distinct molecularly defined diseases. Strong histopathologic markers reflecting tumor biology such as lymph vascular space invasion (LVSI) were identified. Importantly, anatomical borders were shown to lose their prognostic relevance for EC patients in the presence of dominant tumor biology-markers such as molecular subtypes/LVSI (10, 11). This emphasizes the integration of these novel markers into a prognostic staging system that aims to be relevant to patients. The 2023 FIGO staging system for EC harmonizes and integrates old and new knowledge on anatomic, histopathologic, and molecular features (12). It requires a change in our perception of a staging system, from a traditional purely anatomical borders-based system to an integrated staging system integrating anatomical borders and tumor biology as pivotal prognostic factors for EC patients while providing important information for treatment decision making. Therefore, the 2023 FIGO staging system demonstrates the logical next step in the evolution of the revolution in a patient-centric staging approach. Below, we elucidate the rationale for the FIGO 2023 endometrial cancer staging system.

Risk-Tailoring Radiotherapy for Endometrial Cancer: A Narrative Review

Endometrial cancer is the most common gynecologic cancer in the United States and it contributes to the second most gynecologic cancer-related deaths. With upfront surgery, the specific characteristics of both the patient and tumor allow for risk-tailored treatment algorithms including adjuvant radiotherapy and systemic therapy. In this narrative review, we discuss the current radiation treatment paradigm for endometrial cancer with an emphasis on various radiotherapy modalities, techniques, and dosing regimens. We then elaborate on how to tailor radiotherapy treatment courses in combination with other cancer-directed treatments, including chemotherapy and immunotherapy. In conclusion, this review summarizes ongoing research that aims to further individualize radiotherapy regimens for individuals in an attempt to improve patient outcomes.

Impact of molecular profile on prognosis and relapse pattern in low and intermediate risk endometrial cancer

INTRODUCTION

The role of molecular classification in patients with low/intermediate risk endometrial cancer (EC) is uncertain. Higher precision in diagnostics will inform the unsettled debate on optimal adjuvant treatment. We aimed to determine the association of molecular profiling with patterns of relapse and survival.

MATERIAL AND METHODS

This retrospective cohort study included patients referred to The Norwegian Radium Hospital, Oslo University Hospital from 2006-2017. Patients with low/intermediate risk EC were molecularly classified as pathogenic polymerase epsilon (POLE)-mutated, mismatch repair deficient (MMRd), p53 abnormal, or no specific molecular profile (NSMP). The main outcomes were time to recurrence (TTR) and cancer-specific survival (CSS).

RESULTS

Of 626 patients, 610 could be molecularly classified. Fifty-seven patients (9%) had POLE-mutated tumors, 202 (33%) had MMRd tumors, 34 (6%) had p53 abnormal tumors and 317 (52%) had NSMP tumors. After median follow-up time of 8.9 years, there was a statistically significant difference in TTR and CSS by molecular groups. Patients with p53 abnormal tumors had poor prognosis, with 10 of the 12 patients with relapse presenting with para-aortic/distant metastases. Patients with POLE mutations had excellent prognosis. In the NSMP group, L1CAM expression was associated with shorter CSS but not TTR.

CONCLUSIONS

The differences in outcome by molecular groups are driven by differences in relapse frequency and -patterns and demand a higher precision in diagnostics, also in patients with low/intermediate risk EC. Tailored adjuvant treatment strategies need to consider systemic treatment for patients with p53 abnormal tumors and de-escalated treatment for patients with POLE mutated tumors.

Assessing the New 2020 ESGO/ESTRO/ESP Endometrial Cancer Risk Molecular Categorization System for Predicting Survival and Recurrence

This study aimed to evaluate the efficacy of the 2020 European Society of Gynecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology (ESGO/ESTRO/ESP) guidelines for endometrial cancer (EC). Additionally, a novel risk category incorporating clinicopathological and molecular factors was introduced. The predictive value of this new category for recurrence and survival in Korean patients with EC was assessed, and comparisons were made with the 2013 and 2016 European Society of Medical Oncology (ESMO) risk classifications. Patients with EC were categorized into the POLE-mutated (POLEmut), mismatch repair-deficient (MMRd), p53-aberrant (P53abn), and nonspecific molecular profile (NSMP) subtypes. Recurrence, survival, and adjuvant therapy were assessed according to each classification. Notably, patients with the POLEmut subtype showed no relapse, while patients with the P53abn subtype exhibited higher recurrence (31.8%) and mortality rates (31.8%). Regarding adjuvant therapy, 33.3% of low-risk patients were overtreated according to the 2020 ESGO/ESTRO/ESP guidelines. Overall and progression-free survival differed significantly across molecular classifications, with the POLEmut subtype showing the best and the P53abn subtype showing the worst outcomes. The 2020 ESGO molecular classification system demonstrated practical utility and significantly influenced survival outcomes. Immunohistochemistry for TP53 and MMR, along with POLE sequencing, facilitated substantial patient reclassification, underscoring the clinical relevance of molecular risk categories in EC management.

Review of brachytherapy clinical trials: a cross-sectional analysis of ClinicalTrials.gov

INTRODUCTION

Characterizing the landscape of clinical trials including brachytherapy can provide an overview of the current status and research trends which may guide further areas of investigation.

METHOD

We queried 449,849 clinical trials from the ClinicalTrials.gov registry using brachytherapy-related keywords from 1980 to 2023, yielding 245 multi-arm and 201 single-arm, brachytherapy trials. Multi-arm and single-arm brachytherapy trials were compared using 12 trial protocol elements.

RESULTS

The number of trials including brachytherapy has increased over time, with over 60% of trials registered in 2010 onwards. The majority of clinical trials were Phase 2 or 3, evaluated both safety and efficacy, and were funded by academic sponsors. The most common tumor sites evaluated in brachytherapy clinical trials include prostate, cervix, liver, endometrium, and breast.

CONCLUSION

There remains continued interest in clinical trials including brachytherapy focused on evaluation of novel delivery systems, treatment planning, and new indications. More brachytherapy clinical trials are needed to define the optimal clinical utilization and advance prospective research in this field.

Treatment outcomes of early-stage endometrial cancer patients: A propensity score matching of vaginal brachytherapy versus pelvic radiotherapy

OBJECTIVES

This study aimed to report the treatment outcomes of radiation therapy for early-stage endometrial cancer patients. In addition, this study intended to identify high-risk factors that require pelvic radiotherapy (PRT) in addition to vaginal brachytherapy (VBT) for intermediate-risk endometrial cancer patients.

METHODS

Patients with early-stage endometrial cancer receiving postoperative VBT alone or with PRT were included. Propensity score matching was used to balance the two study groups. The primary endpoint was locoregional recurrence (LRR). Age-adjusted Charlson comorbidity index and substantial lymphovascular space invasion were selected for subgroup analyses to identify the benefits of PRT over VBT alone.

RESULTS

From 2005 to 2017, a total of 288 patients underwent analysis following propensity score matching. Of these, 144 received VBT and 144 received PRT. There was no significant difference in 5-year LRR between VBT and PRT for both intermediate (0% vs. 0%) and high-intermediate risk patients (3.5% VBT vs. 5.4% PRT; HR 0.54: 0.05-6.00; p = 0.616). The subgroup analyses revealed no significant factors favoring PRT over VBT. Patients with high comorbidities may have higher risks of non-cancer death after receiving PRT.

CONCLUSIONS

Postoperative VBT alone is sufficient for early-stage intermediate-risk endometrial cancer patients.

Interventional Radiotherapy in Gynecological Cancer

This special issue of "Cancers" explores unusual and very particular aspects of interventional radiotherapy (brachytherapy) in gynecological cancer [...].