Durvalumab Plus Carboplatin/Paclitaxel Followed by Maintenance Durvalumab With or Without Olaparib as First-Line Treatment for Advanced Endometrial Cancer: The Phase III DUO-E Trial

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Training, Validating, and Testing Machine Learning Prediction Models for Endometrial Cancer Recurrence

PURPOSE

Endometrial cancer (EC) is the most common gynecologic cancer in the United States with rising incidence and mortality. Despite optimal treatment, 15%-20% of all patients will recur. To better select patients for adjuvant therapy, it is important to accurately predict patients at risk for recurrence. Our objective was to train, validate, and test models of EC recurrence using lasso regression and other machine learning (ML) and deep learning (DL) analytics in a large, comprehensive data set.

METHODS

Data from patients with EC were downloaded from the Oncology Research Information Exchange Network database and stratified into low risk, The International Federation of Gynecology and Obstetrics (FIGO) grade 1 and 2, stage I (N = 329); high risk, or FIGO grade 3 or stages II, III, IV (N = 324); and nonendometrioid histology (N = 239) groups. Clinical, pathologic, genomic, and genetic data were used for the analysis. Genomic data included microRNA, long noncoding RNA, isoforms, and pseudogene expressions. Genetic variation included single-nucleotide variation (SNV) and copy-number variation (CNV). In the discovery phase, we selected variables informative for recurrence (P < .05), using univariate analyses of variance. Then, we trained, validated, and tested multivariate models using selected variables and lasso regression, MATLAB (ML), and TensorFlow (DL).

RESULTS

Recurrence clinic models for low-risk, high-risk, and high-risk nonendometrioid histology had AUCs of 56%, 70%, and 65%, respectively. For training, we selected models with AUC >80%: five for the low-risk group, 20 models for the high-risk group, and 20 for the nonendometrioid group. The two best low-risk models included clinical data and CNVs. For the high-risk group, three of the five best-performing models included pseudogene expression. For the nonendometrioid group, pseudogene expression and SNV were overrepresented in the best models.

CONCLUSION

Prediction models of EC recurrence built with ML and DL analytics had better performance than models with clinical and pathologic data alone. Prospective validation is required to determine clinical utility.

Endometrial cancer: Part II. Multimodality treatment of uterine high-grade serous carcinoma (clinical course I)

Endometrial cancer (EC) is the most frequently diagnosed gynecological malignancy with rapid growth of incidence in the high-income countries and Taiwan. Since the integration of modern molecular pathology into traditional clinico-pathology for the diagnosis and classification of EC, the treatment is apparently switched to more precise molecular-guided or -targeted therapy, having been reviewed in the part I (2022). The current review is the part II describing the previous history (clinical course I) of the complex clinical course occurred in a 66-year-old woman with uterine high-grade serous carcinoma (HGSC, post-curettage diagnosis), who was treated with robotic staging surgery without additional postoperative adjuvant therapy due to absence of any residual malignancy in February 2019 (Rationales and controversial issues 1-5). Recurrences at the multiple sites, including vaginal cuff, liver, adrenal and lung metastases occurred in December 2020. Suboptimal cytoreductive surgery and following 6 cycles of paclitaxel-carboplatin regimen between January and April 2021 achieved nearly complete remission (Rationales 6,7 and controversial issues 6,7 for the first recurrence). However, this equivocal clinical situation made the following treatment in confusion. Using positron emission tomography/magnetic resonance image (MRI) or computed tomography (CT) not only serving as a valuable tool for detecting occult metastatic lesions but also giving an answer for uncertain clinical diagnosis provided the additional therapy (Rationales 8-10 and Controversial issues 7-9). This case highlights an aggressive nature of uterine HGSC, even though the initial diagnosis was an early-stage disease (no residual tumor) and the hospital shopping makes the clinical course much complex. This part II (Clinical course I) has explored the first journey from the initial diagnosis and initial treatment at the hospital "A" and "B" to the subsequent management of the recurrent disease at the hospitals "C,D,E,F", including the rationale and controversial issues in the clinical course I.

Real-world outcomes in molecular subgroups for patients with advanced or recurrent endometrial cancer treated with platinum-based chemotherapy

OBJECTIVE

There is scarce real-world evidence on patients with advanced/recurrent endometrial cancer treated with platinum-based chemotherapy. We assessed the oncological outcome in groups by molecular classification.

METHODS

This retrospective cohort study included patients with advanced/recurrent endometrial cancer treated with platinum-based chemotherapy after hysterectomy at The Norwegian Radium Hospital, Oslo University Hospital, Norway, between January 2006 and December 2017. Patients were molecularly classified as pathogenic POLE mutated, mismatch repair deficient, p53 abnormal, or no specific molecular profile. Time-to-recurrence and cancer-specific survival were calculated.

RESULTS

We identified 264 advanced-stage patients (stage III/IV) and 96 patients with recurrent disease. The molecular classification was prognostic for time-to-recurrence (p < .0001) and cancer-specific survival (p < .0001) in patients with advanced disease, but the outcome did not differ significantly by molecular groups in recurrent patients. In all molecular groups, patients with stage III disease had longer time-to-recurrence and cancer-specific survival compared to patients with stage IV disease. The worst outcome was observed in patients with p53 abnormal tumors with an HR of 1.57 (95% CI 1.07 to 2.30) for time-to-recurrence and HR of 1.78 (95% CI 1.19 to 2.65) for cancer-specific survival in stage III/IV disease and an HR of 1.45 (95% CI 0.83 to 2.52) for time-to-recurrence and HR of 1.60 (95% CI 0.99 to 2.68) for cancer-specific survival in patients with recurrent disease. The few patients with POLE mutated tumors had favorable outcomes despite the advanced/recurrent disease status.

CONCLUSIONS

Oncological outcomes differ by molecular groups, in particular among patients with advanced disease. Patients with p53 abnormal tumors have the worst outcome, while patients with POLE mutated tumors have favorable outcomes even with recurrent disease. Implementation of the addition of immunotherapy to chemotherapy is expected to lead to substantial improvement of outcome, particularly in patients with mismatch repair deficient advanced/recurrent disease. There is still a high unmet need in advanced/recurrent patients with p53 abnormal and no specific molecular profile tumors.

Multi-center, international endometrial cancer consortium highlights

The multi-center, international consortium on endometrial cancer held in January 2025 at Mayo Clinic in Rochester, Minnesota brought together leading experts in gynecologic oncology to explore the latest advancements in the understanding, diagnosis, and treatment of endometrial cancer. Discussions centered on key topics, including updates in molecular testing and disease staging, emerging treatment strategies for advanced and recurrent disease, fertility-sparing management, and critical pathology challenges, particularly, the assessment of lympho-vascular space invasion. Each topic was examined in dedicated working group sessions, fostering in-depth exchanges to identify research priorities and develop actionable strategies. This summary highlights the central themes and insights from the meeting, outlining a roadmap for future advancements in the field. By promoting inter-disciplinary collaboration, the meeting laid the foundation for future research, policy recommendations, and clinical innovations aimed at improving patient outcomes.

Pathogenic germline variants among women with uterine cancer by ancestry: A commercial laboratory collaborative research registry study

OBJECTIVE

Uterine cancer (UC) is the most common gynecologic cancer in the United States, and 5-15 % of patients harbor a germline pathogenic variant (gPV) in a cancer predisposition gene. This study aims to characterize the germline landscape of patients with UC by self-identified ancestry.

METHODS

Patients with UC who received germline testing were identified from the publicly available Myriad Collaborative Research Registry. Rates of gPVs were calculated, overall and by self-reported ancestry, with a focus on genes associated with UC, including Lynch syndrome (LS) and homologous recombination-related (HR) genes.

RESULTS

Among 35,310 patients with UC, 23,081 (65.4 %) identified as White, 3683 (10.4 %) as Hispanic, 2132 (6.0 %) as Black, 1244 (3.5 %) as Ashkenazi Jewish (AJ), 1093 (3.1 %) as Asian, and 7550 (21.4 %) as Other. Overall, 5141 (14.6 %) patients had a gPV, with highest rates among White (15.5 %) and Asian (17.8 %) compared to Black (10.4 %) and Hispanic (11.6 %) patients, p < 0.0001. LS gPVs were observed in 3155 (8.9 %) patients and was most prevalent in Asian women (12.9 %), particularly MLH1 and MSH2-associated LS. HR-related gPVs were found in 1066 (3.0 %) patients overall and were most common in AJ (4.1 %) and Black (4.0 %) patients, with high rates of BRCA1/2 gPVs in AJ patients and non-BRCA HR-related gPVs in Black patients.

CONCLUSIONS

Of the over 35,000 patients with UC, 14.5 % had a gPV identified, supporting consideration of universal germline testing in endometrial cancer given high actionability. We observed heterogeneity in gPVs by self-reported ancestry with Black and Hispanic patients having the lowest rates, potentially contributing to disparities in UC.

Exploring the Genetic and Clinical Landscape of Dedifferentiated Endometrioid Carcinoma

Dedifferentiated endometrioid carcinoma (DDEC) is rare, has a poor prognosis, and the genes responsible for dedifferentiation remain unclear. This study aimed to clarify the characteristics of DDEC in Japanese patients and develop treatment strategies. Eighteen DDEC cases were included; their clinicopathological features and prognoses were analyzed and compared to those of other histological subtypes. The samples were divided into well-differentiated and undifferentiated components; immunostaining and whole-exome sequencing (n = 3 cases) were conducted. The incidence of DDEC was 2.0% among endometrial cancers. The 5-year progression-free survival and the 5-year overall survival for DDEC was approximately 40% and 30%, respectively. Immunohistochemistry showed that 66.7% of patients were mismatch repair deficient. The rate of p53 mutations was higher than that reported in previous studies, and patients with p53 mutations in the undifferentiated components had a poor prognosis. Whole-exome sequencing revealed different gene mutations and mutation signatures between well-differentiated and undifferentiated components. New genetic mutations in undifferentiated regions were uncommon in all three cases. One case (case 1) exhibited homologous recombination deficiency, whereas the other two showed microsatellite instability-high and hypermutator phenotypes. Genetic analysis suggests that immune checkpoint and poly (ADP-ribose) polymerase inhibitors and drugs targeting the p53 pathway may be effective against DDEC.

ADAGIO: A Phase IIb, Open-Label, Single-Arm, Multicenter Study Assessing the Efficacy and Safety of Adavosertib (AZD1775) as Treatment for Recurrent or Persistent Uterine Serous Carcinoma

PURPOSE

This phase IIb, single-arm, multicenter, global study (ADAGIO; ClinicalTrials.gov identifier: NCT04590248) assessed the efficacy and safety of adavosertib in patients with recurrent/persistent uterine serous carcinoma (USC) who had previously received platinum-based chemotherapy.

METHODS

Eligible patients were age 18 years and older and had histologically confirmed recurrent/persistent USC, previously treated with at least one platinum-based chemotherapy regimen, and with evidence of measurable disease. Adavosertib was administered orally at 300 mg once daily on days 1-5 and 8-12 of a 21-day cycle until discontinuation criteria were met. The primary end point was objective response rate (ORR) by blinded independent central review (BICR). Secondary end points included duration of response (DoR), progression-free survival (PFS), safety, and tolerability. Biomarkers previously associated with adavosertib response in other settings were assessed in archival tissue samples.

RESULTS

In 104 evaluable patients, one complete response and 26 partial responses were observed, for an ORR by BICR of 26.0% (95% CI, 17.9 to 35.5). Median DoR was 4.7 months (95% CI, 3.8 to 8.3); median PFS was 2.8 months (95% CI, 2.6 to 3.9). Biomarker analysis identified no single predictive alteration for adavosertib response, although a trend was observed for CCNE1 amplification or high cyclin E1 protein expression. Most patients (97.2%) experienced treatment-related adverse events (TRAEs), most frequently diarrhea (59.6%), nausea (59.6%), and anemia (58.7%). Grade ≥3 TRAEs occurred in 60.6% of patients, with neutropenia (21.1%) and fatigue (13.8%) most common. 17.4% of patients discontinued adavosertib due to AEs (treatment-related in 14.7%).

CONCLUSION

Adavosertib showed some antitumor activity in patients with recurrent/persistent USC. However, at 300 mg once daily dosing, it was not well tolerated in this population. Exploratory biomarker studies suggest CCNE1/cyclin E1 expression may enrich for response to Wee1 inhibition in USC.

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.

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

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

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

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

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 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.

Randomized study evaluating optimal dose, efficacy, and safety of E7386 plus lenvatinib versus treatment of physician's choice in advanced/recurrent endometrial carcinoma previously treated with platinum-based chemotherapy and immune checkpoint inhibitors

BACKGROUND

Randomized controlled trial data for patients with endometrial cancer who experience disease progression after anti-programmed cell death [ligand] 1 (PD-[L]1) therapy are lacking. E7386, a novel small-molecule inhibitor, has been shown to enhance anti-angiogenesis when combined with lenvatinib. The escalation and expansion parts of Study 102 showed preliminary anti-tumor activity and manageable safety of E7386 plus lenvatinib in patients with advanced, un-resectable, or recurrent endometrial cancer previously treated with anti-PD-(L)1.

PRIMARY OBJECTIVE

This study aimed to determine the optimal dose of E7386 in combination with lenvatinib.

STUDY HYPOTHESIS

E7386 plus lenvatinib will show a manageable safety profile and clinically meaningful anti-tumor activity in patients with advanced, un-resectable, or recurrent endometrial carcinoma previously treated with chemotherapy and anti-PD-(L)1 therapy.

TRIAL DESIGN

Study 102 is an open-label, global, phase 1b/2 trial. Patients with endometrial carcinoma will be randomized 1:1:1:1 to E7386 120 mg twice daily plus lenvatinib 14 mg once daily, E7386 60 mg twice daily plus lenvatinib 14 mg once daily, lenvatinib 24 mg once daily monotherapy, or treatment of physician's choice (doxorubicin 60 mg/m2 once every 3 weeks or paclitaxel 80 mg/m2 once weekly [3 weeks on/1 week off]).

MAJOR INCLUSION/EXCLUSION CRITERIA

Eligible patients are aged ≥18 years with Eastern Cooperative Oncology Group performance status of 0 to 1 and must have advanced, un-resectable, or recurrent endometrial carcinoma that has progressed on/after prior platinum-based chemotherapy and PD-(L)1-directed therapy. Up to 3 previous lines of therapy are permitted. Individuals with prior treatment with lenvatinib or E7386 or known intolerance and/or known hypersensitivity to E7386, lenvatinib, doxorubicin, or paclitaxel, or any of their excipients, are not eligible to participate.

PRIMARY END POINTS

The primary end points are safety and the objective response rate per Response Evaluation Criteria in Solid Tumors version 1.1 by investigator assessment at week 24.

SAMPLE SIZE

The study aims to include 120 patients across approximately 80 investigational sites in North America, Europe, and Asia-Pacific regions. Estimated Dates for Completing Accrual and Presenting Results: Enrollment is expected to take approximately 9 months, with presentation of results in 2026.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov, NCT04008797.

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.

Real-world treatment patterns and clinical outcomes in patients with advanced or recurrent endometrial cancer re-challenged with platinum-based chemotherapy in Europe

OBJECTIVE

Although platinum re-challenge is a treatment option for patients with advanced/recurrent endometrial cancer, real-world outcomes for these patients in Europe are not well-documented. Thus, this study aimed to evaluate real-world treatment patterns and outcomes for platinum re-challenge in patients with advanced/recurrent endometrial cancer.

METHODS

Endometrial Cancer Health Outcomes-Europe (ECHO-EU) is a multi-center, retrospective, medical record review conducted in France, Germany, Italy, Spain, and the United Kingdom, evaluating treatment patterns and outcomes. Patients with advanced/recurrent endometrial cancer treated with first-line systemic therapy and experiencing disease progression between July 2016 and June 2019 were eligible for inclusion in ECHO-EU. This analysis used data from a subset of patients, the platinum re-challenge cohort, who received platinum-based chemotherapy as second-line therapy after previous adjuvant/neoadjuvant and/or first-line platinum therapy. Kaplan-Meier analyses since initiation of second-line therapy estimated real-world progression-free survival and overall survival.

RESULTS

Of the 475 ECHO-EU patients, 70 patients (15%) were platinum re-challenged and had a median age of 67 years (range; 44-81). The platinum-free interval (PFI) was <6 months for 27 patients (38.6%) and >6 months for 43 patients (61.4%). Complete or partial response to second-line therapy were achieved in 37.1% of patients, with similar overall response rates reported for patients with PFI <6 months (33.3%) and PFI ≥6 months (39.5%). The median (95% CI) overall survival from second-line therapy was 12 months (11-not estimable [NE]) overall and 14.1 (8.7-NE) and 12.0 (10.5-NE) months for patients with PFI <6 months and PFI >6 months, respectively. The median real-world progression-free survival from initiation of second-line therapy was 8.1 months (95% CI 7.6 to 10.0) overall and 7.6 (95% CI 5.3 to 19.8) and 8.5 (95% CI 7.9 to 12.0) months for patients with PFI <6 months and PFI ≥6 months, respectively.

CONCLUSION

Patients with advanced/recurrent endometrial cancer who were re-challenged with a platinum-based therapy had similar outcomes, irrespective of their PFI, indicating that further research is needed to assess the value of PFI in endometrial cancer. The findings also suggest an unmet medical need and scope for novel treatments that may improve the overall survival for these patients.

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.

Next-Generation Sequencing in Oncology-A Guiding Compass for Targeted Therapy and Emerging Applications

Multigene sequencing technologies provide a foundation for targeted therapy and precision oncology by identifying actionable alterations and enabling the development of treatments that substantially improve clinical outcomes. This review emphasizes the importance of having a molecular compass guiding treatment decision-making through the multitude of alterations and genetic mutations, showcasing why NGS plays a pivotal role in modern oncology.

First-Line Lenvatinib Plus Pembrolizumab Versus Chemotherapy for Advanced Endometrial Cancer: A Randomized, Open-Label, Phase III Trial

PURPOSE

Lenvatinib plus pembrolizumab (len + pembro) significantly improved progression-free survival (PFS) and overall survival (OS) versus chemotherapy in previously treated advanced or recurrent endometrial cancer (aEC) in the phase III Study 309/KEYNOTE-775. We report results from the phase III, randomized, open-label European Network of Gynaecological Oncological Trial-en9/LEAP-001 study (ClinicalTrials.gov identifier: NCT03884101) that evaluated len + pembro versus chemotherapy in first-line aEC.

METHODS

Patients with stage III to IV or recurrent, radiographically apparent EC and no previous chemotherapy or disease progression ≥6 months after neo/adjuvant platinum-based chemotherapy were randomly assigned 1:1 to lenvatinib 20 mg once daily plus pembrolizumab 200 mg once every 3 weeks or paclitaxel 175 mg/m2 plus carboplatin AUC 6 mg/mL/min once every 3 weeks. Primary end points were PFS and OS, evaluated in the mismatch repair-proficient (pMMR) and all-comers populations. Noninferiority was assessed for OS at final analysis (FA) for len + pembro versus chemotherapy (multiplicity-adjusted, one-sided nominal alpha, .0159; null hypothesis-tested hazard ratio [HR], 1.1).

RESULTS

Eight hundred forty-two patients were randomly assigned (len + pembro, n = 420 [pMMR population, n = 320]; chemotherapy, n = 422 [pMMR population, n = 322]). At FA (data cutoff, October 2, 2023), median PFS (95% CI) in the pMMR population was 9.6 (8.2 to 11.9) versus 10.2 (8.4 to 10.5) months with len + pembro versus chemotherapy (hazard ratio [HR], 0.99 [95% CI, 0.82 to 1.21]) and among all-comers was 12.5 (10.3 to 15.1) versus 10.2 (8.4 to 10.4) months (HR, 0.91 [95% CI, 0.76 to 1.09]; descriptive analyses). Median OS (95% CI) in the pMMR population was 30.9 (25.4 to 37.7) versus 29.4 (26.2 to 35.4) months with len + pembro versus chemotherapy (HR, 1.02 [95% CI, 0.83 to 1.26]; noninferiority P = .246, not statistically significant per multiplicity control strategy) and among all-comers was 37.7 (32.2 to 43.6) versus 32.1 (27.2 to 35.7) months (HR, 0.93 [95% CI, 0.77 to 1.12]). Grade ≥3 treatment-related adverse events occurred in 331/420 (79%) versus 274/411 (67%) treated patients.

CONCLUSION

First-line len + pembro did not meet prespecified statistical criteria for PFS or OS versus chemotherapy in pMMR aEC.

Phase 2 study of neoadjuvant durvalumab plus docetaxel, oxaliplatin, and S-1 with surgery and adjuvant durvalumab plus S-1 for resectable locally advanced gastric cancer

BACKGROUND

Based on the phase 3 PRODIGY study, neoadjuvant docetaxel, oxaliplatin, and S-1 (DOS) have emerged as a viable treatment option for Asian patients with resectable locally advanced gastric cancer (LAGC). This phase 2 study evaluated the efficacy and safety of combining neoadjuvant durvalumab with DOS, followed by surgery and adjuvant durvalumab plus S-1 chemotherapy, for resectable LAGC.

METHODS

Patients with LAGC with cT2/3N+or cT4Nany tumors were enrolled in this study. Patients with proficient mismatch repair protein (pMMR) tumors received three cycles of neoadjuvant durvalumab plus DOS, administered every 3 weeks, followed by surgery and adjuvant S-1 plus durvalumab (main study arm). The primary endpoints were the rate of pathologic complete regression (pCR) and safety. An exploratory arm evaluated patients with deficient mismatch repair protein (dMMR) tumors, who received three cycles of neoadjuvant durvalumab and tremelimumab, followed by surgery and adjuvant durvalumab.

RESULTS

In the main study arm, 50 pMMR patients were enrolled, and received at least one dose of neoadjuvant treatment. The median age was 63 years, with 72.0% being men. 18 and 32 patients presented with clinical stage II and III tumors, respectively. 49 (98.0%) underwent surgery, with 45 achieving R0 resection. A pCR rate of 30.0% was observed, meeting the prespecified primary efficacy endpoint. With a median follow-up of 21.8 months, the 3-year progression-free survival and overall survival rates were 69.9% and 88.1%, respectively. 10% of patients experienced predefined unacceptable severe toxicities, including febrile neutropenia (n=3) and persistent G4 neutropenia (n=2) lasting more than 7 days, thereby meeting the primary safety endpoint. Nine patients with dMMR tumors were enrolled in the exploratory arm. All nine underwent surgery, with a pCR rate of 22.2%.

CONCLUSIONS

This study met its primary efficacy and safety endpoints. The combination of neoadjuvant durvalumab plus DOS, followed by surgery and adjuvant durvalumab plus S-1 chemotherapy, warrants further investigation in a phase 3 trial for Asian patients with LAGC.

CLINICAL TRIAL INFORMATION

04221555.

Diagnostic accuracy and prognostic factors of uterine serous carcinoma in Japanese women: a multi-center study

OBJECTIVE

This multi-center retrospective study aimed to clarify the characteristics, diagnostic accuracy, treatment outcomes, and prognostic factors of uterine serous carcinoma (USC) in Japanese women.

METHODS

The medical records of 193 patients who were treated between 2006 and 2008 at 24 participating institutions in the Japanese Clinical Oncology Group were examined, and pathological slides of 188 patients were re-checked through central pathology review (CPR), hematoxylin-eosin staining, and immunohistochemistry.

RESULTS

USC was confirmed in 144 of the 188 (76.6%) patients using CPR, and only 50% were correctly diagnosed preoperatively. Forty-three patients were diagnosed with non-serous carcinoma, whereas one patient had metastasis from another organ. The average age was 65.7 years, and 19% of patients had a history of other cancers. The incidence of stage III-IV disease was 52.8%, and lymph node metastasis was found in 28.5% of patients. Extrauterine spread and distant metastasis occurred in 39% and 14% of patients, respectively. The 2-year overall survival and progression-free survival (PFS) rates were 56% and 42%, respectively. The PFS of patients with stage I and II who underwent complete staging surgery was 92.3%, and that of those without lymph node dissection or omentectomy was 33.3%. Patients with USC had a significantly worse prognosis than 43 patients with non-serous carcinoma.

CONCLUSION

USC in Japanese women has characteristics different from those of endometrioid carcinoma, worse prognosis, and is difficult to diagnose preoperatively. Complete surgical staging is necessary even for early-stage disease. Additionally, new adjuvant treatment strategies, including molecular targeted therapy, should be explored.

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

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

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Endometrial cancer]

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

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.

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.

Real-World Molecular Testing Rates and Patterns in Patients With Primary Advanced or Recurrent Endometrial Cancer in the United States

PURPOSE

This retrospective cohort study estimated the real-world utilization of biomarker testing among patients with primary advanced/recurrent endometrial cancer (pA/rEC) and characterized testing according to demographic and clinical characteristics.

MATERIALS AND METHODS

A nationwide electronic health record-derived deidentified database was used. Records from January 1, 2013, to August 31, 2023, for women age 18 years and older with pA/rEC were searched for DNA mismatch repair (MMR)/microsatellite instability (MSI), human epidermal growth factor receptor 2 (HER2), and estrogen receptor (ER) or progesterone receptor (PR) testing; a subsample data set (advEndo Spotlight) was searched from April 1, 2013, to November 30, 2022, for additional biomolecular testing. Testing rates were reported by index year and molecular marker. Multivariate logistic regression analyses were conducted to identify characteristics associated with testing.

RESULTS

The full data set included 2,982 patients, of whom 53% were age 65 years and older; most were non-Hispanic White (56%) and received care in a community setting (73%). The advEndo Spotlight subsample (n = 509) had similar characteristics. From 2013 to 2021, testing for any biomarker increased from 53% to 89% (MMR/MSI, 17% to 81%; ER/PR, 45% to 62%; HER2, 15% to 43%). Patients who received care at an academic versus community facility, had commercial/other insurance versus Medicare/Medicaid, had primary advanced versus recurrent EC, had endometrioid versus nonendometrioid carcinoma, or had no previous surgery as part of primary treatment were more likely to receive testing.

CONCLUSION

Molecular testing rates in pA/rEC have increased over time, likely due in part to incorporation of biomarker testing into treatment guidelines. This highlights an unmet need to ensure universal access to testing in patients with pA/rEC. Understanding these factors can inform approaches to increase access to molecular testing and increase testing rates.

Efficacy comparison of PD-1/PD-L1 inhibitor monotherapy and combination with PARPis or antiangiogenic agents in advanced or recurrent endometrial cancer: a systematic review and network meta-analysis

PURPOSE

The network meta-analysis (NMA) was aimed to compare and assess the effectiveness of programmed cell death 1 (PD-1)/ programmed cell death ligand 1 (PD-L1) inhibitor monotherapy or combination therapy with other agents for individuals with advanced or recurrent endometrial cancer (EC).

METHODS

The NMA was registered on the PROSPERO website (ID: CRD42024545968) and multiple databases were queried to retrieve the articles. It assessed the progression-free survival (PFS) and overall survival (OS) of persons with advanced or recurrent EC, as well as those with deficient mismatch repair (dMMR) and proficient mismatch repair (pMMR) in terms of PFS.

RESULTS

The NMA included 12 studies involving a total of 4,515 patients. Compared to chemotherapy, the PD-1/PD-L1 inhibitor monotherapy (hazard ratio [HR], 0.59; 95% confidence interval [CI]: 0.44-0.78) in PFS, combination therapy with poly (ADP-ribose) polymerase inhibitors (PARPis) (HR, 0.53; 95% CI: 0.32-0.89) or with antiangiogenic agents (HR, 0.48; 95% CI: 0.25-0.83) all showed significant improvements in PFS. PD-1/PD-L1 inhibitor monotherapy resulted in a significantly higher OS (HR, 0.61; 95% CI: 0.37-0.97) compared to chemotherapy. Combination therapy with antiangiogenic agents demonstrated the highest efficacy in extending PFS, while the combination with PARPis had the best performance in extending OS. Patients with dMMR and pMMR subtypes derive greater benefits from PD-1/ PD-L1 inhibitor monotherapy and PD-1/PD-L1 inhibitors combined with PARPis respectively.

CONCLUSION

Monotherapy with PD-1/PD-L1 inhibitors and combination therapies with PARPis or antiangiogenic agents demonstrate significant potential for individuals with advanced or recurrent EC.

Microsatellite instability-high status as a pan-cancer biomarker for immunotherapy efficacy

BACKGROUND

Microsatellite instability-high (MSI-H) cancers are linked to exceptional benefit from immune checkpoint inhibitors (ICIs), but studies on their efficacy across various MSI-H cancer types are limited.

METHODS

Randomized clinical trials (RCTs) comparing ICIs to chemotherapy in advanced MSI-H/dMMR cancers were systematically reviewed. Eligible studies included 13 RCTs with 1633 MSI-H patients across colorectal, gastric, and endometrial cancers. Data were analyzed using hazard ratios for progression-free survival (PFS) and overall survival (OS), with subgroup analyses by tumor type. Statistical heterogeneity was assessed using Cochrane's Q and I2.

RESULTS

Immunotherapy significantly improved PFS and OS in MSI-H patients, with an HR for OS of 0.35 (95% CI 0.27-0.46; p < 0.00001) versus 0.81 for MSS patients. PFS showed a 64% reduced risk of progression (HR = 0.36, 95% CI 0.28-0.46; p < 0.0001). Subgroup analyses highlighted PFS benefits across tumor types: colorectal (HR = 0.28, 95% CI 0.11-0.73), gastric (HR = 0.43, 95% CI 0.27-0.68), and endometrial cancers (HR = 0.34, 95% CI 0.27-0.42).

CONCLUSIONS

This meta-analysis establishes MSI-H as a predictive biomarker for ICIs, supporting its role in therapy selection and underscoring the need for MSI-H/dMMR-focused clinical trials.

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

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

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

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

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 [...].

The PENDOR study: establishment of a panel of patient-derived tumor organoids from endometrial cancer to assess efficacy of PARP inhibitors

BACKGROUND

Combination of chemotherapy and immunotherapy is the current standard of care for advanced endometrial cancer. However, survival outcome remains poor, highlighting the urgent need for new treatments and reliable tools to identify patients who will benefit from them. Patient-Derived Tumor Organoids (PDTO) are three-dimensional structures established from patient tumors, and are closely mimicking the features of the tumor of origin. Moreover, more and more evidences show that PTDOs hold promises as predictive tools for the response to treatment of patients.

METHOD

The PENDOR study is a monocentric observational study designed to assess the feasibility of generating and testing PDTOs derived from endometrial cancer for evaluating treatment sensitivity. PDTOS will be established from surgical specimens not required for anatomopathological diagnosis. Tumor cells will be dissociated, embedded in extracellular matrix, and cultured in a medium supplemented with growth factors and signaling pathways inhibitors. Molecular and histological analyses will be conducted to validate the resemblance of PDTO to the original tumor. Response of PDTO to conventional chemotherapy and PARP inhibitors will be evaluated and compared to clinical response and to the results of an academic HRD test Genomic Instability Scar (GIScar), respectively, to assess their predictive value.

DISCUSSION

This pilot study aims to validate the feasibility to develop PDTOs from endometrial cancer from patients who will undergo surgical resection. We aim to provide a proof of concept regarding the predictive value of these models for their potential application into routine clinical practice as part of precision medicine. This approach could therefore facilitate the identification of patients who could benefit from PARP inhibitors.

TRIAL REGISTRATION

This clinical trial (N°ID-RCB: 2024-A01206-41) has been validated by local research ethic committee on July 16th 2024 and registered at ClinicalTrials.gov with the identifier NCT06603506 on September 6th 2024, version 1.

Innate Immune Activation with Multifunctional Nanoparticles for Cancer Immunotherapy

Immune checkpoint blockade (ICB) has revolutionized the treatment of many cancers by leveraging the immune system to combat malignancies. However, its efficacy is limited by the immunosuppressive tumor microenvironment and other regulatory mechanisms of the immune system. Innate immune modulators (IIMs) provide potent immune activation to complement adaptive immune responses and help overcome resistance to ICB. This minireview provides an overview of IIMs and their roles in antitumor immune responses and summarizes recent advances in developing nanotechnology to enhance the delivery of IIMs to tumors for potentiating cancer immunotherapy and mitigating systemic toxicity. We discuss innovative nanoparticle platforms for the delivery of IIMs targeting the cyclic GMP-AMP synthase-stimulator of interferon genes pathway, the toll-like receptor pathway, and the retinoic acid-inducible gene I-like receptor pathway. We review the preliminary clinical readouts of representative IIM nanoptherapeutics and highlight the development of multifunctional nanoparticles for combination treatments of IIMs with conventional treatment mdoalities such as chemotherapy, radiotherapy, photodynmic therapy, and tumor antigens. Finally, we summarize the lessons learned from the existing systems, the challenges in the field, and future perspectives for this exciting field of nanotherapeutics for cancer immunotherapy.

The emerging regulatory interface between DNA repair and steroid hormone receptors in cancer

Human cells potentiate highly diverse functions through tight transcriptional regulation and maintenance of genome integrity. While the DNA damage response (DDR) safeguards the genome, ligand-activated transcription factors, such as steroid hormone receptors (SHRs), provide complex transcriptional outputs. Interestingly, an increasing body of evidence reveals a direct biological and functional interplay between DDR factors and SHR cascades in cancer. SHRs can directly affect DDR gene expression, but DDR factors in turn act as transcriptional coregulators, enabling oncogenic SHR-mediated signaling, which has the potential for novel therapeutic interventions. With a focus on breast and prostate cancer, we describe in this review recent developments in, and insights into, the complex interplay between SHR signaling and the DDR, highlighting opportunities for future clinical interventions.

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

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Artificial intelligence-based spatial analysis of tertiary lymphoid structures and clinical significance for endometrial cancer

With the incorporation of immune checkpoint inhibitors into the treatment of endometrial cancer (EC), a deeper understanding of the tumor immune microenvironment is critical. Tertiary lymphoid structures (TLSs) are considered favorable prognostic factors for EC, but the significance of their spatial distribution remains unclear. B cell receptor repertoire analysis performed using six TLS samples located at various distances from the tumor showed that TLSs in distal areas had more shared B cell clones with tumor-infiltrating lymphocytes. To comprehensively investigate the distribution of TLSs, we developed an artificial intelligence model to detect TLSs and determine their spatial locations in whole-slide images. Our model effectively quantified TLSs, and TLSs were detected in 69% of the patients with EC. We identified them as proximal or distal to the tumor margin and demonstrated that patients with distal TLSs (dTLSs) had significantly prolonged overall survival and progression-free survival (PFS) across multiple cohorts [hazard ratio (HR), 0.56; 95% confidence interval (CI), 0.36-0.88; p = 0.01 for overall survival; HR, 0.58; 95% CI, 0.40-0.84; p = 0.004 for PFS]. When analyzed by molecular subtype, patients with dTLSs in the copy-number-high EC subtype had significantly longer PFS (HR, 0.51; 95% CI, 0.29-0.91; p = 0.02). Moreover, patients with dTLSs had a higher response rate to immune checkpoint inhibitors (87.5 vs. 41.7%) and a trend toward improved PFS. Our findings indicate that the functions and prognostic implications of TLSs may vary with their locations, and dTLSs may serve as prognostic factors and predictors of treatment efficacy. This may facilitate personalized therapy for patients with EC.

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

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