ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

Correlation between radiation dose to bone marrow subregions and acute hematologic toxicity inendometrial cancer treated with external beam radiotherapy

Aim

To identify dosimetric parameters associated with acute hematologic toxicity (HT) in endometrial cancer treated with volumetric modulated arc therapy (VMAT-RT).

Methods

Patients with uterine adenocarcinoma treated in our Institution from March 2019 to November 2022 were retrospectively enrolled in this study. All patients underwent adjuvant external beam radiotherapy with Volumetric modulated arc therapy (VMAT) strategy plus a brachytherapy boost on vaginal cuff. When indicated, adjuvant platin-based chemotherapy was administered after surgery in upfront or sandwich setting. Pelvic bone marrow was contoured for each patient and divided into three subsites: lumbosacral spine (LSBM), ilium (IBM) and lower pelvis (LPBM). The volume of each region receiving 10,20,30 and 40 Gy (V10, V20, V30, V40, respectively) and mean dose (Dmean) was collected. Hematological toxicity during radiotherapy treatment was graded according to the CTCAE V 5.0. Linear logistic regression models were used to test associations between dosimetric parameters and HT.

Results

Data from 99 patients were retrospectively analyzed. Adjuvant external beam radiotherapy was delivered to the pelvis with Volumetric modulated arc therapy (VAMT) strategy for a total dose of 45  Gy, 1.8  Gy/fraction plus a brachytherapy boost on vaginal cuff for a total dose of 10 Gy in 2 fractions weekly. Thirty-one patients developed during radiotherapy treatment an HT ≥ grade 2.With a sensitivity of 83.3 % and specificity of 61.5 %, V20 Gy LSBM < 64 % is associated to a maximum 20 % risk of Grade 2 or worse HT in patients with < 60 years old; for patients older than 70, the risk of toxicity is below 20 % independently by the percentage volume of V20Gy LSBM (95 % CI 0.60-0.87; p = 0.03).No association between hematological toxicity and V10-20-30-40 or Dmean of IBM and LPBM were observed.Dosimetric parameters involving the lower pelvis had stronger association with hematological toxicity than those involving the ilium, even if not significant.

Conclusions

In this experience a dose constraint age-dependent was proposed, to reduce the risk of HT.The volume of lombo-sacral pelvis receiving low-dose radiation (V20 LSBM > 64 %) seems to be associated with HT in younger patients; instead in older than 70 patients the percentage of V20Gy LSBM seems not correlate with risk of toxicity. Future investigations should seek to confirm these findings through the inclusion of these parameters in the planning process.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

Acceptability and somatic mutations in cervicovaginal self-sampling for early endometrial cancer detection in women with Lynch syndrome

New molecular approaches are being developed to detect endometrial cancer using minimally invasive sampling methods. This study aims to evaluate the acceptability of self-collected cervicovaginal samples among women with Lynch syndrome, a group at high risk for developing endometrial cancer. Participants collected cervicovaginal self-samples and answered an at-home acceptability questionnaire in a cross-sectional study. Self-samples from a subset of these women were analyzed for somatic mutations using next-generation sequencing (NGS), targeting a panel of 47 genes. A total of 61 (88.4%) out of 69 eligible women participated in the study. The overall self-sampling experience was rated good or very good (N = 55, 90.2%). Most of the women were confident about correctly sampling (N = 58, 95.1%), and most reported no or mild pain (N = 56, 91.8%). During self-sample collection, most women reported feeling calm and comfortable and experiencing safety, privacy, and normality. In a pilot study using a subset of 15 samples, five somatic variants were identified in four self-samples (4/15, 26.7%) in ACVR2A, ARID1A, APC, and KMT2D. During follow-up, three out of four women with variants detected in the self-sample underwent prophylactic hysterectomy at a median of 9.1 months, while one out of four developed endometrial cancer after 3.9 years since the collection of the sample. Self-sampling is well-accepted and well-tolerated in women with Lynch syndrome and could potentially reduce some barriers associated with gynaecological surveillance. Further research is needed to evaluate the feasibility of implementing cervicovaginal self-collection and the accuracy of molecular testing for gynaecological surveillance in women with Lynch syndrome.

Brachytherapy: Perspectives for combined treatments with immunotherapy

Combining brachytherapy with immunotherapies, particularly immune checkpoint inhibitors (ICIs), is a promising approach for potentiating both local control of the tumor and fully exploiting the synergies between pharmaceutic immunomodulation and radiotherapy. Compared to other radiotherapy techniques, BT has a potential to better spare lymphatic drainage areas and gut microbiota, thus reducing the immunosuppressive effects of radiation therapy. In addition, it delivers a broad range of doses due to inherent dose inhomogeneity within the implanted volume. This variability increases the probability that immune infiltrates would be activated, particularly since the optimal dose for immune activation is not yet firmly established. Even if preclinical models show that radiotherapy can stimulate immune responses, it can also induce toxic effects on immune effectors and combination trials show conflicting outcomes. There is a need for refining radiation modalities to enhance immune potentiation. The dosimetric specificities of BT may offer various advantages and should be explored further. Scarce clinical data on combining brachytherapy with ICIs in advanced cancer suggest potential benefits, with case reports of complete local responses and abscopal effects. However, validation requires a large number of patients in randomized clinical trials for which ideal design is discussed. In parallel with ongoing clinical developments, there is a need to refine preclinical models in order to better analyze the specific biological effects involved in BT, in light of immunomodulatory systemic treatments.

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Predictors for sentinel lymph node mapping failure using indocyanine green injection in apparent early stages of endometrial cancer: A single-center prospective study

OBJECTIVE

The current study aimed to analyze predictive factors of sentinel lymph node mapping failure in apparently early stages of endometrial cancer using intracervical indocyanine green injection.

METHODS

A single-center prospective study was conducted between June 2019 and August 2023 at the Department of Gynecology and Obstetrics, University Hospital Brno, Czech Republic. All patients with apparently early stage (I or II according to FIGO [International Federation of Gynecology & Obstetrics] 2009) endometrial cancer, who were indicated for sentinel node biopsy were consecutively included. The injection of 4-6 mL of indocyanine green was applied superficially and deeply into cervical tissue at the 3- and 9-o'clock positions. Patients' clinical data, surgical characteristics, and histopathological information were recorded. Univariable and multivariable regression analyses were applied.

RESULTS

A total of 225 patients were eligible during the study period. Considering bilateral and unilateral failed mapping together, the only statistically significant factors for risk of failure in univariable analysis were body mass index (BMI; P = 0.036), FIGO 2009 stage (P = 0.019), and the presence of a myoma (P = 0.017). Nevertheless, when the multivariable logistic regression analysis was applied, all factors became statistically insignificant except for myoma (P = 0.031). Regarding only bilateral mapping failure, in univariable analysis, BMI (P = 0.021) and FIGO 2009 stage (P = 0.046) were significant predictors of failure. Interestingly, multivariable logistic regression analysis revealed that in addition to BMI (P = 0.007), age (P = 0.004) was also an independent predictor of bilateral failure.

CONCLUSIONS

Higher BMI and age were statistically significant independent factors for bilateral sentinel node mapping failure in early-stage endometrial cancer.

Genetic predictors of unexpected recurrence in low-risk endometrial cancer: A comprehensive genomic analysis reveals FGFR2 as a risk factor and a rare fatal POLE-mutated recurrence

OBJECTIVE

Endometrial cancer is the most common gynecological malignancy in high-income countries. While early-stage endometrial cancer generally has a favorable prognosis, a small proportion of low-risk patients experience unexpected recurrence. This study aimed to identify molecular factors contributing to recurrence in stage 1 A grade 1-2 low-risk endometrioid endometrial cancer.

METHODS

We performed next-generation sequencing (NGS) on tumor samples from 19 patients who experienced recurrence despite favorable clinicopathological features and compared them with six control patients without recurrence. Results were also compared to a matched cohort of low-risk endometrial cancers from The Cancer Genome Atlas (TCGA) database.

RESULTS

Mutations in PTEN, PIK3CA, ARID1A, and FGFR2 were the most frequent in the recurrence group. FGFR2 mutations were exclusive to the recurrence group (9/19, 47.4 %) and absent in the non-recurrent group (0/6), a difference approaching statistical significance (p = 0.0571). FGFR2 mutations were also significantly more prevalent in the recurrence cohort compared to the TCGA low-risk cohort (p = 0.0039). Prominent FGFR2 missense mutations included S252W, K659E, and N549K, which may drive oncogenesis and tumor progression. Among the recurrence group, a rare POLE-mutated tumor recurred unexpectedly and proved fatal, highlighting the potential for poor outcomes even in typically favorable molecular subtypes.

CONCLUSION

FGFR2 mutations may play a role in tumor recurrence in a subset of low-risk endometrial cancers, underscoring the importance of molecular profiling in identifying patients at risk. FGFR2 represents a potential therapeutic target, warranting further validation in larger cohorts to establish its clinical utility.

Comparative analysis of surgical outcomes between the hinotori™ surgical robot system and da Vinci® Xi for simple hysterectomy with sentinel lymph node biopsy in low-risk endometrial cancer

OBJECTIVES

This study aimed to compare the surgical outcomes of simple hysterectomy with sentinel lymph node biopsy for low-risk endometrial cancer performed using the hinotori™ Surgical Robot System and the da Vinci® Xi system.

MATERIALS AND METHODS

We retrospectively analyzed the data of 234 patients who underwent simple hysterectomy with sentinel lymph node biopsy at Kagoshima University Hospital between January 2017 and June 2024. Amongst them, 20 patients underwent surgery using the hinotori™ Surgical Robot System and 214 using the da Vinci® Xi. Surgical factors, including operative time, cockpit/console time, blood loss and sentinel lymph node detection, were evaluated. Statistical analyses included chi-square and Wilcoxon tests, with significance set at P < 0.05.

RESULTS

The median operative and cockpit/console times were comparable between the two systems. However, the time from roll-in to the start of cockpit/console surgery was significantly longer for the hinotori™ Surgical Robot System than for the da Vinci® Xi (P = 0.0039). No significant differences were observed for blood loss, length of hospital stay, or complication rates. The sentinel lymph node detection rates and number of sentinel lymph nodes resected were similar between the two systems, with metastatic sentinel lymph node rates of 6% in both groups.

CONCLUSION

Simple hysterectomy with sentinel lymph node biopsy performed using the hinotori™ Surgical Robot System demonstrated outcomes comparable with those using the da Vinci® Xi system, with no significant differences in key surgical factors. These results suggest that the hinotori™ Surgical Robot System is a viable alternative for minimally invasive surgery in low-risk endometrial cancer. Further studies with larger sample sizes are required to validate these findings.

Presentation of the ENDO-SFOG CAMPUS app: An easy therapeutic decision support app in endometrial cancer created by the French Society of Young Gynecological Oncologists (SFOG Campus)

OBJECTIVE

This study evaluates a new decision support tool-a computer/mobile application designed to align with the latest ESGO guidelines, French practices, and molecular biology data-to aid in decision-making for endometrial cancer management.

METHODS

An observational, multicenter, retrospective study was conducted. It compared management decisions from multidisciplinary tumor boards (MTBs) with those suggested by the application for patients with histologically confirmed endometrial cancer, irrespective of their FIGO stage. Each center included the last 20 cases discussed in multidisciplinary tumor boards between May to December 2022.

RESULTS

Thirteen centers participated: eight university hospitals (61.5 %), four cancer centers (30.8 %), and one private center (7.7 %). A total of 259 patients were included, with a mean age of 69 years (range 30-96 years). Most patients had endometrioid tumors (77.2 %), low-grade (62.6 %), FIGO stage IA (41.3 %), no lymphovascular invasion (77.9 %), and a non-specific molecular profile (50.6 %). The application's recommendations matched the MTB decisions 76.6 % of the time. Discrepancies arose mainly from the non-administration of brachytherapy (22.8 %), rare presentations or pathological discordance (22.8 %), and patients' deteriorated conditions precluding standard treatments (19.3 %).

CONCLUSION

The SFOG campus application demonstrates a high concordance with multidisciplinary tumor board decisions, indicating its potential as an efficient, and valuable tool for managing endometrial cancer.

MRI-based radiomics model for predicting endometrial cancer with high tumor mutation burden

PURPOSE

To evaluate the performance of MRI-based radiomics in predicting endometrial cancer (EC) with a high tumor mutation burden (TMB-H).

METHODS

A total of 122 patients with pathologically confirmed EC (40 TMB-H, 82 non-TMB-H) were included in this retrospective study. Patients were randomly divided into training and testing cohorts in a ratio of 7:3. Radiomics features were extracted from sagittal T2-weighted images and contrast-enhanced T1-weighted images. Then, the logistic regression (LR), random forest (RF), and support vector machine (SVM) algorithms were used to construct radiomics models. The area under the receiver operating characteristic curve (AUC) was calculated to evaluate the diagnostic performance of each model, and decision curve analysis was used to determine their clinical application value.

RESULTS

Four radiomics features were selected to build the radiomics models. The three models had similar performance, achieving 0.771 (LR), 0.892 (RF), and 0.738 (SVM) in the training cohort, and 0.787 (LR), 0.798 (RF), and 0.777 (SVM) in the testing cohort. The decision curve demonstrated the good clinical application value of the LR model.

CONCLUSIONS

The MRI-based radiomics models demonstrated moderate predictive ability for TMB-H EC and thus may be a tool for preoperative, noninvasive prediction of TMB-H EC.

Current challenges and emerging tools in endometrial cancer diagnosis

The diagnostic process of endometrial cancer includes imaging methods such as trans-vaginal ultrasound, along with procedures to obtain endometrial tissue for histologic evaluation. Common techniques for tissue sampling include Pipelle endometrial biopsy, hysteroscopy, and dilation and curettage, which are used to confirm the diagnosis, determine tumor histology, grade, and molecular profile. However, diagnostic algorithms for endometrial cancer differ significantly across countries, influenced by local resources, protocols, and the availability of diagnostic methods. These variations include differences in the endometrial thickness threshold for recommending a biopsy and the choice of the initial diagnostic test. Moreover, patients often have multiple tests and appointments before a definitive diagnosis, although only 5%-10% of women with post-menopausal bleeding are diagnosed with endometrial cancer. Current diagnostic techniques have limitations. Pipelle endometrial biopsy has a significant false-negative rate (10%-20%) and may fail to provide adequate diagnostic material in up to 30% of cases. Hysteroscopy, while useful, is associated with pain in up to 65% of patients and can delay diagnosis because of limited availability. Dilation and curettage is an invasive procedure requiring general anesthesia and has a higher complication rate. In response to these challenges, there is growing interest in developing new diagnostic tools that are less invasive and provide 1-step diagnoses, including liquid biopsies from urine, blood, cervico-vaginal and endometrial fluid samples by means of genomics and proteomics. This review will examine the current diagnostic algorithms in European and American guidelines, evaluate the sensitivity, specificity, and accuracy of current techniques, and explore new diagnostic tools under development.

Effect of substantial lymphovascular space invasion on location of first disease recurrence in surgical stage I endometrioid endometrial adenocarcinoma

OBJECTIVE

Lymphovascular invasion can predict nodal spread and recurrence in endometrioid endometrial cancer; however, the impact of lymphovascular invasion quantification on local versus distant recurrence in surgically staged patients has not yet been established.

METHODS

This multicenter, retrospective cohort study included surgically staged patients with International Federation of Obstetrics and Gynecology 2009 stage I node-negative endometrioid endometrial cancer. Patients were treated between January 2012 and December 2019 at 2 tertiary cancer centers. Staging included a total hysterectomy and lymph node assessment. The extent of lymphovascular invasion was defined using the World Health Organization criteria as focal (<5 vessels involved on at least 1 pathology slide) or substantial (≥5 vessels involved). Recurrence and death were considered as events. A competing risk analysis was performed and controlled for multicenter clustering.

RESULTS

Overall, 1555 patients met the inclusion criteria: 65 (4.2%) had substantial invasion, 119 (7.7%) had focal, and 1371 (88.2%) had no invasion. The median follow-up was 61.5 months (range; 0.8-133.9). There were 173 evaluable events among the 1554 patients: 56 local recurrences, 43 distant recurrences, and 74 deaths without recurrence. Deep (>50%) myoinvasion and grade 3 histology were more frequently observed in patients with substantial myoinvasion. Overall, 323 patients (20.8%) received adjuvant therapy. The 5-year cumulative incidence failure rates for any recurrence were 6.0% for no, 19.5% for focal, and 19.0% for substantial invasion. Compared to no lymphovascular invasion, substantial invasion was associated with an increased risk of distant recurrence (adjusted HR 2.29, 95% CI 1.17 to 4.46).

CONCLUSIONS

In patients with surgical stage I endometrioid endometrial cancer, the focal and substantial lymphovascular invasion was associated with a 3-fold increased risk of cumulative incidence failure versus no lymphovascular invasion. Patients with substantial invasion had more deeply invasive and grade 3 tumors and appeared to experience more distant than local recurrences. These findings challenge the International Federation of Obstetrics and Gynecology 2023 staging classification that combines no lymphovascular invasion and focal lymphovascular invasion into a single risk category.

Preoperative risk stratification of early-stage endometrial cancer assessed by multimodal magnetic resonance functional imaging

Endometrial cancer is a common disease in women. Stratifying the risk of early-stage endometrial cancer can aid in personalized treatment for patients. Risk stratification is primarily based on tumor grade, histological type, lymph node metastasis, and depth of myometrial invasion. Multimodal magnetic resonance functional imaging (including DCE-MRI, DWI, IVIM, DTI, DKI) has significant value in assessing the extent of myometrial and cervical infiltration, extrauterine involvement range, determining lymph node metastasis and tumor size. This article provides a brief overview of these techniques.

Immunohistochemical markers of potential utility in identifying POLE-mutant endometrial carcinomas: An assessment of autocrine motility factor (AMF) and autocrine motility factor receptor (AMFR)

POLE status determination is necessary for the molecular classification of endometrial carcinomas (EC). However, this determination is only achievable by molecular techniques, which are not available in many practice settings. A previously published study reported elevated AMF/GPI and AMFR/gp78 levels in POLE-mutant EC. We examined the relationship between POLE status and AMF and AMFR expression. Our study included 55 molecularly classified EC, assessed for AMF and AMFR immunohistochemically. Staining intensity was scored 0 (negative), 1 (weak), 2 (medium), 3 (strong), extent was scored 0 (0 %), 1 (1-25 %), 2 (26-50 %), 3 (51-75 %), 4 (76-100 %), with those parameters summed for the final score for each case. The molecular subtypes POLE mutant, mismatch repair-deficient, no specific molecular profile, p53 abnormal had mean AMF scores of 5.909, 4.643, 5.000, 4.667, respectively. The POLE-mutant subtype had a significantly higher average AMF score than POLE wild-type (POLEwt) group (p = 0.003). Using POLE mutant status as an end-point, ROC analysis showed that an AMF immunohistochemical score of 6 and above had an 81.8 % sensitivity, 61.4 % specificity, AUC of 0.708 (95 % CI, 0.565-0.851). POLE-mutant subtype had higher prevalence of a score of 6 and above than the POLEwt group (9/11 vs 17/44 cases, p = 0.010). An AMF score 6 and above increased the likelihood of being POLE-mutant by a factor of 10.496 (95 % CI, 1.592-69.212). Similarly, the POLE-mutant subtype had higher prevalence of AMFR scores of 5 and above than the POLEwt group (p = 0.023). AMF may offer some promise in identifying POLE-mutant EC with relatively high sensitivity, but suboptimal specificity indicates that it cannot be applied alone in practice. Additional studies are required to determine whether AMF can be combined with other markers to more optimally identify POLE mutant EC.

Health care organization for gynecologic oncology patients fleeing Ukraine: Insights from the European Network of Young Gyne Oncologists survey during the first six months of the military conflict

OBJECTIVE

The Russian invasion of Ukraine in February 2022 caused a mass displacement of over 6 million people, including many women requiring urgent medical care, such as those with gynecologic malignancies. The disruption of cancer treatment in conflict zones poses critical challenges because timely oncologic care is vital for patient survival. This study, conducted by the European Network of Young Gynecologic Oncologists, aimed to assess the health care responses provided to Ukrainian gynecologic oncology patients across European countries during the first 6 months of the conflict.

METHODS

A cross-sectional survey was distributed to European Network of Young Gynecologic Oncologists members between July and August 2022, gathering insights from health care providers about their experiences in managing Ukrainian gynecologic oncology patients. The survey explored the medical needs of displaced patients, challenges encountered, and the resources available. Descriptive statistics were used for data analysis.

RESULTS

During the study period, approximately 400 gynecologic oncology patients fleeing Ukraine received care in 38 European health care centers represented by the respondents (N = 50). Surgical interventions (54%), chemotherapy (40%), and specialist consultations (32%) were identified as the most common medical needs. The key barriers to care included language difficulties (44%), lack of previous medical documentation (40%), and inconsistencies in treatment protocols between centers. Psychological support was notably insufficient, with 36% of respondents reporting a lack of adequate resources for addressing mental health needs.

CONCLUSIONS

The study identifies critical barriers to the continuity of gynecologic oncology care for displaced patients during humanitarian crises. Addressing language barriers, ensuring access to patient medical histories, and providing psychological support are essential to improve care for refugees. The findings underscore the importance for international collaboration and the development of robust frameworks for delivering oncologic care during crises.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Circulating tumor DNA in endometrial cancer: clinical significance and implications

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

Improving pre-operative binary grading: relevance of p53 and PR expression in grade 2 endometrioid endometrial carcinoma

OBJECTIVE

This study aimed to evaluate the association between pre-operative progesterone receptor (PR) and p53 expression and prognosis in pre-operative grade 2 endometrioid endometrial carcinoma compared with grade 1 and grade 3 carcinomas.

METHODS

Three European endometrial carcinoma cohort studies were included. Patients with pre-operative grade 2 endometrioid carcinoma and known pre-operative PR and p53 status were included (n = 400), as were patients with pre-operative grade 1 (n = 602) or grade 3 (n = 148) endometrioid carcinomas. Kaplan-Meier and Cox regression analyses were performed to analyze disease-specific and disease-free survival.

RESULTS

Patients with pre-operative grade 2 endometrial carcinoma and wild-type p53 plus PR-positive expression showed a similar 7-year disease-specific survival to grade 1 endometrial carcinoma patients (95.8% vs 97.5%, p = .13), while the 7-year disease-specific survival of patients with grade 2 endometrial carcinoma with p53 aberrant and/or negative PR expression (83.5%) was significantly lower (p < .001). The combination of these markers was an independent prognostic factor in multivariate Cox regression analyses.

CONCLUSIONS

The prognostic impact of pre-operative p53 and PR expression in patients with grade 2 endometrioid endometrial carcinoma supports a modified binary grading system in which grade 2 patients should be pre-operatively classified as low- or high-grade depending on p53 and PR expression.

The role of the Androgen Receptor (AR) in endometrial cancer aggressiveness: Correlation with other prognostic markers and therapeutic implications. A retrospective observational study

Endometrial carcinoma (EC) is the most common gynecological malignancy, with increasing incidence linked to rising risk factors. This retrospective observational study investigates the role of the Androgen Receptor (AR) in EC aggressiveness, its correlation with other prognostic markers, and its potential therapeutic implications. A total of 143 cases of EC treated with hysterectomy were analyzed for AR expression and its association with clinicopathological and molecular markers, including estrogen receptor (ER), progesterone receptor (PR), Ki-67, p53, β-catenin, E-cadherin, Bcl-2, Cyclin D1, and mismatch repair (MMR) status. AR expression was significantly higher in low-grade endometrioid carcinoma (LGEC) compared to high-grade endometrioid carcinoma (HGEC) and other high-risk histologies (p = 0.015), suggesting a role in less aggressive tumor phenotypes. AR strongly correlated with ER and PR (p < 0.0001), indicating shared regulatory pathways. A borderline association with tumor-infiltrating lymphocytes (TILs) suggests a potential role in immune response. However, AR expression did not significantly correlate with markers of proliferation (Ki-67) or tumor suppression (p53), nor with β-catenin, E-cadherin, Bcl-2, Cyclin D1, or MMR status. These findings support AR as a prognostic marker in hormone-responsive EC subtypes and suggest that AR-targeted therapies could be beneficial, particularly in ER/PR-negative tumors. The study highlights the potential integration of AR status into molecular profiling, aiding in personalized treatment strategies for improved patient outcomes in EC management.

Impact of morbid obesity on surgical and oncological outcomes in patients with endometrial cancer undergoing robotic assisted laparoscopic hysterectomy and pelvic lymph node staging

INTRODUCTION

Minimally invasive surgery is the preferred surgical approach in endometrial cancer. Robotic assisted laparoscopy could provide benefits in the obese population.

OBJECTIVE

To compare surgical and oncological outcomes between patients with a BMI < 35 kg/m2 (Group 1) and those with a BMI ≥ 35 kg/m2 (Group 2) who underwent robotic assisted laparoscopic total non-conservative hysterectomy with pelvic lymph node staging for endometrial cancer.

MATERIAL AND METHODS

This retrospective monocentric study was conducted at Saint-Louis University Hospital in Paris. The two groups were compared using a univariate analysis.

RESULTS

52 patients were included, 39 patients in Group 1 and 13 patients in Group 2. Operative room occupancy time and operative time were significantly longer in Group 2 than in Group 1 (255.1 min ± 57.0 vs 210.5 min ± 38.3, p = 0.02 and 166.8 min ± 39.7 vs 139.6 min ± 35.3, p = 0.04 respectively). No significant difference was found in length of hospital stay between the 2 groups even if it appears that patients in Group 2 had slightly longer hospitalization than patients in Group 1 (2 days vs 1 day). Only one complication (laparotomy conversion for digestive injury) was observed in Group 2. No significant difference was found in recurrence between the 2 groups.

DISCUSSION

Severe morbid obesity does not affect surgical morbidity or oncological outcomes in women with endometrial cancer who underwent robotic-assisted laparoscopic hysterectomy, bilateral adnexectomy, and pelvic lymph node staging. Optimizing operating room occupancy management must be improved in this patient population.

The Node Reporting and Data System (Node-RADS) for standardized MRI evaluation of lymph nodes in endometrial cancer, integrated with clinicopathological and molecular data

OBJECTIVES

To evaluate the diagnostic performance of Node-RADS score using magnetic resonance imaging (MRI) in predicting lymph node involvement (LNI) in patients with endometrial cancer (EC). Additionally, the applicability of the Node-RADS score was evaluated by three readers with different levels of experience in pelvic imaging. Finally, this study investigated the correlation between the Node-RADS score and the extent of myometrial invasion, histological type, lympho vascular invasion (LVI) and molecular subtype.

METHODS

Out of 108 cases, 82 patients with histologically confirmed locally advanced EC met the inclusion criteria for retrospective analysis. LNI risk was assessed for each pelvic lymph node station using a Node-RADS score (1-5). Diagnostic accuracy was determined by comparing scores to histologic findings, considered as the gold standard. Three independent readers with different experience levels assigned scores.

RESULTS

The Node-RADS score strongly correlated with histologically confirmed LNI (AUC: 0.832). A cutoff of Node-RADS ≥ 3 optimally detected metastatic lymph nodes, with 85.71 % sensitivity and 76.47 % specificity. Interobserver agreement was high, with κ values of 0.86 (senior vs. junior reader 1) and 0.70 (senior vs. junior reader 2). A significant positive correlation was found between Node-RADS score and myometrial invasion as well as LVI.

CONCLUSION

Node-RADS score is a reliable, standardized tool for assessing LN stations and enhancing diagnostic accuracy in locoregional staging of EC.

Robotic single site versus robotic multiport hysterectomy in endometrial cancer: a systematic review and meta-analysis

OBJECTIVE

This meta-analysis aims to compare the safety and efficacy of robotic single-site hysterectomy (RSSH) with robotic multiport hysterectomy (RMPH) in treating endometrial cancer.

METHODS

We conducted a comprehensive literature search across several databases, including PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase, the Chinese National Knowledge Infrastructure (CNKI), Wan Fang, and the Chinese Science and Technology Journal Full Text Database (VIP). The search covered literature from inception until October 17, 2024. The primary outcomes included intraoperative complications, postoperative complications, postoperative pain scores, and satisfaction with cosmetic outcomes. The secondary outcomes included operative time (min), estimated blood loss (ml), hemoglobin drop, blood transfusion, conversion, postoperative hospital stay, lymph nodes harvested, sentinel lymph node identification, recurrence, and mortality during follow-up. Data analysis was performed using random-effects or fixed-effects models, calculating combined risk ratios (RR), weighted mean difference (WMD), and 95% confidence intervals (95% CI).

RESULTS

Five studies describing a total of 448 patients were retained and included for this meta-analysis. No significant differences were found between RSSH and RMPH regarding intraoperative complications, postoperative complications, and postoperative pain scores. There were also no differences in terms of operation time, estimated blood loss, hemoglobin drop, blood transfusion, conversion, postoperative hospital stay, lymph nodes harvested, and sentinel lymph node identification.

CONCLUSION

This systematic review and meta-analysis provides evidence that RSSH is effective and safe for the treatment of endometrial cancer, as it is generally equivalent to RMPH regarding perioperative outcomes.

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

IMPORTANCE

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

OBSERVATIONS

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

CONCLUSION AND RELEVANCE

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

Safety of minimally invasive surgery in early-stage endometrial cancer: A systematic Retrospective analysis based on 2023 FIGO staging system☆

OBJECTIVE

To evaluate the efficacy and safety of minimally invasive surgery in the management of early-stage endometrial cancer.

METHOD

This study involved a retrospective analysis of clinical data and prognosis for 382 patients diagnosed with early-stage endometrial cancer (stage I and II) who underwent either laparoscopy or laparotomy at Shanghai Sixth People's Hospital between June 2011 and November 2022. The postoperative pathological diagnoses were based on 2023 FIGO staging system.

RESULTS

A total of 189 patients underwent laparotomy and 193 patients underwent laparoscopic surgery. The intraoperative blood loss and postoperative complications (pulmonary embolism, pulmonary infection, intestinal obstruction, suboptimal healing or infection of surgical incision) rates in laparoscopy group was significantly lower than that in laparotomy group (P < 0.05). Regarding long-term prognosis (mean follow-up duration of 81.8 ± 41.1 months), there were no significant differences in DFS (Disease-Free Survival) and OS (Overall Survival) between two groups (P > 0.05). By integrating the new FIGO staging with risk factors for stratified analysis, the results still indicated that there were no significant differences in DFS or OS between laparoscopy group and laparotomy group across all risk stratification (P > 0.05).

CONCLUSIONS

In the management of early-stage EC, laparoscopy significantly reduces intraoperative blood loss and postoperative complication rates, which facilitate patient recovery without adversely affecting recurrence or survival outcomes.

The Application of Liquid Biopsy for the Development and Validation of a Non-Invasive Screening and Diagnosis Test for Endometrial Premalignant and Malignant Lesions: A Prospective Innovative Pilot Study

Background/Objectives: Endometrial cancer (EC) is a common malignancy in developed countries, with incidence closely linked to lifestyle factors and genetic predispositions, notably Lynch syndrome. Traditional biopsy methods for diagnosis and monitoring are invasive. This study aims to develop and validate a non-invasive diagnostic method for EC using liquid biopsy, specifically examining circulating tumor DNA (ctDNA) for its potential in early detection and disease monitoring. Methods: A cohort of 63 patients with EC or atypical endometrial hyperplasia (AEH) was recruited from the Gynecological Unit of the Azienda Ospedaliera Universitaria Federico II. Plasma samples were processed to extract ctDNA, which was sequenced and analyzed for mutations. Matched tumor tissue and germline DNA were also examined to confirm mutation concordance and assess potential genetic predispositions. Results: Pathogenic mutations were identified in plasma ctDNA in 59 out of 63 cases (93%), with a 65% concordance between plasma ctDNA mutations and those found in solid tumor samples. Key mutations in genes such as PTEN, PIK3R1, and KMT2C were significantly associated with a higher tumor grade and advanced stage disease, such as myometrial infiltration. Conclusions: Liquid biopsy shows promise as a minimally invasive diagnostic and monitoring tool for EC, offering real-time insights into tumor biology. The high mutation concordance between the plasma ctDNA and tumor tissue underscores the potential of a liquid biopsy in managing EC, particularly for patients at risk of recurrence. Further longitudinal studies are needed to establish ctDNA as a standard tool in EC diagnosis and monitoring.

Primary or Interval Debulking Surgery for Advanced Endometrial Cancer with Carcinosis: A Systematic Review and Individual Patient Data Meta-Analysis of Survival Outcomes

OBJECTIVE

To compare the survival outcomes of primary debulking surgery and platinum-based adjuvant chemotherapy versus interval debulking surgery after platinum-based neoadjuvant chemotherapy in patients with stage IVb endometrial cancer and peritoneal carcinosis.

METHODS

The online search included the following data sources: PubMed, Scopus, WOS, and the Cochrane Library from 1990 to 2024 (PROSPERO registration code: CRD42023438602). A total of 3230 studies were identified, with the inclusion of 16. Individual patient data on survival outcomes, disease distribution, and residual tumors, as well as details of neoadjuvant chemotherapy and adjuvant treatment, were extracted.

RESULTS

A total of 285 patients were included: 197 (69%) underwent primary debulking surgery and 88 (31%) underwent interval debulking surgery. The pooled analysis revealed a median progression-free survival in the primary debulking surgery group of 18.0 months compared to 12.0 months in the interval debulking surgery group (p = 0.028; log-rank test), and a median overall survival of 30.92 months versus 28.73 months (p = 0.400; log-rank test). Among the 134 patients with available information on the residual tumor after primary debulking surgery or interval debulking surgery, 110 (82%) had no macroscopic residual tumor (residual tumor = 0). The median progression-free survival was 18.9 months in the residual tumor = 0 group compared to 6.19 months in the residual tumor > 0 group (p < 0.001; log-rank test); the median overall survival was 40.6 months versus 21 months (p = 0.028; log-rank test).

CONCLUSIONS

These results indicate that primary debulking surgery should be considered the preferred treatment approach for advanced endometrial cancer with carcinosis, especially in carefully selected patients where complete cytoreduction is achievable. Further prospective studies are warranted to confirm these results and to establish standardized criteria for patient selection, incorporating molecular-integrated risk profiles for endometrial cancer.

Screening and prevention of gynecologic malignancies in patients with lynch syndrome: following the guidelines

Lynch syndrome (LS), a hereditary condition caused by germline mutations in mismatch repair (MMR) genes, significantly elevates the lifetime risk of endometrial cancer (EC) (40-60%) and ovarian cancer (8-10%) in affected women. Despite advances in colorectal cancer screening for LS patients, optimal strategies for gynecologic cancer prevention remain under debate. Current recommendations for EC surveillance, including annual transvaginal ultrasound and endometrial biopsy starting at age 30-35, lack robust evidence for effectiveness. Risk-reducing hysterectomy with bilateral salpingo-oophorectomy (BSO) is frequently advised after childbearing to mitigate cancer risk. Emerging data suggest that hormonal interventions, such as oral contraceptives and progestin-based therapies, may reduce EC risk by up to 50%, offering non-surgical preventive options. Lifestyle modifications, including weight management and physical activity, further complement risk reduction strategies. Molecular diagnostic advancements, including immunohistochemistry and microsatellite instability testing, enhance early identification of LS-associated gynecologic malignancies. For patients with advanced or recurrent EC, the integration of immunotherapy into treatment regimens has demonstrated significant efficacy. Agents such as pembrolizumab and dostarlimab, particularly in combination with carboplatin and paclitaxel, have improved progression-free and overall survival rates for patients with MMR-deficient tumors. This review highlights the need for personalized, evidence-based approaches to gynecologic cancer screening and prevention in LS, emphasizing the importance of integrating genetic testing, patient education, and novel therapeutic options. Future research should focus on refining screening protocols and expanding non-invasive preventive strategies to improve outcomes for this high-risk population.

The prognostic and clinical significance of substantial lymphovascular space invasion in early-stage endometrial carcinoma

OBJECTIVES

Substantial lymphovascular space invasion (LVSI) has been incorporated into the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system for endometrial carcinoma. This study aims to evaluate whether classifying LVSI into substantial LVSI (≥5 involved vessels) and no/focal LVSI (≤4 involved vessels) provides meaningful prognostic differentiation in early-stage endometrial carcinoma.

METHODS

We retrospectively enrolled patients with FIGO 2009 stage I-II endometrial carcinoma who underwent surgical staging between January 2013 and August 2020. LVSI was graded as no LVSI, focal LVSI (1-4 involved vessels), or substantial LVSI (≥5 involved vessels), following the World Health Organization 2020 definition.

RESULTS

Among 1796 patients, 112 (6.2 %) had substantial LVSI, 170 (9.5 %) had focal LVSI, and 1514 (84.3 %) had no LVSI. The 5-year progression-free survival (PFS) rates were 81.7 % for substantial LVSI, 89.9 % for focal LVSI, and 95.0 % for no LVSI (P < 0.001). Multivariate analysis found that substantial LVSI was an independent predictor of worse PFS (substantial vs. no LVSI: HR 2.49, P < 0.001; substantial vs. focal LVSI: HR 1.90, P = 0.047). No statistically significant difference in PFS was observed between patients with focal LVSI and those with no LVSI (HR 1.31, P = 0.321). The overall survival (OS) analysis showed consistent results.

CONCLUSIONS

Substantial LVSI is an independent prognostic factor for PFS and OS in early-stage endometrial carcinoma, while focal LVSI shows similar outcomes to no LVSI. Our findings support the use of substantial LVSI (≥5 involved vessels) as a key determinant for risk stratification and staging, aligning with the FIGO 2023 staging system recommendations.

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.

Mark3 a Prognostic Marker for the Endometrial Cancer

Introduction: Endometrial cancer (EC) is one of the most common gynecologic cancers, with an increasing incidence due to variables such as aging and lifestyle changes. Current biomarkers exhibit limited prognostic value, despite advancements in understanding their molecular basis, underscoring the necessity for new molecular markers. Microtubule affinity-regulating kinase 3 (MARK3) has been identified as a potential candidate owing to its established prognostic significance in various cancers; however, its function in endometrial cancer (EC) is not yet well understood. Methods: This study investigates the function of MARK3 in endometrial cancer through the analysis of Ishikawa and HEC-1B cell lines. A series of assays were conducted, including colony formation, CCK-8 viability, EDU proliferation assays, scratch wound healing tests, and Transwell migration assays, to investigate the effects of MARK3 overexpression. We conducted RT-qPCR, Western blot, and immunofluorescence assays to evaluate the molecular mechanisms influencing cell proliferation and migration. Bioinformatics analysis utilized publicly available datasets to examine the gene enrichment and co-expression networks. Results: The overexpression of MARK3 markedly reduced colony formation in both Ishikawa (p = 0.0039) and HEC-1B (p = 0.0014) cell lines. Furthermore, the overexpression of MARK3 led to decreased cell viability, as demonstrated by the EDU assay results (Ishikawa-OE p = 0.0302; HEC-OE p = 0.0037). The molecular analysis supported these findings, indicating an increase in phosphorylated AKT (pAKT), thereby suggesting MARK3's role in regulating cell survival pathways. Gene enrichment analysis revealed pathways associated with cell cycle regulation and apoptosis, whereas co-expression analysis pinpointed critical interacting genes that may play a role in EC progression. Conclusions: MARK3 is essential in the regulation of cell proliferation and migration in endometrial cancer, positioning it as a potential prognostic biomarker and therapeutic target. This study represents the inaugural investigation into the functional role of MARK3 in endothelial cell progression, thereby enhancing our comprehension of its mechanistic influence on cancer biology and its implications for personalized therapy. Bioinformatics analysis reinforces the relevance of MARK3 in endometrial cancer, offering new insights into its clinical significance.

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

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

Outcomes of low-risk endometrial cancer with isolated tumor cells in the sentinel lymph nodes: a prospective, multi-center, single-arm, observational study (ENDO-ITC study)

BACKGROUND

It is unclear whether isolated tumor cells (ITCs) in sentinel lymph nodes (SLNs) adversely affect prognosis, especially in low-risk endometrial cancer. In a retrospective study, we showed a worse recurrence-free survival for low-risk endometrial cancer with ITCs than the node-negative group.

PRIMARY OBJECTIVE

Our aim is to evaluate whether the likelihood of disease recurrence differs between a prospective cohort of patients with low-risk endometrial cancer with ITCs and an historical cohort with negative SLNs.

STUDY HYPOTHESIS

We hypothesize that patients with low-risk endometrial cancer and ITCs will have a worse recurrence-free survival than patients who are node-negative.

TRIAL DESIGN

This is a prospective, multi-center, single-arm observational study. Consecutive patients with low-risk endometrial cancer with ITCs in the SLNs will be accrued. Observation only will be suggested after surgery.

MAJOR INCLUSION/EXCLUSION CRITERIA

We will include patients with endometrial cancer undergoing pelvic SLN biopsy and ultra-staging with the following characteristics: endometrioid histology, grades 1 to 2, <50% myometrial invasion, without substantial/extensive lympho-vascular space invasion. ITCs in SLNs are defined as tumor cell aggregates ≤0.2 mm or <200 cells.

PRIMARY END POINT

The primary end point is recurrence-free survival, measured from the date of surgery to the date of recurrence, death, or last disease evaluation.

SAMPLE SIZE

With a sample size of 132 women with low-risk endometrial cancer and ITCs, a 1-sided log-rank test achieves 85% power at a 0.05 significance level to detect an HR of 2.1. The expected number of events during the study is 17.3.

ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS

The study duration will be 60 months: 24 for enrollment and 36 for follow-up. The results are expected in 2029.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT06689956.

SLYMEC II study: Overall survival analysis of the impact of LVSI in apparent early stage endometrioid endometrial cancer

In our initial report of the SLYMEC study we published the results evaluated the prognostic impact of substantial lymphovascular space invasion (LVSI) on the sentinel lymph node status and the impact of the different types of LVSI on 3-year disease-free survival. The aim of the SLYMEC II study was to assess the impact of focal and substantial lymphovascular space invasion on 5-years overall survival in the subgroup of patients with endometrioid endometrial cancer. A total of 2030 patients were included in the analysis from the original data set. Focal LVSI were identified in 131 patients (6.4 %), whereas 319 patients (15.7 %) showed substantial LVSI at final pathology. Among 1876 patients who underwent minimally invasive surgery (92.6 %), 442 patents (21.8 %) underwent robotic assisted surgery, whereas and 150 patients (7.6 %) patients underwent open surgery. Rate of overall survival at 5 years was 83.6 % versus 100 % for substantial and focal LVSI groups, respectively (HR for death = 2.1 [95 % CI, 1.4 to 3.2]; P < 0.0001). Patients with endometrioid endometrial cancer having substantial LVSI after surgery showed an increased risk of death in the after 5-years overall survival when compared to patients with negative, or focal LVSI. The presence of positive LVSI in patients with positive sentinel nodes showed a trend toward reduced 5-year overall survival compared to SLN-negative patients, although it did not reach statistical significance.

Establishment and validation of a prognostic nomogram for overall survival in type II endometrial carcinoma patients

This study aimed to develop and validate a nomogram model to predict overall survival (OS) in patients with type II endometrial carcinoma (EC). Data from patients with confirmed type II EC enrolled between 2010 and 2018 were extracted from the Surveillance, Epidemiology, and End Results (SEER) database. Patients were randomly allocated to training and validation groups in a 7:3 ratio. Univariable and multivariable analyses were performed to identify independent prognostic risk factors, which were included in constructing the nomogram model. The concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to assess the prediction accuracy and clinical utility of the nomogram model. The effects of different variables on survival probability were analyzed using the Kaplan-Meier method. A total of 3,933 eligible patients with type II EC were identified and included in this study. Independent risk factors for type II EC were found to be race, tumor size, histology, grade, T stage, N stage, M stage, examination of para-aortic lymph nodes, examination of pelvic lymph nodes, surgery, lung metastasis, radiation therapy, and chemotherapy. A prognostic nomogram was constructed based on these variables. The C-index for the training cohort was 0.791 (95% CI 0.780-0.802) and for the validation cohort was 0.798 (95% CI 0.778-0.818). The ROC curve demonstrated good prediction accuracy. The calibration curve indicated strong agreement between predicted and actual values. The DCA showed that the nomogram model has significant clinical utility and potential. This study developed a survival prediction model for patients with type II EC to assist clinicians in evaluating prognostic factors, predicting OS, and determining appropriate treatment protocols to improve patient outcomes.

Ultrasound in endometrial cancer: evaluating the impact of pre-surgical staging

Preoperative staging in endometrial cancer has recently been implied as an important factor in accurately selecting low-risk cases, ultimately avoiding unnecessary lymph node debulking. Transvaginal ultrasound seems promising in clinical staging as it offers the possibility to assess the depth of myometrial infiltration and cervical stromal invasion. This commonly available, non-invasive, and low-cost modality serves as an accurate alternative to MRI, especially in middle- and low-income countries, where MRI may not be promptly available and cost is an important issue. This review aims to summarize the progressive role of clinical implementation of pelvic ultrasonography in the locoregional staging of endometrial carcinoma and to compare its accuracy with other preoperative methods.

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer

BACKGROUND

Although the rates of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time in the surgical management of early-stage uterine cancer, practice varies significantly in the United States, and there are disparities among low-volume centers and patients of Black race. A significant number of counties in the United States are without a gynecologic oncologist, and almost half of the counties with the highest gynecologic cancer rates lack a local gynecologic oncologist.

OBJECTIVE

This study aimed to evaluate the relationships of distance traveled and proximity to gynecologic oncologists with the receipt of and racial disparities in the quality of surgical care among patients who underwent a hysterectomy for nonmetastatic uterine cancer.

STUDY DESIGN

Patients who underwent a hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in the 2012 to 2018 State Inpatient Database and the State Ambulatory Surgery Services Database files. County-to-county distances were used as the distances traveled to the nearest gynecologic oncologist. Factors associated with the receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models, as was the assessment of the interaction between travel for surgery and patient race.

RESULTS

Among 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; overall, 55.5% traveled to another county for surgery, including 88% of those who lacked a local gynecologic oncologist. Patients who lacked access to a local gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were affected even more. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had a similar likelihood of undergoing minimally invasive surgery (71%) but had a greater likelihood of undergoing lymph node dissection (64.7% vs 57.2%) than nontravelers. Among those in counties without a gynecologic oncologist, a longer distance traveled was associated with receipt of a lymph node assessment. When compared with non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models that controlled for a diagnosis of fibroids, Black race was an independent risk factor for the receipt of open surgery. There was a significant interaction between Black race and travel for surgery, and Black patients who lived in counties without a gynecologic oncologist who did not travel faced an incrementally lower likelihood of receiving minimally invasive surgery (odds ratio, 0.57 when compared with non-Black patients who traveled for surgery; odds ratio, 0.60 as interaction term; P<.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery.

CONCLUSION

Patients, particularly those of Black race, who lacked local access to gynecologic oncologist specialty care benefitted from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

[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.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSION

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

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.

Fertility Sparing Medical Management Options in Gynecologic Cancers

OPINION STATEMENT

There is an increasing use of medical management for gynecologic cancers given the rise in neoadjuvant therapies, delayed childbearing, and use of assisted reproductive technology. Chemotherapy, albeit broadly used in most gynecologic cancers, lacks long term data with respect to its associated gonadotoxicity and potential adverse pregnancy outcomes. Immunotherapy and other targeted therapies that have demonstrated promising responses in other tumor types are increasingly being studied in gynecologic malignancies. These therapies may offer opportunities for enhanced treatment response in an effort to minimize more toxic, invasive, or surgical management approaches that could have significant negative implications on fertility. Given that some of these therapies do not represent the standard of care and currently only exist in the experimental setting, detailed counseling and careful selection of patients for fertility sparing treatment remains critical. It is reasonable for patients with early stage, low-risk endometrial cancers to attempt conservative management while establishing clear treatment objectives. Early involvement of fertility specialists is necessary in order to optimize these patients' pregnancy goals. An emphasis on lifestyle changes and in particular weight loss should also be discussed with these patients. Neoadjuvant chemotherapy followed by fertility sparing surgery in cervix cancer patients with low-risk, small tumors shows promising results that suggest this can be a safe treatment option. Patients with advanced stage disease of any primary tumor or aggressive histology such as in many cases of ovarian cancer are not appropriate candidates for prioritization of fertility sparing treatment options. Ongoing and future studies will help to better identify appropriate patients and maximize medical management options in early-stage gynecologic cancers.

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.

Patient-reported lymphedema after sentinel lymph node mapping in women with low-grade endometrial cancer

BACKGROUND

Sentinel lymph node mapping is a minimally invasive surgical staging procedure that allows identification of macro- and micrometastases. The implementation of sentinel lymph node mapping to women with low-grade endometrial cancer allows detection of lymph node metastases and avoids the morbidity of radical pelvic lymphadenectomy. The extent of myometrial invasion is highly predictive of lymph node metastases but is hard to determine precisely preoperatively. The exact rate of lymph node metastases in the large group of women with <50% myometrial invasion is low but unknown. The benefit of detecting metastases in this group should balance the risk of lymphedema. There is limited knowledge of early and late lymphedema and its impact on the quality of life in women with low-grade endometrial cancer following sentinel lymph node mapping.

OBJECTIVE

The primary objective was to investigate the risk of patient-reported lymphedema after sentinel lymph node mapping in women with low-grade endometrial cancer. In addition, we aimed to evaluate risk factors for lymphedema and the condition-specific quality of life (QoL) among women who reported lymphedema 12 months after surgery.

STUDY DESIGN

Women with presumed stage I low-grade endometrial cancer were included in a national prospective cohort study on sentinel lymph node mapping from March 2017 to February 2022. Women completed a package of validated patient-reported outcome measures before surgery, 3 and 12 months after surgery. The primary outcome was the leg lymphedema domain score from the European Organisation for Research and Treatment of Cancer-Endometrial Cancer Module (EORTC QLQ-EN24). The lymphedema assessment was further supplemented by 7 validated single items from the European Organisation for Research and Treatment of Cancer item library addressing lymphedema of legs, genitals, and groin. The disease-specific quality of life was assessed using the validated Lymphedema Quality of Life Tool. Scores were linearly transformed to 0 to 100. A change from baseline of 8 points in leg lymphedema sum-score was considered clinically important. Mean difference scores over time with 95% confidence interval were estimated. Multiple linear regression models evaluated baseline predictors associated with the 12 months postoperative lymphedema score, and if early lymphedema predicted lymphedema at 12 months after surgery. Lymphedema condition-specific quality of life was evaluated for women with lymphedema.

RESULTS

Seventy-nine % (486/617) completed patient-reported outcome measures at baseline and 12 months. The mean difference score of leg lymphedema from baseline to 12 months was 5.0, confidence interval [3.3, 6.8], that is, below the threshold for clinical importance. Baseline leg lymphedema score and body mass index were positively associated with the leg lymphedema score at 12 months. The leg lymphedema score at 3 months was associated with a higher 12-month score. High scores of lymphedema at 12 months were negatively associated with the women's daily activities, appearance, emotional functioning, and global quality of life and increased their subjective symptom burden.

CONCLUSION

Women with low-grade endometrial cancer have a low risk of lymphedema after sentinel lymph node mapping. Leg swelling at baseline and body mass index predicted more lymphedema at 12 months after surgery. Early lymphedema at 3 months predicted persistent lymphedema. A high leg lymphedema score at 12 months is associated with impairment in several aspects of quality of life.

[Practical application of the 2023 FIGO classification for endometrial cancer]

Since the last FIGO classification in 2009, numerous studies and recommendations have contributed to improving the management of endometrial cancer. The introduction of molecular classification (including POLE, MMR, and P53 status) has enabled better categorization of these cancers by defining specific patient groups, thus allowing for more tailored surgical management and adjuvant treatment. The data and analyses on molecular and histological classification developed in the 2021 guidelines from the European Societies of Gynecologic Oncology (ESGO), Radiation Therapy and Oncology (ESTRO), and Anatomical Pathology (ESP) have been utilized to develop the new 2023 FIGO classification for endometrial cancer. We are witnessing an evolution of the FIGO classification, shifting from a purely anatomical classification to a risk-based classification. It is important in pathology reports to specify the histological type of the tumor, the grade for endometrioid tumors, the presence or absence of lymphovascular space invasion, and the extent of the tumor (myometrial invasion, involvement of the serosa, cervix, vagina, adnexa, or neighboring organs). These essential points are included in the 2023 FIGO classification and will enable precise staging of the tumor. This article aims to clarify and simplify the classification of patients according to the new 2023 FIGO classification for endometrial cancer.

Carbon dye versus indocyanine green for sentinel lymph node mapping in endometrial cancer: a prospective dual-center study

OBJECTIVE

To compare the detection rates and diagnostic accuracy of sentinel lymph node (SLN) mapping using carbon dye and indocyanine green (ICG) in patients with early-stage endometrial cancer.

METHODS

The present study was a dual-center, prospective cohort study conducted between September 2021 and August 2022 involving patients with early-stage endometrial cancer. For SLN mapping, one center exclusively used carbon dye, while the other solely used ICG. Subsequently, all patients underwent complete systematic pelvic lymphadenectomy. The detection rates, sensitivity, and negative predictive value of SLN mapping were analyzed.

RESULTS

This study included 179 patients, of whom 89 (49.7%) were mapped using carbon dye and 90 (50.3%) were mapped using ICG laparoscopically. Unilateral detection rates of SLNs were similar, 94.4% (84/89) for carbon dye and 97.8% (88/90) for ICG (p = .25). In contrast, bilateral detection rates were significantly higher with carbon dye compared to ICG (82.0% [73/89] vs 64.4% [58/90], p = 0.008). The sensitivity and negative predictive value were both 100% for ICG and 83.3% and 98.8% for carbon dye, respectively. The empty node packet rate was 5.6% (5/90) for ICG and 0% (0/89) for carbon dye (p = .17). Although this difference did not reach statistical significance, all cases of empty node packets were observed in patients with successful unilateral but failed bilateral detection.

CONCLUSIONS

Carbon dye is a safe and effective agent for SLN mapping, demonstrating adequate detection rates, satisfactory sensitivity, and a high negative predictive value in patients with early-stage endometrial cancer. The use of carbon dye might reduce the rate of empty node packets, thereby enhancing the accuracy of nodal evaluation. While carbon dye may be a promising alternative tracer, particularly in low-resource settings, further comparative studies are needed to evaluate its cost-effectiveness relative to other widely used tracers, including blue dyes.

Prognostic significance of lymph node ratio in patients with endometrial cancer: A systematic review and meta-analysis

BACKGROUND

The ratio of harvested lymph nodes to the number of metastatic nodes is known as the lymph node ratio (LNR) and its prognostic significance was investigated in many types of cancer.

OBJECTIVES

However, until now, the therapeutic role of lymphadenectomy in the management of endometrial cancer (EC) has remained controversial.

SEARCH STRATEGY

The search strategy involved the Medline, Scopus, Clinicaltrials.gov, Cochrane Central Register of Controlled Trials CENTRAL, and Google Scholar databases.

SELECTION CRITERIA

We included prospective and retrospective observational studies.

DATA COLLECTION AND ANALYSIS

The current systematic review includes seven studies with a total of 6050 patients. From Cox regression analyses, pooled hazard ratios (HRs) were obtained to reduce the confounding effect of other factors that affect the survival outcomes.

MAIN RESULTS

The meta-analysis revealed a significant difference in progression-free survival in patients with LNR below the cut-off point in comparison to individuals with LNR above the cut-off point (HR 2.06, 95% CI 1.57-2.71, data from 6 studies). Similarly, a significantly smaller overall survival was observed among patients with LNR above the cut-off value (HR 1.99, 95% CI 1.53-2.60; data from five studies).

CONCLUSIONS

The results of this systematic review provide strong evidence that LNR could be a prognostic factor for EC patients regarding the need for adjuvant therapy and survival rate. Further studies should focus on the specific cut-off levels of LNR and the role of the molecular markers in assessing the prognosis of EC patients.

The exciting journey of progress: Exploring FIGO 2023 staging for endometrial cancer at a leading ESGO institution

INTRODUCTION

The 2023 FIGO staging of endometrial cancer integrates tumor grade and histology along with molecular features that recognize the prognostic significance of p53 and POLE mutations, accounting for potential conflicts such as lymphovascular space invasion and subserosal invasion.

MATERIALS AND METHODS

In this single-institution retrospective study, data were collected on 229 endometrial cancer patients from January 2020 to September 2024 and re-stage them according to FIGO 2023 criteria.

RESULTS

From FIGO stage 2009 IA, 70 patients do not cross stage (21 are FIGO 2023 IA1 and 49 IA2), 8 patients are upgraded to FIGO IC because of aggressive histotype; 1 is upstaged because of substantial LVSI, and 12 because of aggressive myoinfiltrating tumors (23 % of upstaging). From FIGO 2009 stage IB 34 patients remain in FIGO 2023 IB, while 5 become stage IIB (LVSI) and 27 IIC (aggressive myoinfiltrating), for a total of 32 upstages (48 % of upstaging). Within FIGO 2009 stage II, no proper upstage was possible. We observed a statistical correlation between stages and BMI, as well as between stages and age, for both FIGO 2009 (p = 0.009 and p < 0.001 respectively) and FIGO 2023 (p = 0.002 and p = 0.003 respectively) classifications. Additionally, a correlation was found between tumor grade and BMI (p = 0.02).

CONCLUSIONS

The FIGO 2023 staging system is gaining importance as recent studies highlight the role of molecular classification in prognosis and personalized therapy. Updating our study's follow-up data will clarify its impact in clinical practice.

HER2 amplification and HER2 low expression in endometrial carcinoma: prevalence across molecular, histological and clinicopathological risk groups

BACKGROUND

Emerging HER2-targeted therapies provide new treatment options for patients with HER2-expressing tumors. This study investigates the prevalence of HER2 amplification and HER2 low expression across a well-characterized cohort of endometrial carcinoma.

METHODS

HER2 chromogenic in situ hybridization (CISH) was used to detect HER2 amplification in endometrial carcinoma samples. Chromogenic HER2 immunohistochemistry (IHC) was performed. HER2 low was defined as IHC 1 + /2+ and negative CISH.

RESULTS

CISH confirmed HER2 amplification in 2% (n = 26) of the 1239 endometrial carcinoma samples including all the IHC 3+ cases (n = 13) and 20% of the 2+ cases (n = 55). Amplified cases presented various histotypes but consisted almost exclusively of p53 abnormal tumors. HER2 low 2+ category (n = 44) was heterogeneous with regard to molecular subgroup and histotype with 64.3% of the patients having high-risk disease. HER2 status did not independently predict disease-specific survival.

CONCLUSIONS

p53 abnormal molecular subgroup predicts HER2 amplification better than histotype. HER2 low cases present a wide range of histotypes and molecular subgroups including many patients with high-risk uterine cancer. Future trials of anti-HER2 therapies will clarify the clinical relevance of HER2 low status, treatment indications and guidelines for HER2 testing in endometrial carcinoma.

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

Background

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

Methods

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

Results

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

Prediction of molecular subtypes for endometrial cancer based on hierarchical foundation model

MOTIVATION

Endometrial cancer is a prevalent gynecological malignancy that requires accurate identification of its molecular subtypes for effective diagnosis and treatment. Four molecular subtypes with different clinical outcomes have been identified: POLE mutation, mismatch repair deficient, p53 abnormal, and no specific molecular profile. However, determining these subtypes typically relies on expensive gene sequencing. To overcome this limitation, we propose a novel method that utilizes hematoxylin and eosin-stained whole slide images to predict endometrial cancer molecular subtypes.

RESULTS

Our approach leverages a hierarchical foundation model as a backbone, fine-tuned from the UNI computational pathology foundation model, to extract tissue embedding from different scales. We have achieved promising results through extensive experimentation on the Fudan University Shanghai Cancer Center cohort (N = 364). Our model demonstrates a macro-average AUROC of 0.879 (95% CI, 0.853-0.904) in a five-fold cross-validation. Compared to the current state-of-the-art molecular subtypes prediction for endometrial cancer, our method outperforms in terms of predictive accuracy and computational efficiency. Moreover, our method is highly reproducible, allowing for ease of implementation and widespread adoption. This study aims to address the cost and time constraints associated with traditional gene sequencing techniques. By providing a reliable and accessible alternative to gene sequencing, our method has the potential to revolutionize the field of endometrial cancer diagnosis and improve patient outcomes.

AVAILABILITY AND IMPLEMENTATION

The codes and data used for generating results in this study are available at https://github.com/HaoyuCui/hi-UNI for GitHub and https://doi.org/10.5281/zenodo.14627478 for Zenodo.