Review
Update in the molecular classification of
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Department of Pathology, Antoni
van Leeuwenhoek, Amsterdam,
The Netherlands
Correspondence to
Dr Alicia Léon-­Castillo,
Department of Pathology, Antoni
van Leeuwenhoek, Amsterdam
1066CX, Netherlands; ​a.​Leon@​
nki.n​ l
Received 16 November 2022
Accepted 20 January 2023
© IGCS and ESGO 2023. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Léon-­Castillo A. Int J
Gynecol Cancer 2023;33:333–
342.
endometrial carcinoma
Alicia Léon-­Castillo  ‍ ‍
ABSTRACT
The pathological classification of endometrial carcinomas,
one of the cornerstones in patient clinical management,
has traditionally been based on morphologic features.
However, this classification system does not fully reflect
the biological diversity of endometrial carcinomas and has
limited reproducibility. In the last decade, several studies
have reported the strong prognostic value of the molecular
endometrial carcinoma subgroups and, more recently, its
potential to inform adjuvant treatment decisions. This has
in turn resulted in a transition from a purely morphological
classification towards an integrated histological and
molecular system in the latest World Health Organization
(WHO) classification of tumors of female reproductive
organs. The new European treatment guidelines
combine the molecular subgroups with traditional
clinicopathological features in order to guide treatment
decision-­making. Accurate molecular subgroup assignment
is therefore essential for adequate patient management.
This review aims to address caveats and evolution of
molecular techniques relevant in the implementation of the
molecular endometrial carcinoma classification, as well as
challenges in the integration of the molecular subgroups
with traditional clinicopathological features.
INTRODUCTION
The molecular endometrial carcinoma classifica-
tion introduced by The Cancer Genome Atlas (TCGA)
has elicited a transition from a purely morphological
classification towards an integrated morphological-
and molecular-­based system. In the TCGA landmark
study, the molecular subgroups (POLE, microsatel-
lite unstable, copy-­ number low and copy-­ number
high) had distinct molecular landscapes and also
significant differences in their clinical outcomes.1
In subsequent years, surrogate markers that are
easy to apply on formalin-­fixed, paraffin-­embedded
tissue were developed, allowing the identification of
subgroups analogous to the ones described by the
TCGA (Table 1).2–4 Through sequencing of the exonu-
clease domain of the DNA polymerase epsilon (POLE)
and assessment of the expression of mismatch repair
(MMR) proteins (MLH1, PMS2, MSH2, MSH6) and
p53 by immunohistochemistry, endometrial carci-
noma could now be classified into POLE-­ultramutated
(POLEmut), MMR-­ deficient (MMRd), p53-­ abnormal
(p53abn), or no specific molecular profile (NSMP).
Using this highly reproducible methodology several
studies have proved the strong prognostic value of the
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772
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molecular endometrial carcinoma classification, inde-
pendent of other clinicopathological factors such as
stage or histology: POLEmut endometrial carcinomas
have an indolent behavior, p53abn endometrial carci-
nomas have a poor clinical outcome, and MMRd and
NSMP endometrial carcinomas have an intermediate
prognosis.2–6 Furthermore, the molecular subgroups
also have the potential to guide adjuvant treatment,
as they show different benefit from adjuvant chemo-
therapy and radiotherapy. This has ultimately resulted
in a turning point in the clinical care of patients with
endometrial carcinoma.
The clinical relevance of the molecular endometrial
carcinoma classification has led to a novel combined
histological and molecular classification in the latest
World Health Organization (WHO) classification of
tumors of female reproductive organs.7 Additionally,
the 2021 European Society of Gynaecological Oncol-
ogy/European Society for Radiotherapy and Oncolo-
gy/European Society of Pathology (ESGO/ESTRO/ESP)
guidelines and the most recent European Society of
Medical Oncology (ESMO) clinical practice guidelines
have integrated the molecular subgroups with tradi-
tional clinicopathological features into a novel risk
stratification system to assess relative risk of recur-
rence, with subsequent impact on adjuvant treatment
decisions. The European guidelines have therefore
encouraged the implementation of the molecular clas-
sification in all endometrial carcinomas.8 9 However,
implementation and interpretation of the surrogate
markers in clinical practice can be challenging,
especially for the assessment of POLE variants. Addi-
tionally, different pathological features, as well as
potential biomarkers, may hold distinct prognostic
value within each specific molecular subgroup. This
review aims to discuss caveats and advances on the
implementation of the molecular endometrial carci-
noma classification and the novel integrated clinico-
pathological and molecular risk model.
IMPLEMENTATION OF SURROGATE MARKERS
The identification of surrogate markers has made
feasible the implementation of the molecular endo-
metrial carcinoma classification in everyday practice.
Currently this entails performing immunohistochem-
ical stains for MMR proteins and p53, and tumor DNA
sequencing to identify POLE exonuclease domain
333
Review

Table 1  Molecular and clinicopathological features of molecular subgroups

Int J Gynecol Cancer: first published as 10.1136/ijgc-2022-003772 on 6 March 2023. Downloaded from http://ijgc.bmj.com/ on April 4, 2023 by guest. Protected by copyright.
POLEmut EC MMRd EC NSMP EC p53abn EC
Frequency 5–15% 20–30% 30–60% 10–25%
Surrogate NGS (POLE sequencing) MMR proteins IHC: PMS, MSH6 p53-­IHC
markers (MLH1, MSH2)
Sanger MSI assay NGS (TP53 sequencing)
Hot-­spot targeted techniques
Molecular Ultramutated (>100 mut/Mb) Hypermutated (>10 mutations/ Low TMB Low TMB
features Mb)
Somatic copy number alteration-­ Somatic copy number alteration-­ Somatic copy number Somatic copy number
low low alteration-­low alteration-­high
20% with MMR deficiency or MSI MSI MSS MSS
20% with p53 mutant-­ 10% with p53 mutant-­ TP53 wild-­type TP53 mutated
expression/TP53 mutations expression/TP53 mutations
PTEN mutations Frequent homologous
recombination deficiency
PI3CA mutations 20–25% Her2 amplification
CTNNB1 mutations
Associated Mostly high-­grade endometrioid Mostly high-­grade endometrioid Mostly low-­grade Mostly high-­grade, all
histological endometrioid histologies
features
Ambiguous morphology Substantial LVSI Squamous metaplasia Substantial LVSI
Tumor giant cells MELF-­like invasion ER/PR positive High-­grade atypia
High immune infiltrate (intra-­ High immune infiltrate (intra-­
epithelial CD8+ lymphocytes and epithelial CD8+ lymphocytes and
TLS) TLS)
Associated Low BMI High BMI High BMI Low BMI
clinical
Early stage Advanced stage
features
Younger patients 10% Lynch syndrome carriers Older patients
Local recurrences Distant recurrences
Prognosis Excellent Intermediate Intermediate-­poor; stage Poor
and histologic-­grade
dependent
Potential TLS CD8 intra-­epithelial CD8 intra-­epithelial
biomarkers lymphocytes lymphocytes
for prognosis
Molecular mechanism (MLH1 L1CAM
refinement
promoter methylation vs
germline mutations)
CTNNB1 mutations
ER/PR expression

BMI, body mass index; EC, endometrial carcinoma; ER, estrogen receptor; IHC, immunohistochemistry; L1CAM, L1 cell adhesion molecule; LVSI,
lymphovascular space invasion; MELF, microcystic elongated and fragmented-­type invasion; MMR, mismatch repair; MMRd, mismatch repair-­
deficient; MSI, microsatellite instability; MSS, microsatellite stable; NGS, next generation sequencing; NSMP, no specific molecular profile; p53abn,
p53-­abnormal; POLEmut, polymerase epsilon-­ultramutated; PR, progesterone receptor; TLS, tertiary lymphoid structure; TMB, tumor mutational
burden.

mutations. However, in order to ensure an accurate subgroup allo-
cation, it is important to be aware of caveats and pitfalls of these
techniques
Interpretation of Somatic POLE Exonuclease Domain Variants
There are five hotspot POLE exonuclease domain mutations that are
widely recognized as pathogenic (in this context meaning causal of
an ultramutated phenotype and, ultimately, of a favorable clinical
outcome): P286R, V411L, S297F, S497F, and A456P. However, it is
challenging to determine the effect that rarer non-­hotspot variants
will have on the tumor’s biology. Although POLEmut endometrial
carcinomas have characteristic genomic features (high mutational
burden, high proportion of C>A substitutions, low proportion of
C>G, and almost no indels, as well as COSMIC mutational signature
10), 1 10 11 these parameters were ill defined, hampering the anno-
tation of non-­hotspot POLE variants.
Additionally, these genomic correlates can only be prop-
erly assessed after performing whole genome or whole exome
sequencing, techniques that are currently not (or only rarely) avail-
able in clinical practice. This represented an important hurdle in
the adoption of the molecular endometrial carcinoma classification,

334 Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772


Box 1  Described pathogenic POLE exonuclease domain
mutations13
Protein change
P286R
V411L
S297F
S459F
A456P
F367S
L424I
M295R
P436R
M444K
D368Y
as an incorrect annotation of a POLE variant could lead to an erro-
neous allocation of an endometrial carcinoma within the POLEmut
subgroup, and thus impact the prognostic assessment and clinical
management of the patient.8 This was highlighted by the study by
Imboden et al, in which patients with an endometrial carcinoma
with one of the five POLE hotspot exonuclease domain mutations
had a significantly better clinical outcome than those with non-­
POLEmut endometrial carcinoma.12 However, this difference was
no longer observed when comparing patients with an endometrial
carcinoma with any POLE variant with patients with a POLE wild-­
type carcinoma.
Analysis of the TCGA endometrial carcinoma cohort using cancers
with a hotspot POLE exonuclease domain mutation as a truth set
revealed genomic features that allowed generation of a scoring
system, with well-­defined cut-­off points, to assess POLE variants’
pathogenicity.13 Furthermore, this scoring system identified a set of
11 POLE exonuclease domain mutations eliciting an ultramutated
phenotype and causative of indolent clinical behavior (Box 1). This
has provided a pragmatic guideline for the interpretation of POLE
variants, facilitating the implementation of POLE testing in clinical
practice. Importantly, only 11 of the 21 different POLE exonuclease
domain variants in the TCGA cohort qualified as pathogenic, proving
that the sole presence of a POLE variant is insufficient to classify
an endometrial carcinoma as POLEmut. This was further illustrated
by the individual patient data meta-­analysis by McAlpine et al,
where patients with endometrial carcinomas with non-­pathogenic
POLE variants (a variant different from the 11 POLE exonuclease
domain mutations previously mentioned) had a significantly poorer
outcome than those with a POLEmut.14 Of note, as whole genome/
exome sequencing techniques become more widely available and
more endometrial carcinomas undergo extensive sequencing, the
initial list of 11 POLE exonuclease domain mutations causative of
ultramutation is bound to be expanded in upcoming years.
Testing for MMR Deficiency in Endometrial Carcinomas
Identification of endometrial carcinomas with MMR deficiency
has a threefold value: it (1) serves to detect patients at higher
risk of presenting a Lynch syndrome, (2) provides prognostic
information as a surrogate marker for MMRd endometrial carci-
nomas (once POLE pathogenic mutations have been excluded, see
later in the text), and (3) holds predictive value, as patients with
MMRd endometrial carcinomas benefit from check-­point inhibitor
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772
Review
treatment.15 16 Furthermore, it can aid in the histological subtyping
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of endometrial carcinomas as MMRd endometrial carcinomas have
most frequently an endometrioid morphology.
Approximately 10% of MMRd endometrial carcinomas and 3%
of all endometrial carcinomas are due to Lynch syndrome, a cancer
susceptibility syndrome caused by germline mutations in the MMR
genes (MLH1, PMS2, MSH2, MSH6) or EPCAM.17 Although MMRd
endometrial carcinomas are enriched for high-­grade endometrioid
subtype, occasionally non-­endometrioid cancers are encountered,
also in the context of Lynch syndrome. For example, in the study
by Post et al, 14% and 8% of patients with endometrial carcinoma
and Lynch syndrome presented with a serous or clear cell histology
respectively, while Ryan et al reported two (12.5%) carcinosar-
comas, two (12.5%) mixed endometrial carcinoma, and one dedif-
ferentiated carcinoma (6.3 %) in a group of patients with endometrial
carcinoma and Lynch syndrome.18 19 Those carcinomas arising in
the context of Lynch syndrome can also be encountered at any age,
with approximately 17% and 86% of cases presenting in women
over 70 and 50 years of age, respectively.18 Accordingly, current
guidelines for Lynch syndrome screening recommend staining for
MMR proteins on all endometrial carcinomas, regardless of histo-
logic type or patient’s age.8 18 20
In order to classify MMRd endometrial carcinomas, either immu-
nohistochemistry or DNA-­based techniques (panels of microsatel-
lite markers for detection of microsatellite instability) can be used.
MMR immunohistochemistry consists of staining for the four major
MMR proteins: MLH1, PMS2, MSH2, and MSH6. MMRd endometrial
carcinomas will have loss of one or more MMR protein. Alternatively,
it is possible to use a two-­marker approach (immunohistochemistry
stain for only PMS2 and MSH6) to identify MMRd endometrial carci-
nomas.21–24 MMR proteins occur as heterodimers in the cell. While
MLH1 and MSH2 can stabilize in the cell by forming heterodimers
with different partners in the absence of PMS2 and MSH6, respec-
tively, this is not the case for PMS2 and MSH6.25 As a result, there
will always be loss of PMS2 expression in absence of MLH1, and
MSH6 will always be lost in absence of MSH2. Accordingly, it is
possible to use a two-­antibody approach to identify MMRd endo-
metrial carcinomas. In cases of PMS2 or MSH6 loss, MLH1 and
MSH2 should be performed, followed by MLH1 promoter methyl-
ation analysis in endometrial carcinomas with MLH1-­PMS2 loss in
order to screen for Lynch syndrome carriers. This strategy has been
established to be sufficient in endometrial carcinoma to detect
MMRd cases.21–24
The concordance between MMR immunohistochemistry and
microsatellite instability analysis is high (93–95%).22 26 Discrepant
results between both techniques can occur in the context of
subclonal MMR deficiency (a well-­delimited area of the tumor
with loss of expression of a major MMR protein), as these MMRd
areas can be overlooked by using microsatellite instability analysis.
Additionally, cancers with MSH6 mutations, which are frequently
encountered in endometrial carcinoma, can present as microsat-
ellite stable.22 26–28 It is also important to note that correct inter-
pretation of microsatellite instability assay results requires highly
trained personnel, as changes in endometrial carcinoma can be
more subtle than those described in colorectal cancer.29 Since
immunohistochemistry can identify the defective protein, allows
correlation with morphology, and is a widely available and cheaper
335
Review

technique, its use is currently favored in clinical practice over that POLEmut-­MMRd-­p 53abn), where TP53 mutations are not

of DNA methods.
Surrogate Markers for p53abn Endometrial Carcinomas
p53 immunohistochemistry or TP53 sequencing is used
currently as surrogate markers for the identification of p53abn
endometrial carcinomas. There are four distinct p53 mutant-­
expression patterns: mutant overexpression (diffuse and
strong nuclear positivity) associated with missense mutations,
null mutant (complete absence of expression) with frequent
frameshift or nonsense mutations, cytoplasmic (overexpres-
sion in the cytoplasm) due to mutations in the tetramerization
or C-­terminal domain, and subclonal (a well-­d elimited area of
the tumor with mutant expression of p53 in a background of
wild-­type expression).30 No differences in recurrence rates
have been observed between the different mutant-­e xpression
patterns or mutation types.31
Subclonal mutant p53 expression is frequently defined with
a lower threshold of 10% of the tumor's area with mutant-­
expression pattern. However, tumors with minimal and multi-
focal areas with mutant expression have also been described,
a finding occurring most frequently in the context of POLEmut
or MMRd endometrial carcinomas. The clinical value of these
small mutant areas is still unknown. Since a lower-­limit 10%
threshold has been used in previous studies for molecular
subgroup assignment, for uniformity purposes it is advisable
to use this as a lower-­limit cut-­o ff point.
Both p53 immunohistochemistry and TP53 sequencing
have a high concordance rate (90.7–92.3%).30 31 Discrep-
ancies are most frequently encountered in POLEmut or
MMRd endometrial carcinoma (multiple classifier endo-
metrial carcinomas: POLEmut-­p 53abn, MMRd-­p 53abn, or
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driving events and do not confer a poor prognosis.32 Once
POLEmut and MMRd endometrial carcinomas are excluded,
the concordance between both techniques reaches 94.5–
95.1%. 30 31 Discrepancies between both methods can also be
caused by suboptimal pre-­p rocessing or staining of the sample,
or to misinterpretation of the immunohistochemistry staining
pattern. Pathologists must therefore be trained in the variety of
mutant-­e xpression patterns and be aware of possible pitfalls.
A small remaining group of MMR proficient and POLE wild-­type
endometrial carcinomas will show true discrepancies between
both techniques. Given that most studies assessing the prog-
nostic value of the molecular subgroups have been based on
p53 immunohistochemistry, and the affordable price and wide
availability of this technique, p53 immunohistochemistry is
overall favored as the preferred surrogate marker for p53abn
endometrial carcinomas.
Molecular Subgroup Diagnosis
Correct molecular subgroup allocation requires all surrogate
markers to be performed in order to correctly categorize carci-
nomas with more than one classifying feature (multiple clas-
sifier endometrial carcinomas), accounting for approximately
3–7% of all endometrial carcinomas. 32 A simple stepwise
diagnostic algorithm now allows molecular subgroup assign-
ment of these endometrial carcinomas (Figure 1).13 32 33 First,
POLE exonuclease domain is sequenced to classify POLEmut
endometrial carcinomas. Carcinomas without a pathogenic
POLE exonuclease domain mutation are then stained for MMR
proteins to identify MMR-­d eficient endometrial carcinomas.
Finally, MMR-­p roficient endometrial carcinomas are stained
for p53, to classify p53abn cancers.

Figure 1  Diagnostic algorithm for the integrated molecular endometrial carcinoma classification. Adapted from Vermij et al.33
EC, endometrial carcinoma; EDM, exonuclease domain mutation; MMR, mismatch repair; MMRd, mismatch repair-­deficient;
MMRp, mismatch repair-­proficient; NOS, not otherwise specified; NSMP, no specific molecular profile; p53abn, p53-­abnormal;
POLE, polymerase epsilon; POLEmut, polymerase epsilon-­ultramutated. aPathogenic POLE mutations include p.Pro286Arg,
p.Val411Leu, p.Ser297Phe, p.Ala456Pro and p.Ser459Phe.13 bMMR deficiency is defined by loss of one or more MMR proteins
(MLH1, PMS2, MSH2 and MSH6). cp53 immunohistochemistry is an acceptable surrogate marker for TP53 mutation status in
MMR-­proficient, POLE wild-­type endometrial carcinoma. Permission to use figure under a creative commons (CC) by license,
Wiley https://creativecommons.org/licenses/by/4.0/.33

336 Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772

 Review

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Figure 2  Study design PORTEC-­4a trial. Reprinted from van den Heerik et al with permission.36 (A) Trial design of the
PORTEC-­4a trial. (B) Decision tree for the molecular-­integrated profile; CTNNB1, β-catenin; EBRT, external beam radiotherapy;
HIR, high-­intermediate risk; L1-­CAM, L1-­cell adhesion molecule; LVSI; lymph-­vascular space invasion; POLE, polymerase-­
epsilon. *Stage Ia (with invasion) disease, grade 3 tumor; stage Ib disease, grade 1 or 2 tumor, with either age 60 years or older
or substantial LVSI; stage Ib disease, grade 3 tumor, without LVSI; or stage II (microscopic) disease, grade 1 tumor. 36

INTEGRATED CLINICOPATHOLOGICAL AND MOLECULAR RISK
MODEL
Using the surrogate marker approach, several studies have repeat-
edly proved the strong prognostic significance of the molecular
subgroups. Whether addressing selected cohorts of patients, such
as (high-­)intermediate risk or high-­grade endometrial carcinomas,
or unselected cohorts, POLEmut endometrial carcinomas show
an indolent behavior with barely any recurrences or endometrial
carcinoma-­related deaths, patients with p53abn endometrial carci-
noma have a poor clinical outcome, and patients with MMRd and
NSMP have an intermediate prognosis.2–4 34 35 Even in high-­risk
cohorts, including non-­endometrioid histology and stage III disease,
the molecular classification is predictive of recurrence and overall
survival, independently of other clinicopathological factors.5
The latest European clinical practice guidelines have adopted
a model integrating clinicopathological features and molecular
subgroups, resulting in a more accurate risk stratification and
selection of adjuvant treatment for patients with endometrial carci-
noma.2 4 8 9 This approach is currently being tested in patients with
(high-­)intermediate risk disease in the ongoing phase III clinical trial,
PORTEC-­4a (Figure 2).36 In this trial, patients with (high-) interme-
diate risk endometrial carcinoma will be randomized to a standard
adjuvant treatment arm (vaginal brachytherapy) or an experimental
arm where adjuvant treatment will be dependent on patholog-
ical and molecular features, including substantial lymphovascular
space invasion (LVSI), molecular subgroups, CTNNB1 mutations,
and L1 cell adhesion molecule expression.36
Importantly, the prognostic weigh of traditionally relevant
pathological features (such as stage, International Federation of
Gynecology and Obstetrics (FIGO) grade, histotype, and LVSI) and
biomarkers will differ across the molecular subgroups.
Prognostic Role of Stage Within the Molecular Classification
Stage is one of the most important prognostic factors for recurrence
and survival in edometrial carcinoma. In multivariable analyses
including the molecular subgroups and pathologic characteristics,
stage showed a strong and independent prognostic feature.5 35
Stage is a particularly relevant prognostic factor for MMRd and
NSMP endometrial carcinomas, for whom it is a chief feature for
risk assignment and clinical management decision making.8 9
Considering the higher frequency of advanced stage disease at
diagnosis observed in p53abn endometrial carcinomas as compared
with the other molecular subgroups,2 3 5 34 and the fact that there
were no studies addressing the clinical outcome of the molecular
subgroups in patients staged by lymphadenectomy, it had been
suggested that the poor outcome of p53 endometrial carcinoma
could partly be due to undetected lymph node metastases (unde-
tected FIGO stage IIIc disease). In a recent study analyzing a cohort
of high-­grade endometrial carcinomas staged by lymphadenec-
tomy, multivariable analysis including the molecular subgroups and
relevant clinicopathological features rendered p53abn as a strong
prognostic factor for poor survival and recurrence, independently
of stage.6 Moreover, a subanalysis of patients staged by lymph-
adenectomy as stage I confirmed a poor clinical outcome for lymph
node-­negative patients with p53 endometrial carcinoma (28.1%
5-­year recurrence rate and 66.2% 5-­year overall survival).6
POLEmut endometrial carcinomas present most frequently with
early-­stage disease (stage I–II). Few stage III POLEmut endome-
trial carcinoma have been described in the literature. In the meta-­
analysis by McAlpine et al only two of the 25 patients with stage
III POLEmut endometrial carcinoma had a recurrence and only one
died due to endometrial carcinoma.14 In PORTEC-­3, 23.5% of 51
POLEmut endometrial carcinomas were stage III, of which only
one patient with advanced lymphatic disease at presentation had
recurrence and ultimately died due to her cancer.5 Of note, this
patient had a supraclavicular node identified at the time of the first
external beam radiotherapy session. These data suggest that the
outstanding clinical outcome of POLEmut endometrial carcinoma
shown in previous studies could also hold true for stage III endome-
trial carcinoma and would support adjuvant treatment de-­escala-
tion. Prospective studies, like the blue trial in the Refining Adjuvant
treatment IN endometrial cancer Based On molecular features

Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772 337

Review
(RAINBO) program, a single-­arm trial where patients with POLEmut
endometrial carcinoma will receive no/de-­escalation of adjuvant
treatment and be prospectively registered, will help to define the
adequate adjuvant treatment (if any) for these patients.37
Prognostic Role of FIGO Grade and Histotype in the Molecular
Classification
NSMP endometrial carcinoma is generally considered to have an
intermediate prognosis. However, when addressing cohorts enriched
for high grade histologies, particularly clear cell carcinomas, NSMP
endometrial carcinoma shows a poor clinical outcome, similar
to that of p53abn endometrial carcinomas.5 38–40 A recent study
addressing the prognostic value of FIGO grading in the context of
the molecular subgroups found a lower risk of recurrence for low-­
grade NSMP endometrial carcinoma as compared with high-­grade
NSMP (82.4% vs 55.2% for low-­grade NSMP; p=0.007).41 The
variation in clinical outcome of low-­grade versus high-­grade NSMP
endometrial carcinoma could mirror differences in their molecular
background. Momeni-­Boroujeni et al reported three distinct molec-
ular clusters in NSMP endometrial carcinoma, cluster C3 presenting
a higher proportion of non-­endometrioid and high-­grade histologies
as compared with the other two clusters.42 While clusters C1 and
C2 were characterized by PTEN mutations combined with PIK3R1
or PIK3CA mutations, respectively, cluster C3 was defined by KRAS
mutations and 1q high level gain or CTNNB1 mutations in combi-
nation with AKT1 mutations, as well as a higher fraction of their
genome altered as compared with the other two clusters. Addition-
ally, cluster C3 had a higher proportion of estrogen receptor and
progesterone receptor negative endometrial carcinomas. A suba-
nalysis of PORTEC-­3 patients with NSMP endometrial carcinoma
revealed a poorer clinical outcome for those patients with estrogen
receptor and progesterone receptor negative NSMP endometrial
carcinoma.43 These estrogen receptor/progesterone receptor nega-
tive tumors more often had high-­risk features such as high-­grade
histology and L1 cell adhesion molecule expression.
Importantly, serous p53abn endometrial carcinomas do not show
significant difference in survival as compared with p53abn of other
histologies.5 44 45 Accordingly, there are similarities in the mutational
landscape between p53abn with different histologies, and a lack
of molecular features exclusive to any histologic type.45 Similar
results have been reported regarding POLEmut and MMRd endo-
metrial carcinomas when comparing low-­grade and high-­grade
carcinomas.41
Prognostic role of Lymphovascular Space Invasion in the
Molecular Classification
LVSI is an important prognostic feature for endometrial carcinomas.
Several studies have reported the relevance of the extension, rather
than the mere presence, of LVSI. Substantial LVSI, defined as more
than four to five vessels with tumor emboli, has proved to be an
important predictor of lymph node and distant metastases as well
as reduced overall survival.46 47 Furthermore, substantial LVSI is
an adverse prognostic factor independent of molecular features in
(high-­)intermediate risk as well as in high-­grade endometrial carci-
noma.4 6 It is therefore an excellent candidate to further refine the
risk assessment of molecularly classified endometrial cancer.
A higher proportion of substantial LVSI is frequently described by
p53abn and MMRd endometrial carcinomas. It is probably within
338
the MMRd and particularly the NSMP group, given its hetero-
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geneous clinical outcomes in the different cohort studies, that
substantial LVSI will play a major role. This was highlighted by
the study on (high-­)intermediate risk presented by Stelloo et al.4
Although limited cases are available in literature, substantial LVSI
does not seem to have an impact on the prognosis of patients with
POLEmut endometrial carcinoma.
Biomarkers in the Context of the Molecular Subgroups
Although the integration of the molecular subgroups with clin-
icopathological features enhances risk stratification of patients
with endometrial carcinoma, new biomarkers are still needed to
provide an even more accurate prognostic assessment beyond
the improved integrated clinicopathological and molecular model.
A promising biomarker for further prognostic refinement is anti-­
tumor immune infiltrate, for which several studies have reported its
prognostic value.48 49
More recently, two research groups have addressed the value of
T-­cell response in the context of the molecular classification.50 51
As previously reported, both studies showed a high prevalence of
POLEmut and MMRd endometrial carcinoma in cases with high
immune infiltrate.52 More surprisingly though, they also found a
significant group of p53abn and NSMP endometrial carcinomas
with a high-­density immune infiltrate (60% and 37% of p53abn
and NSMP endometrial carcinomas with tumour-­ infiltrating
lymphocytes-­high, and 40.8% and 36.0% of p53abn and NSMP
endometrial carcinomas with immune high densities as per hier-
archical clustering analysis).50 51 In the multivariable analysis
presented by Talhouk and colleagues including the molecular
subgroups, immune clusters, and tumour-­infiltrating lymphocytes,
only the molecular subgroups proved to have an independent prog-
nostic significance.51 In contrast, the study presented by Horeweg
et al did find a significant prognostic value of intra-­epithelial CD8
lymphocytes, independent of the molecular subgroups.50 Further-
more, exploratory analysis on the predictive value for recurrence of
intra-­epithelial CD8+ lymphocytes found a significant effect within
the p53abn and NSMP endometrial carcinomas, although weaker in
this last subgroup. These discrepancies could be due to differences
in methodology, sample size, or cohort characteristics (while the
study of Talhouk et al used a retrospective cohort, Horeweg and
colleagues used material from the clinical trials PORTEC-­1 and 2).
More recently, tertiary lymphoid structures have also awakened
interest in the field of endometrial carcinoma.53 These structures
consist of B-­cell aggregates with germinal B-­cells centers and
dendritic cells surrounded by T-­cells, and associated with high
endothelial venules. These aggregates can be more easily identified
with L1 cell adhesion molecule immunohistochemistry, facilitating
its implementation in clinics. Importantly, tertiary lymphoid struc-
tures could have a favorable predictive value for recurrence and
death related to endometrial carcinoma, independent of molecular
subgroups and clinicopathological features, particularly in MMRd
cancers.53
MMRd endometrial carcinomas are most frequently due to MLH1
promoter methylation (70–75%) or somatic mutations (15–20%),
with a minority of cases arising in the context of germline muta-
tions in MMR genes (10%).18 These different molecular mecha-
nisms might have an impact on the mutational landscape of MMRd
endometrial carcinomas and ultimately on their risk of recurrence.
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772

MMRd endometrial carcinomas due to MLH1 promoter methyla-
tion could be associated with enrichment of JAK1 mutations, lower
tumor mutational burden, and lower tumour-­infiltrating lympho-
cytes densities, compared with MMRd endometrial carcinomas with
germline mutations.54 Furthermore, MMRd endometrial carcinomas
with MLH1 promoter methylation could have shorter progression-­
free survival compared with MMRd endometrial carcinomas with
germline mutations, although this difference in survival was not
found significant in multivariable analysis including clinicopatho-
logical features such as stage, age, or LVSI.18 54
The need for prognostic refinement is particularly relevant in
the context of NSMP endometrial carcinomas. These are defined
by absence of pathogenic POLE exonuclease domain mutations,
MMR proficiency, and p53 wild-­type staining pattern. In other
words, NSMP endometrial carcinomas do not have a distinct
molecular feature but a heterogeneous molecular landscape, and
thus a heterogeneous clinical outcome,1 with potential biomarkers
with prognostic value. CTNNB1 exon 3 mutations are a candidate
molecular feature to further refine the molecular classification, as
several studies have reported a poorer clinical outcome in low-­
grade, early-­stage (NSMP) endometrial carcinomas carrying these
mutations.4 55 56 Several studies have also suggested a prognostic
role for L1 cell adhesion molecule expression (assessed through
immunohistochemistry stain) as a biomarker for poor clinical
outcome.4 57 58 Although this marker frequently co-­ exists with
p53abn expression, the prognostic value of L1 cell adhesion mole-
cule is independent of the latter.4 57 Additionally, lack of expression
of estrogen receptor could identify a subgroup of NSMP endome-
trial carcinomas at higher risk of recurrence.42 43 The clinical role
in the decision-­making about adjuvant treatment of a molecular-­
integrated risk model, including CTNNB1 exon 3 mutations and L1
cell adhesion molecule expression, is being tested in the ongoing
PORTEC-­4a clinical trial.36
COST-EFFECTIVENESS OF THE MOLECULAR ENDOMETRIAL
CARCINOMA CLASSIFICATION
Reducing the Costs of Molecular Testing
The new ESGO/ESTRO/ESP and ESMO guidelines have integrated
the molecular subgroups into the new endometrial carcinoma
prognostic risk groups and encouraged the implementation of the
molecular classification in all endometrial carcinoma.8 9 This would
entail performing immunohistochemistry stains for MMR proteins
and p53, and tumor DNA sequencing to identify POLE exonuclease
domain mutations. Immunohistochemistry stains for MMR proteins
and p53 are used regularly in clinical practice and are easy to
perform. As previously discussed, MMR immunohistochemistry is
a valuable screening tool to identify patients at risk of having Lynch
syndrome and should therefore be performed on all endometrial
carcinomas regardless of histologic type or patient’s age.8 18 20 p53
immunohistochemistry is a useful marker to identify serous carci-
nomas with pseudoglandular morphology that could otherwise be
misdiagnosed as grade 1 endometrioid cancers. However, lack of
resources may not allow sequencing of all endometrial carcinomas
to identify POLE exonuclease domain mutations.
The implementation challenge for the molecular classifica-
tion lies therefore in POLE testing. Sequencing methods such as
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772
Review
Sanger and next generation sequencing panels can be used to
Int J Gynecol Cancer: first published as 10.1136/ijgc-2022-003772 on 6 March 2023. Downloaded from http://ijgc.bmj.com/ on April 4, 2023 by guest. Protected by copyright.
identify POLE mutations in the exonuclease domain (exons 9–14).
Nevertheless, these techniques are time consuming and costly, and
require expertise. Sequencing methods restricted to the analysis of
the hotspot POLE exonuclease domain mutations, easier to inter-
pret and implement, with faster turn-­around time, and more afford-
able price, could be a valid alternative to Sanger or next generation
sequencing techniques and would facilitate a broad implementa-
tion of the molecular classification on all endometrial carcinoma.59
60 61
Nevertheless, it is important to point out that even the use
of in-­house or comprehensive next generation sequencing panels
offered by commercial companies for the molecular profiling of
high-­risk, early-­stage endometrial carcinoma has been shown to
be cost-­effective in a first study.62
Should Molecular Testing be Performed on All Endometrial
Carcinomas?
Currently, it is recommended that molecular classification
is carried out on all endometrial carcinomas. However, until
rapid, reliable, and cheap testing techniques for the identifi-
cation of POLE exonuclease domain mutations are developed,
it might not be possible to perform POLE testing on all tumors.
Hence, in a setting with limited resources, it is important to
establish which patients with endometrial carcinoma would
benefit most from molecular profiling and should therefore be
prioritized for molecular testing.
In recent years it has become apparent that the molecular
endometrial carcinoma classification has prognostic value
and can also guide adjuvant treatment, potentially reducing
overtreatment and undertreatment. The molecular profiling of
high-­risk endometrial carcinomas in PORTEC-­3 translational
study demonstrated differences in prognosis and also in treat-
ment benefit between the molecular subgroups.5 Patients with
p53abn endometrial carcinoma had a significant and clinically
relevant benefit from addition of chemotherapy to external
beam radiotherapy (absolute difference of 22.4% for 5-­y ear
recurrence-­free survival). These results are in line with the
clinical trial results, where patients with serous endome-
trial carcinoma had a greater absolute benefit from adjuvant
chemotherapy and radiotherapy. 63 There was no benefit from
added chemotherapy in patients with POLEmut endometrial
carcinoma, as both treatment arms had an excellent prog-
nosis. Small studies have also evaluated the sensitivity of
POLEmut endometrial carcinomas (the majority of them with
low-­g rade endometrioid endometrial carcinomas) to adjuvant
radiotherapy. 64 65 Analysis of patients in the observation arm
of PORTEC-­1 revealed a 10-­y ear recurrence-­free survival of
100% for POLEmut endometrial carcinoma versus 80.1% for
POLE wild-­t ype endometrial carcinoma (HR=0.143, p=0.049). 64
Similar results were reported by McConechy et al: patients
with POLEmut endometrial carcinomas and no adjuvant treat-
ment had no endometrial carcinoma-­related events and had
a favorable outcome compared with those patients with POLE
wild-­t ype endometrial carcinomas. 65 In a large cohort of high-­
grade endometrial carcinomas, patients with a POLEmut high-­
grade endometrial carcinoma not receiving adjuvant treatment
had an excellent clinical outcome, presenting no recurrences
or endometrial carcinoma-­ r elated deaths.6 This is in line
339
Review
with a meta-­analysis based on individual patient data on the
treatment effect on POLEmut endometrial carcinomas, where
patients with POLEmut endometrial carcinoma did not seem
to benefit from adjuvant treatment.14 These data suggest that
the omission of adjuvant radiotherapy would also be safe for
patients with high or (high-) intermediate risk POLEmut endo-
metrial carcinoma.14 64 65
Given the potential of the molecular subgroups to improve patient
management, the most recent European treatment guidelines have
included specific recommendation for POLEmut and p53abn endo-
metrial carcinomas: no adjuvant treatment should be considered
for patients with POLEmut stage I–II, while adjuvant external beam
radiation and chemotherapy are recommended for patients with
p53abn with myometrial invasion.8 9 Risk assignment and adju-
vant treatment for patients with MMRd or NSMP further depend
on stage, histotype, FIGO grade and LVSI. Patients with high-­grade,
advanced stage II or higher or substantial LVSI should be therefore
prioritized for molecular subtyping, as these results will be relevant
to guide adjuvant treatment decisions and avoid overtreatment or
undertreatment. This strategy was considered cost-­effective, as
reported by Orellana et al.62
The added clinical value of the molecular classification for women
with low-­risk endometrial carcinoma (stage IA, low-­grade endome-
trioid endometrial carcinoma without/focal LVSI) is unclear. Given
the low recurrence risk of carcinoma in these patients (approxi-
mately 5%),66 the identification of POLEmut endometrial carci-
nomas would have limited clinical value. Since NSMP and MMRd
endometrial carcinomas represent most of low-­risk endometrial
carcinomas,4 the findings of previous studies regarding survival
of patients at low risk are largely applicable to these molecular
subgroups. Nevertheless, p53abn subgroup might hold prognostic
value in the context of low-­risk cancers, although there are few
survival data available.
A small subanalysis of low/low-­i ntermediate risk endometrial
carcinomas (n=242) within the molecularly profiled PORTEC-­1
and 2 cohorts revealed a trend towards significance for a
higher risk of distant recurrences and reduced overall survival
for patients with p53abn in univariable analysis (distant recur-
rence HR=3.939, 95% CI 0.941 to 16.487, p=0.061; overall
survival HR=1.989, 95% CI 0.977 to 4.048, p=0.058).4 Impor-
tantly, p53abn endometrial carcinoma represented approx-
imately only 9% of low/low-­ i ntermediate risk endometrial
4 classification of the PORTEC-­3 trial for high-­risk endometrial cancer:
carcinomas. In order to avoid the extra cost of POLE testing
in low-­risk endometrial carcinomas, p53 immunohistochem-
istry could be used as a screening method in this group of
patients (only tumors with a mutant p53 staining pattern and
MMR-­p roficient would be tested for POLE exonuclease domain
mutations).67 Future studies assessing the clinicopathological
and molecular features of low-­risk p53abn endometrial carci-
nomas will elucidate the best clinical management for these
patients. Until then, treatment decisions for patients with low-­
risk p53abn endometrial carcinomas should be made on an
individual basis.68 Of note, the use of only MMR and p53 immu-
nohistochemistry (no POLE testing) is insufficient to molecu-
larly classify endometrial carcinomas, and consequently the
terms NSMP/MMRd/p53abn endometrial carcinoma should be
avoided.
340
CONCLUSION
Int J Gynecol Cancer: first published as 10.1136/ijgc-2022-003772 on 6 March 2023. Downloaded from http://ijgc.bmj.com/ on April 4, 2023 by guest. Protected by copyright.
Clinicopathological features are the basis of risk group stratification
in endometrial carcinoma, which has guided the adjuvant treatment
of these patients. In recent years, there has been a paradigm shift
with the incorporation of the molecular endometrial carcinoma
classification. The strong prognostic value of the molecular classi-
fication and its potential to guide adjuvant treatment has prompted
its integration with traditional clinicopathological features into
endometrial carcinoma risk groups in the latest European clinical
practice guidelines. The specific prognostic value and size effect of
pathological variables within each molecular subgroup should be
evaluated in coming years to further improve risk assessment and
patient management. In order to further refine prognosis assess-
ment and to provide patients with tailored adjuvant therapy options,
future clinical trials should address the molecular endometrial
carcinoma subgroups in their designs.
Acknowledgements  The author is grateful to Dr T Bosse, Professor Dr CL
Creutzberg, and Professor Dr VTHBM Smit for their intellectual contributions.
Contributors  AL-­C conceived the idea and wrote the manuscript.
Funding  The author has not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  AL-­C reports personal fees from Astra Zeneca and
Diaceutics.
Patient consent for publication  Not applicable.
Ethics approval  Not applicable.
Provenance and peer review  Commissioned; internally peer reviewed.
ORCID iD
Alicia Léon-­Castillo http://orcid.org/0000-0003-0873-5362
REFERENCES
1 Kandoth C, Schultz N, Cherniack AD, et al. Integrated genomic
characterization of endometrial carcinoma. Nature 2013;497:67–73.
2 Talhouk A, McConechy MK, Leung S, et al. Confirmation of ProMisE:
a simple, genomics-­based clinical classifier for endometrial cancer.
Cancer 2017;123:802–13.
3 Talhouk A, McConechy MK, Leung S, et al. A clinically applicable
molecular-­based classification for endometrial cancers. Br J Cancer
2015;113:299–310.
4 Stelloo E, Nout RA, Osse EM, et al. Improved risk assessment by
integrating molecular and clinicopathological factors in early-­stage
endometrial cancer-­combined analysis of the PORTEC cohorts. Clin
Cancer Res 2016;22:4215–24.
5 León-­Castillo A, de Boer SM, Powell ME, et al. Molecular
impact on prognosis and benefit from adjuvant therapy. J Clin Oncol
2020;38:3388–97.
6 Leon-­Castillo A, Horeweg N, Peters EEM, et al. Prognostic relevance
of the molecular classification in high-­grade endometrial cancer
for patients staged by lymphadenectomy and without adjuvant
treatment. Gynecol Oncol 2022;164:577–86.
7 Kurman RJ. WHO classification of tumours. female genital organ
tumours. 5th ed. Lyon: International agency for research on cancer
IARC, 2020.
8 Concin N, Matias-­Guiu X, Vergote I, et al. ESGO/ESTRO/ESP
guidelines for the management of patients with endometrial
carcinoma. Int J Gynecol Cancer 2021;31:12–39.
9 Oaknin A, Bosse TJ, Creutzberg CL, et al. Endometrial cancer:
ESMO clinical practice guideline for diagnosis, treatment and follow-­
up. Ann Oncol 2022;33:860–77.
10 Shinbrot E, Henninger EE, Weinhold N, et al. Exonuclease mutations
in DNA polymerase epsilon reveal replication strand specific
mutation patterns and human origins of replication. Genome Res
2014;24:1740–50.
11 Alexandrov LB, Nik-­Zainal S, Wedge DC, et al. Signatures of
mutational processes in human cancer. Nature 2013;500:415–21.
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772

12 Imboden S, Nastic D, Ghaderi M, et al. Phenotype of POLE-­mutated
endometrial cancer. PLoS One 2019;14:e0214318.
13 León-­Castillo A, Britton H, McConechy MK, et al. Interpretation
of somatic POLE mutations in endometrial carcinoma. J Pathol
2020;250:323–35.
14 McAlpine JN, Chiu DS, Nout RA, et al. Evaluation of treatment
effects in patients with endometrial cancer and POLE
mutations: an individual patient data meta-­analysis. Cancer
2021;127:2409–22.
15 Marabelle A, Fakih M, Lopez J, et al. Association of tumour
mutational burden with outcomes in patients with advanced solid
tumours treated with pembrolizumab: prospective biomarker
analysis of the multicohort, open-­label, phase 2 Keynote-158 study.
Lancet Oncol 2020;21:1353–65.
16 U.S. Food & Drug Administration. FDA grants accelerated
approval to pembrolizumab for first tissue/site agnostic indication.
Silver Spring, MD, 2017. Available: https://www.fda.gov/Drugs/​
InformationOnDrugs/ApprovedDrugs/ucm560040.htm
17 Ryan NAJ, Glaire MA, Blake D, et al. The proportion of endometrial
cancers associated with Lynch syndrome: a systematic review of the
literature and meta-­analysis. Genet Med 2019;21:2167–80.
18 Post CCB, Stelloo E, Smit VTHBM, et al. Prevalence and prognosis
of Lynch syndrome and sporadic mismatch repair deficiency in
endometrial cancer. J Natl Cancer Inst 2021;113:1212–20.
19 Ryan NAJ, McMahon R, Tobi S, et al. The proportion of endometrial
tumours associated with lynch syndrome (PETALS): a prospective
cross-­sectional study. PLoS Med 2020;17:e1003263.
20 Mills AM, Liou S, Ford JM, et al. Lynch syndrome screening should
be considered for all patients with newly diagnosed endometrial
cancer. Am J Surg Pathol 2014;38:1501–9.
21 Aiyer KTS, Doeleman T, Ryan NA, et al. Validity of a two-­antibody
testing algorithm for mismatch repair deficiency testing in cancer;
a systematic literature review and meta-­analysis. Mod Pathol
2022;35:1775–83.
22 Stelloo E, Jansen AML, Osse EM, et al. Practical guidance for
mismatch repair-­deficiency testing in endometrial cancer. Ann Oncol
2017;28:96–102.
23 Raffone A, Travaglino A, Cerbone M, et al. Diagnostic accuracy of
immunohistochemistry for mismatch repair proteins as surrogate
of microsatellite instability molecular testing in endometrial cancer.
Pathol Oncol Res 2020;26:1417–27.
24 Niu BT, Hammond RFL, Leen SLS, et al. Two versus four
immunostains for Lynch syndrome screening in endometrial
carcinoma. Histopathology 2019;75:442–5.
25 Tamura K, Kaneda M, Futagawa M, et al. Genetic and genomic basis
of the mismatch repair system involved in Lynch syndrome. Int J Clin
Oncol 2019;24:999–1011.
26 McConechy MK, Talhouk A, Li-­Chang HH, et al. Detection of DNA
mismatch repair (MMR) deficiencies by immunohistochemistry can
effectively diagnose the microsatellite instability (MSI) phenotype in
endometrial carcinomas. Gynecol Oncol 2015;137:306–10.
27 Zhao Y, Hu F, Wang F, et al. Meta-­analysis of MSH6 gene mutation
frequency in colorectal and endometrial cancers. J Toxicol Environ
Health A 2009;72:690–7.
28 Wong YF, Cheung TH, Lo KWK, et al. Detection of microsatellite
instability in endometrial cancer: advantages of a panel of five
mononucleotide repeats over the National Cancer Institute panel of
markers. Carcinogenesis 2006;27:951–5.
29 Wu X, Snir O, Rottmann D, et al. Minimal microsatellite shift in
microsatellite instability high endometrial cancer: a significant pitfall
in diagnostic interpretation. Mod Pathol 2019;32:650–8.
30 Singh N, Piskorz AM, Bosse T, et al. P53 immunohistochemistry is
an accurate surrogate for TP53 mutational analysis in endometrial
carcinoma biopsies. J Pathol 2020;250:336–45.
31 Vermij L, Léon-­Castillo A, Singh N, et al. P53 immunohistochemistry
in endometrial cancer: clinical and molecular correlates in the
PORTEC-­3 trial. Mod Pathol 2022;35:1475–83.
32 León-­Castillo A, Gilvazquez E, Nout R, et al. Clinicopathological
and molecular characterisation of “ multiple-­classifier ” endometrial
carcinomas. J Pathol 2020;250:312–22.
33 Vermij L, Smit V, Nout R, et al. Incorporation of molecular
characteristics into endometrial cancer management. Histopathology
2020;76:52–63.
34 Kommoss S, McConechy MK, Kommoss F, et al. Final validation of
the ProMisE molecular classifier for endometrial carcinoma in a large
population-­based case series. Ann Oncol 2018;29:1180–8.
35 Bosse T, Nout RA, McAlpine JN, et al. Molecular classification
of grade 3 endometrioid endometrial cancers identifies distinct
prognostic subgroups. Am J Surg Pathol 2018;42:561–8.
36 van den Heerik ASVM, Horeweg N, Nout RA, et al. PORTEC-­4a:
international randomized trial of molecular profile-­based adjuvant
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772
Review
treatment for women with high-­intermediate risk endometrial cancer.
Int J Gynecol Cancer: first published as 10.1136/ijgc-2022-003772 on 6 March 2023. Downloaded from http://ijgc.bmj.com/ on April 4, 2023 by guest. Protected by copyright.
Int J Gynecol Cancer 2020;30:2002–7.
37 Bosse T, Powell M, Crosbie E, et al. Implementation of collaborative
translational research (transPORTEC) findings in an international
endometrial cancer clinical trials program (RAINBO). Int J Gynecol
Cancer 2021:A108–9.
38 Stelloo E, Bosse T, Nout RA, et al. Refining prognosis and
identifying targetable pathways for high-­risk endometrial cancer; a
transPORTEC initiative. Mod Pathol 2015;28:836–44.
39 Kim SR, Cloutier BT, Leung S, et al. Molecular subtypes of clear cell
carcinoma of the endometrium: opportunities for prognostic and
predictive stratification. Gynecol Oncol 2020;158:3–11.
40 DeLair DF, Burke KA, Selenica P, et al. The genetic landscape of
endometrial clear cell carcinomas. J Pathol 2017;243:230–41.
41 Vermij L, Jobsen J, Brinkhuis M. Prognostic relevance of FIGO
grading is limited to NSMP endometrial carcinomas, abstract
number 393 [abstract]. In: USCAP Annual Meeting. Los Angeles,
2022.
42 Momeni-­Boroujeni A, Nguyen B, Vanderbilt CM, et al. Genomic
landscape of endometrial carcinomas of NO specific molecular
profile. Mod Pathol 2022;35:1269–78.
43 Vermij L, Jobsen JJ, León-­Castillo A, et al. Prognostic refinement
of NSMP high-­risk endometrial cancers using oestrogen receptor
immunohistochemistry. Br J Cancer 2023.
44 Brett MA, Atenafu EG, Singh N, et al. Equivalent survival of
p53 mutated endometrial endometrioid carcinoma grade 3 and
endometrial serous carcinoma. Int J Gynecol Pathol 2021;40:116–23.
45 Momeni-­Boroujeni A, Dahoud W, Vanderbilt CM, et al.
Clinicopathologic and genomic analysis of TP53-­mutated
endometrial carcinomas. Clin Cancer Res 2021;27:2613–23.
46 Bosse T, Peters EEM, Creutzberg CL, et al. Substantial lymph-­
vascular space invasion (LVSI) is a significant risk factor for
recurrence in endometrial cancer--a pooled analysis of PORTEC 1
and 2 trials. Eur J Cancer 2015;51:1742–50.
47 Peters EEM, Léon-­Castillo A, Hogdall E, et al. Substantial
lymphovascular space invasion is an adverse prognostic factor in
high-­risk endometrial cancer. Int J Gynecol Pathol 2022;41:227–34.
48 Kondratiev S, Sabo E, Yakirevich E, et al. Intratumoral CD8+ T
lymphocytes as a prognostic factor of survival in endometrial
carcinoma. Clin Cancer Res 2004;10:4450–6.
49 de Jong RA, Leffers N, Boezen HM, et al. Presence of tumor-­
infiltrating lymphocytes is an independent prognostic factor in type I
and II endometrial cancer. Gynecol Oncol 2009;114:105–10.
50 Horeweg N, de Bruyn M, Nout RA, et al. Prognostic integrated
image-­based immune and molecular profiling in early-­stage
endometrial cancer. Cancer Immunol Res 2020;8:1508–19.
51 Talhouk A, Derocher H, Schmidt P, et al. Molecular subtype not
immune response drives outcomes in endometrial carcinoma. Clin
Cancer Res 2019;25:2537–48.
52 van Gool IC, Eggink FA, Freeman-­Mills L, et al. POLE proofreading
mutations elicit an antitumor immune response in endometrial
cancer. Clin Cancer Res 2015;21:3347–55.
53 Horeweg N, Workel HH, Loiero D, et al. Tertiary lymphoid structures
critical for prognosis in endometrial cancer patients. Nat Commun
2022;13:1373.
54 Manning-­Geist BL, Liu YL, Devereaux KA, et al. Microsatellite
instability-­high endometrial cancers with MLH1 promoter
hypermethylation have distinct molecular and clinical profiles. Clin
Cancer Res 2022;28:4302–11.
55 Liu Y, Patel L, Mills GB, et al. Clinical significance of CTNNB1
mutation and Wnt pathway activation in endometrioid endometrial
carcinoma. J Natl Cancer Inst 2014;106:dju245.
56 Kurnit KC, Kim GN, Fellman BM, et al. CTNNB1 (beta-­
catenin) mutation identifies low grade, early stage endometrial
cancer patients at increased risk of recurrence. Mod Pathol
2017;30:1032–41.
57 Van Gool IC, Stelloo E, Nout RA, et al. Prognostic significance of
L1CAM expression and its association with mutant p53 expression
in high-­risk endometrial cancer. Mod Pathol 2016;29:174–81.
58 van der Putten LJ, Visser NC, van de Vijver K, et al. L1CAM
expression in endometrial carcinomas: an ENITEC collaboration
study. Br J Cancer 2016;115:716–24.
59 Devereaux K, Steiner D, Ho C, et al. A multiplex snapshot assay is
a rapid and cost-­effective method for detecting POLE mutations in
endometrial carcinoma. Mod Pathol 2020;33:1040.
60 Van den Heerik AS, Ter Haar N, Horeweg N, et al. 212 Multiplex qpcr
hotspot testing of pathogenic POLE mutations: a rapid, simple and
reliable approach for POLE assessment in endometrial cancer. Int J
Gynecol Cancer 2021;31:A367–8.
61 Devereaux KA, Weiel JJ, Pors J, et al. Prospective molecular
classification of endometrial carcinomas: institutional
341
Review
implementation, practice, and clinical experience. Mod Pathol
2022;35:688–96.
62 Orellana TJ, Kim H, Beriwal S, et al. Cost-­effectiveness analysis of
tumor molecular classification in high-­risk early-­stage endometrial
cancer. Gynecol Oncol 2022;164:129–35.
63 de Boer SM, Powell ME, Mileshkin L, et al. Adjuvant
chemoradiotherapy versus radiotherapy alone in women with high-­
risk endometrial cancer (PORTEC-­3): patterns of recurrence and
post-­hoc survival analysis of a randomised phase 3 trial. Lancet
Oncol 2019;20:1273–85.
64 Van Gool IC, Rayner E, Osse EM, et al. Adjuvant treatment for POLE
proofreading domain-­mutant cancers: sensitivity to radiotherapy,
chemotherapy, and nucleoside analogues. Clin Cancer Res
2018;24:3197–203.
342
65 McConechy MK, Talhouk A, Leung S, et al. Endometrial carcinomas
Int J Gynecol Cancer: first published as 10.1136/ijgc-2022-003772 on 6 March 2023. Downloaded from http://ijgc.bmj.com/ on April 4, 2023 by guest. Protected by copyright.
with POLE exonuclease domain mutations have a favorable
prognosis. Clin Cancer Res 2016;22:2865–73.
66 Sorbe B, Nordström B, Mäenpää J, et al. Intravaginal brachytherapy
in FIGO stage I low-­risk endometrial cancer: a controlled randomized
study. Int J Gynecol Cancer 2009;19:873–8.
67 Imboden S, Nastic D, Ghaderi M, et al. Implementation of the 2021
molecular ESGO/ESTRO/ESP risk groups in endometrial cancer.
Gynecol Oncol 2021;162:394–400.
68 Concin N, Matias-­Guiu X, Creutzberg CL, et al. Response
to: are we confident treating pt1a G1 lymphovascular space
invasion-­negative patients (with myometrial invasion) with
chemoradiotherapy on the basis of p53abn? Int J Gynecol Cancer
2021;31:947.
Léon-­Castillo A. Int J Gynecol Cancer 2023;33:333–342. doi:10.1136/ijgc-2022-003772