Clinicopathological and molecular characterisation of 'multiple-classifier' endometrial carcinomas

Abstract

Endometrial carcinoma (EC) molecular classification based on four molecular subclasses identified in The Cancer Genome Atlas (TCGA) has gained relevance in recent years due to its prognostic utility and potential to predict benefit from adjuvant treatment. While most ECs can be classified based on a single classifier (POLE exonuclease domain mutations - POLEmut, MMR deficiency - MMRd, p53 abnormal - p53abn), a small but clinically relevant group of tumours harbour more than one molecular classifying feature and are referred to as 'multiple-classifier' ECs. We aimed to describe the clinicopathological and molecular features of multiple-classifier ECs with abnormal p53 (p53abn). Within a cohort of 3518 molecularly profiled ECs, 107 (3%) tumours displayed p53abn in addition to another classifier(s), including 64 with MMRd (MMRd-p53abn), 31 with POLEmut (POLEmut-p53abn), and 12 with all three aberrations (MMRd-POLEmut-p53abn). MMRd-p53abn ECs and POLEmut-p53abn ECs were mostly grade 3 endometrioid ECs, early stage, and frequently showed morphological features characteristic of MMRd or POLEmut ECs. 18/28 (60%) MMRd-p53abn ECs and 7/15 (46.7%) POLEmut-p53abn ECs showed subclonal p53 overexpression, suggesting that TP53 mutation was a secondary event acquired during tumour progression. Hierarchical clustering of TCGA ECs by single nucleotide variant (SNV) type and somatic copy number alterations (SCNAs) revealed that MMRd-p53abn tumours mostly clustered with single-classifier MMRd tumours (20/23) rather than single-classifier p53abn tumours (3/23), while POLEmut-p53abn tumours mostly clustered with single-classifier POLEmut tumours (12/13) and seldom with single-classifier p53abn tumours (1/13) (both p ≤ 0.001, chi-squared test). Finally, the clinical outcome of patients with MMRd-p53abn and POLEmut-p53abn ECs [stage I 5-year recurrence-free survival (RFS) of 92.2% and 94.1%, respectively] was significantly different from single-classifier p53abn EC (stage I RFS 70.8%, p = 0.024 and p = 0.050, respectively). Our results support the classification of MMRd-p53abn EC as MMRd and POLEmut-p53abn EC as POLEmut. © 2019 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of Pathological Society of Great Britain and Ireland.

Keywords: POLE; endometrial cancer; molecular classification.

Figure 1

Flow chart of sample analysis. POLEmut–MMRd ECs are reported separately in León‐Castillo et al 18.

Figure 2

MMRd–p53abn EC IHC and molecular features. Subclonal p53 staining and loss of PMS2 are shown in A (×5 original magnification). Percentage of cases with subclonal and diffuse abnormal p53 staining patterns is depicted in B. (C) Heatmap showing hierarchical clustering of MMRd–p53abn, single‐classifier MMRd, and single‐classifier p53abn ECs in TCGA, based on mutational changes and copy number changes. Individual similarity metrics for copy number and mutational changes were combined using Euclidean distance. Patients were classified in groups based on MMRd–p53abn (brown), single‐classifier MMRd (green), and single‐classifier p53abn (red). Samples were ordered based on hierarchical clustering.

Figure 3

POLEmut–p53abn EC IHC and molecular features. Subclonal p53 staining and H&E stain of a POLEmut–p53abn EC are shown in A (×5 original magnification). Percentage of cases with subclonal and diffuse abnormal p53 staining patterns is depicted in B. (C) Heatmap showing hierarchical clustering of POLEmut–p53abn, single‐classifier POLEmut, and single‐classifier p53abn ECs in TCGA, based on mutational changes and copy number changes. Individual similarity metrics for copy number and mutational changes were combined using Euclidean distance. Patients were classified in groups based on POLEmut–p53abn (pink), single‐classifier POLEmut (blue), and single‐classifier p53abn (red). Samples were ordered based on hierarchical clustering.

Figure 4

Survival analysis of multiple‐classifier EC compared with single‐classifier p53abn EC. Five‐year recurrence‐free survival analysis of stage I MMRd–p53abn EC (A) and POLEmut–p53abn EC (B) compared with single‐classifier p53abn EC. Two‐sided P values were obtained from log‐rank testing. Patients were classified based on POLEmut–p53abn (pink), MMRd–p53abn (brown), and single‐subtype p53abn (red).