Nectin-4 as a Potential Prognostic Biomarker in Endometrial Adenocarcinoma

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While molecular classifications such as TCGA and ProMisE have enhanced prognostic stratification by incorporating genetic alterations like p53 mutations and mismatch repair (MMR) deficiency, these systems may not fully capture tumor invasiveness and immune evasion potential. Nectin-4, a transmembrane cell adhesion molecule, has recently gained attention as a prognostic and therapeutic target in various cancers. However, its role in endometrial adenocarcinoma remains unclear. Aims: This study aims to investigate the expression pattern of Nectin-4 in endometrial adenocarcinoma and assess its correlation with tumor grade, hormone receptor status, p53 expression, and MMR protein expression, in order to evaluate its potential as a prognostic biomarker. Methods: In this retrospective study, 55 formalin-fixed, paraffin-embedded (FFPE) tissue samples collected between 2015 and 2023 were analyzed, including endometrial adenocarcinoma (n = 35), endometrial intraepithelial neoplasia (n = 10), and normal endometrial tissues (n = 10). Immunohistochemistry (IHC) was performed to assess Nectin-4, p53, estrogen/progesterone receptors, and MMR proteins (MLH1, PMS2, MSH2, MSH6). Staining was scored using the H-score method. Statistical correlations were evaluated using Chi-square or Fisher’s exact test for categorical variables, and Spearman’s correlation for continuous variables. Results: Nectin-4 expression was significantly associated with higher histological grades of endometrial adenocarcinoma (p < 0.001). All Grade III tumors showed strong Nectin-4 positivity, while Grades I and II demonstrated variable expression. No Nectin-4 expression was observed in normal endometrium, and only mild expression in intraepithelial neoplasia. Strong Nectin-4 expression was significantly correlated with p53 overexpression (p = 0.007) and PMS2 loss (p = 0.002), but not with other MMR proteins or hormone receptor status. Nectin-4 expression also showed a positive correlation with increasing patient age (p < 0.001). Conclusion: Nectin-4 expression is strongly associated with high-grade endometrial adenocarcinoma, p53 overexpression, and PMS2 loss, suggesting its potential utility as a prognostic biomarker. These findings highlight the need for further large-scale studies to validate Nectin-4’s clinical relevance and investigate its role as a potential therapeutic target in endometrial cancer. Nectin-4 Endometrial Adenocarcinoma Prognostic Biomarker Immunohistochemistry p53 Mismatch Repair Deficiency Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Endometrial adenocarcinoma is the most common gynecological malignancy in developed countries, representing a significant global health burden【1】. Histologically, endometrial cancers are broadly categorized into Type I and Type II tumors. Type I tumors, which include endometrioid adenocarcinomas, account for approximately 80% of cases and are generally associated with a favorable prognosis, being linked to estrogen exposure and microsatellite instability (MSI) or PTEN mutations【2】. In contrast, Type II tumors, such as serous carcinomas, are more aggressive and frequently exhibit p53 mutations and chromosomal instability【3】. Advancements in molecular biology have led to the development of genomic classifications that refine risk stratification and treatment strategies. The Cancer Genome Atlas (TCGA) classification 【4】 defines four molecular subtypes of endometrial cancer: DNA polymerase epsilon (POLE) mutations (associated with excellent prognosis), Microsatellite instability (MSI), which is linked to MMR-deficiency and Lynch syndrome p53-mutant high copy number tumors (aggressive, poor prognosis), and Low copy number tumors (intermediate risk). The Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) further translates these genomic subtypes into clinically relevant prognostic groups, focusing on MMR deficiency (MMR-d), POLE mutations, and p53 alterations【5】. However, despite these advancements, variability in tumor behavior within molecular subtypes underscores the need for additional biomarkers to refine prognosis and guide treatment decisions. Nectin-4: A Novel Prognostic Marker in Endometrial Cancer Nectin-4, a cell adhesion molecule, has emerged as a promising biomarker in various malignancies, including breast, lung, and ovarian carcinomas【6】. It plays a key role in tumor progression, invasion, and metastasis by mediating cell-cell adhesion and interacting with oncogenic signaling pathways【7】. Recent studies suggest that Nectin-4 expression correlates with tumor aggressiveness and is associated with poor prognosis in multiple cancer types【8】. In endometrial cancer, preliminary evidence indicates that Nectin-4 overexpression is linked to higher histological grades, p53 overexpression, and mismatch repair (MMR) protein deficiencies, making it a potential prognostic biomarker【9】. Why is Nectin-4 Important in Addition to Existing Prognostic Markers? While p53 mutations and MMR status are commonly used to stratify endometrial tumors, they do not fully capture tumor adhesion, invasion, and metastatic potential. This is where Nectin-4 adds significant value: Unlike p53 mutations, which mainly reflect genomic instability, Nectin-4 is a functional transmembrane protein involved in tumor adhesion and immune evasion【6】. MMR-deficient tumors exhibit high mutation burden, but Nectin-4 expression identifies tumors with more invasive potential, independent of genetic instability (9) Unlike p53 mutations, which are difficult to target, Nectin-4 is a surface protein, making it an ideal candidate for antibody-drug conjugates (ADCs) such as enfortumab vedotin, which has shown success in bladder cancer therapy (10) If validated in endometrial cancer, Nectin-4 could help stratify patients for novel targeted therapies.【10】. Nectin-4 is part of the immunoglobulin-like adhesion molecule family, which includes E-cadherin, VE-cadherin, and ICAM-1, all of which play crucial roles in tumor invasion and metastasis. Compared to other adhesion molecules like E-cadherin, which is often lost in aggressive tumors, Nectin-4 is actively overexpressed in high-grade cancers【11】. Table 1.Comparison of Nectin-4 with other adhesion molecules in cancer prognosis Adhesion Molecule Main Function in Cancer Prognostic Role Therapeutic Potential Nectin-4 (12) Tumor adhesion, immune evasion, promotes metastasis Strong predictor of poor prognosis in bladder, breast, and ovarian cancer Antibody-drug conjugates (e.g., enfortumab vedotin) in clinical use E-cadherin (13) Cell-cell adhesion, tumor suppression Loss of E-cadherin linked to increased metastasis in gastric and breast cancer Under study for targeted therapies VE-Cadherin (14) Endothelial adhesion, vascular invasion Increased expression linked to tumor angiogenesis in melanoma Targeted in anti-angiogenic therapies ICAM-1 (15) Immune cell interaction, metastasis High expression correlates with immune evasion and poor survival in lung cancer Targeted in immunotherapies Nectin-2 (16) Similar to Nectin-4, but more restricted in expression Plays a role in ovarian cancer prognosis Potential immunotherapy target Nectin-4 has a unique role in tumor adhesion, immune evasion, and metastasis, making it a strong candidate for prognostic evaluation and targeted therapies. Unlike E-cadherin, which is often lost in tumors, Nectin-4 is upregulated in aggressive cancers, making it more useful for prognosis. VE-Cadherin and ICAM-1 contribute to vascular invasion and immune system evasion, but they are not as widely expressed as Nectin-4 across different tumor types. Nectin-2, a close relative of Nectin-4, has been studied in ovarian cancer but lacks the same broad prognostic and therapeutic potential seen with Nectin-4. Study Objective This study aims to evaluate Nectin-4 expression in endometrial adenocarcinoma and its association with histological grade, hormone receptor status, p53 expression, and MMR protein expression. By assessing its prognostic value, we seek to determine whether Nectin-4 can enhance current molecular classifications and serve as a potential therapeutic target in high-risk endometrial cancer cases. Patient Selection and Tissue Samples This retrospective study was conducted on 55 formalin-fixed, paraffin-embedded (FFPE) tissue samples from patients diagnosed with endometrial adenocarcinoma, endometrial intraepithelial neoplasia, and normal endometrial tissues between 2015 and 2023. The samples were obtained from the Pathology Department archives at Aksaray University, Education and Research Hospital. 35 cases of endometrioid endometrial adenocarcinoma, categorized by the FIGO grading system: Grade 1 (n=17) Grade 2 (n=10) Grade 3 (n=8) 10 cases of endometrial intraepithelial neoplasia/hyperplasia. 10 normal endometrial tissues (control group). All cases were independently reviewed by an expert pathologist to confirm the diagnosis and histological grading. Nectin-4 expression was evaluated using immunohistochemistry (IHC) on 4-μm formalin-fixed paraffin-embedded (FFPE) sections. The sections were deparaffinized, rehydrated, and subjected to antigen retrieval using citrate buffer (pH 6.0) at 95°C for 20 minutes. Endogenous peroxidase activity was blocked using 3% hydrogen peroxide for 10 minutes. Sections were incubated overnight at 4°C with a primary anti-Nectin-4 antibody (clone ab192033, Abcam 1/1000), Manufacturer, Dilution 1:200). After washing, sections were treated with secondary HRP-conjugated antibody and visualized using 3,3′-diaminobenzidine (DAB) chromogen. Counterstaining was performed with hematoxylin. Positive controls: Urothelial carcinoma tissue. A pathologist blinded to the clinical data evaluated the staining intensity and percentage of positive tumor cells. The H-score was calculated using the formula: H-score=∑(staining intensity×percentage of positive cells)H\text{-}score = \sum (\text{staining intensity} \times \text{percentage of positive cells})H-score=∑(staining intensity×percentage of positive cells) where staining intensity was graded as: 0 (negative) 1+ (weak) 2+ (moderate) 3+ (strong) Assessment of Molecular Markers To assess potential correlations with molecular subtypes, IHC analysis was also performed for p53, mismatch repair (MMR) proteins (MLH1, PMS2, MSH2, MSH6), and hormone receptors (ER, PR). p53 expression was categorized as: Wild-type (scattered expression pattern) Mutant-like (overexpression or complete absence) MMR-deficiency (MMR-d) was defined as loss of nuclear staining in any of the four MMR proteins. Hormone receptor positivity was defined as ≥1% nuclear staining for ER or PR. Statistical Analysis Statistical analyses were conducted using SPSS v.26 (IBM Corp., USA). The following tests were applied: Chi-square and Fisher’s exact test – To assess associations between categorical variables (Nectin-4 expression and histological grade, p53 status, MMR status). Kruskal-Wallis and Mann-Whitney U tests – To compare continuous variables (H-scores) across tumor grades. Spearman’s correlation coefficient (r) – To evaluate the relationship between Nectin-4 expression, p53 overexpression, and tumor grade. A p-value of <0.05 was considered statistically significant. Supplementary Data Representative images of Nectin-4 staining (low, moderate, and high expression) were included in supplementary materials. Raw H-score values and patient characteristics are provided in Table 2. Table 2. Analysis of demographic and clinical data according to Nectin-4 expression Nectin-4 No Expression Mild Expression Moderate Expression Severe Expression p p53 Wild 0 (0) 10 (33.33) 12 (40) 8 (26.67) 0.007* p53 Overexpression 0 (0) 0 (0) 0 (0) 5 (100) MLH1 No loss 0 (0) 10 (31.25) 11 (34.38) 11 (34.38) 0.762 MLH1 Loss 0 (0) 0 (0) 1 (33.33) 2 (66.67) PMS2 No loss 0 (0) 10 (47.62) 7 (33.33) 4 (19.05) 0.002* PMS2 Loss 0 (0) 0 (0) 5 (35.71) 9 (64.29) MSH2 No loss 0 (0) 10 (29.41) 11 (32.35) 13 (38.24) 0.629 MSH2 Loss 0 (0) 0 (0) 1 (100) 0 (0) MSH6 No loss 0 (0) 10 (38.46) 8 (30.77) 8 (30.77) 0.065 MSH6 Loss 0 (0) 0 (0) 4 (44.44) 5 (55.56) Age - Mean ± SD 40.12 ± 6.20 54.85 ± 5.68 68.42 ± 8.93 63.46 ± 5.21 <0.001** Survival - Mean ± SD - 4.20 ± 1.03 3.83 ± 1.27 3.08 ± 0.95 0.059 *: p<0,05, **: p<0,001 Results We analyzed 55 cases, including: 35 cases of endometrioid adenocarcinoma (17 Grade 1 [low-grade], 10 Grade 2 [intermediate-grade], and 8 Grade 3 [high-grade]) 10 cases of endometrial intraepithelial neoplasia/hyperplasia 10 normal endometrial samples The median age of all patients was 56 years, while the median age among endometrial cancer patients was 63 years. Nectin-4 Expression and Histological Grade Nectin-4 was strongly expressed in high-grade (Grade 3) tumors (87.5%), while Grade 1 and 2 tumors exhibited weak-to-moderate expression (p=0.002, Chi-square test) (Fig. 1–3). No Nectin-4 expression was detected in normal endometrial tissues or hyperplasia cases. A significant difference was observed in PMS2 nuclear expression across histological grades (p=0.002, Fisher’s exact test), whereas no significant correlation was found between other molecular markers and FIGO histological grade (p>0.05) (Fig. 4-5). Nectin-4 Expression and p53 Status Tumors with wild-type p53 expression showed significantly lower Nectin-4 expression (p=0.007, Spearman correlation). All tumors with p53 overexpression exhibited strong Nectin-4 expression (100%, p=0.007, Fisher’s exact test). A significant association was observed between PMS2 deletion and high Nectin-4 expression (64.29%, p=0.002, Table 1), but no correlation was found with MLH1, MSH2, or MSH6 expression (p>0.05). Age and Nectin-4 Expression Nectin-4 expression severity increased significantly with age (p<0.001, Spearman correlation, r=0.62). Discussion Endometrial cancers exhibit biological, molecular, and morphological variations, significantly influencing their development, behavior, and prognosis. Recent classifications, such as The Cancer Genome Atlas (TCGA) and the Proactive Molecular Risk Classifier (ProMisE), categorize endometrial tumors into four subgroups with distinct prognoses and therapeutic implications【1】. Nectin-4 Expression and Its Prognostic Role Nectin-4, a cell adhesion molecule, has been implicated in tumor proliferation, metastasis, and immune evasion【6】Nectin-4 expression is highly upregulated in high-grade endometrial cancers while being absent in normal endometrial tissues and precursor lesions (endometrial intraepithelial neoplasia/hyperplasia). These findings align with prior studies showing that Nectin-4 overexpression is a strong predictor of tumor aggressiveness in multiple cancers (Liu et al., 2023) [8]. Furthermore, emerging evidence suggests that Nectin-4 is a key driver of tumor progression in genitourinary malignancies, including bladder and ovarian cancers (Marandino et al., 2024) [18]. This highlights its potential pan-cancer significance, reinforcing the need for further validation in endometrial carcinoma cohorts. This study investigated Nectin-4’s role in distinguishing benign from malignant endometrial lesions, its staining patterns across molecular subtypes and histological grades, and its prognostic significance. We found that Nectin-4 expression increased with histological grade and was most prominent in advanced-stage endometrial cancers, whereas normal endometrial tissue and precursor lesions (endometrial intraepithelial neoplasia/hyperplasia) exhibited minimal or no Nectin-4 expression. Accordingly, in curettage specimens where there is diagnostic ambiguity between EIN/endometrial hyperplasia and endometrial carcinoma, strong Nectin-4 expression may serve as an ancillary diagnostic marker supporting a diagnosis of adenocarcinoma. Correlation Between Nectin-4 and p53 Status The TP53 gene, located on chromosome 17p13.1, encodes the p53 tumor suppressor protein, which plays a crucial role in cell cycle arrest, senescence, and apoptosis in response to cellular stress【19】. TP53 mutations are the most frequent genetic alterations in human cancers, including high-grade endometrial carcinomas. The PORTEC-3 trial identified a p53-mutant group within endometrial cancers, reinforcing its prognostic relevance【20】. Our findings indicate that all p53-overexpressing tumors exhibited strong Nectin-4 expression (100%), suggesting a potential molecular interaction between these two markers in aggressive tumor phenotypes (Grade 3). Mismatch Repair (MMR) Deficiency and Nectin-4 Expression MMR status determination is critical for prognostic assessment and guiding adjuvant therapy in endometrial carcinoma (Chang et al., 2023)【9】. The MLH1, PMS2, MSH2, and MSH6 genes encode proteins essential for DNA mismatch repair, and their dysfunction leads to microsatellite instability (MSI). In sporadic endometrial carcinoma, MLH1 promoter hypermethylation is the leading cause of MSI, accounting for 20-30% of cases (Hashmi et al., 2019)【21】. Our study found that PMS2 loss was significantly associated with strong Nectin-4 expression (p=0.002). This aligns with previous reports indicating that Nectin-4 expression is enriched in tumors with defective DNA repair mechanisms (Chang et al., 2023) [9]. Additionally, recent investigations suggest that Nectin-4-mediated cell adhesion may interact with MMR-deficient pathways to facilitate immune evasion in aggressive tumors (Ozay et al., 2024) [22]. Diagnostic and Therapeutic Implications Microsatellite instability in endometrial cancer can be evaluated through both immunohistochemical (IHC) and molecular methods. We utilized IHC analysis, which is widely preferred due to its cost-effectiveness and ease of implementation in clinical settings (Berg et al., 2023)【23】. Several multicenter studies comparing diagnostic biopsies and hysterectomy specimens have reported 96% sensitivity and 95% specificity for IHC-based MMR testing compared to genetic analysis (Vermij et al., 2020)【24】. Our findings further support that isolated PMS2 loss is a strong indicator of Lynch syndrome, consistent with other reports (Dudley et al., 2015)【25】. In our cohort, MLH1/PMS2 loss was detected in three cases, two of which were classified as sporadic (due to MLH1 hypermethylation), while one Grade 3 tumor was confirmed as Lynch syndrome-related. Nectin-4 as a Therapeutic Target High Nectin-4 expression is associated with poor prognosis in multiple cancers, including breast, ovarian, and lung cancers (Soysal et al., 2019)【15】. Importantly, Nectin-4 has been identified as a therapeutic target in urothelial carcinoma, where enfortumab vedotin (an FDA-approved Nectin-4-directed antibody-drug conjugate) has shown significant efficacy (Hoffman-Censits & Maldonado, 2022)【26】Notably, Nectin-4 positivity has been identified as a biomarker for ADC response in multiple cancers (Rodler et al., 2022) [10].. Given that our study confirms high Nectin-4 expression in high-grade endometrial carcinomas, these findings open new avenues for adapting ADC-based therapies in endometrial cancer. Further clinical trials are warranted to evaluate whether Nectin-4-targeting drugs (e.g., enfortumab vedotin) can be repurposed for advanced or recurrent endometrial cancer (Nakamura et al., 2025) [27]. Moreover, recent research has explored the potential synergistic effects of Nectin-4 ADCs with immune checkpoint inhibitors (ICIs) in bladder cancer (Klümper et al., 2024) [28]. If similar interactions occur in endometrial cancer, combination therapy strategies could be investigated, particularly in MMR-deficient tumors, which already demonstrate sensitivity to immunotherapy. Limitations The primary limitations of our study include: Cross-sectional design, which restricts causal inference. Small sample size, which may limit the generalizability of the findings. Lack of long-term follow-up, preventing a detailed analysis of survival outcomes. Future research should focus on large-scale, multi-institutional cohorts to confirm our findings and investigate the functional mechanisms underlying Nectin-4-mediated tumor progression. Conclusion Our study highlights Nectin-4 as a promising prognostic biomarker in endometrial adenocarcinoma, particularly in MMR-deficient and p53-mutant tumors. Its strong association with tumor aggressiveness and potential as a therapeutic target suggest that Nectin-4 may enhance personalized treatment approaches in high-risk endometrial cancer patients. Future investigations should focus on: Elucidating the molecular pathways linking Nectin-4, MMR deficiency, and immune evasion. Exploring ADC-based therapies (e.g., enfortumab vedotin) in endometrial cancer clinical trials (Kijima et al., 2025) [29]. Assessing the role of Nectin-4 in combination immunotherapy strategies for advanced disease (Martini et al., 2024) [30]. By integrating Nectin-4 into molecular classification frameworks, we may refine risk stratification and optimize treatment strategies for endometrial cancer patients in the future. Declarations Ethics Approval and Consent to Participate This study was conducted in compliance with the Declaration of Helsinki and was approved by the Aksaray University Clinical Research Ethics Committee (Decision No: 2022/18-04). All participants provided written informed consent before their inclusion in the study. Availability of Data and Materials The datasets analyzed during this study are not publicly available due to patient privacy restrictions. However, they are available from the corresponding author upon reasonable request. Competing Interests The authors declare that they have no competing financial or non-financial interests related to this study. Funding This research was conducted without any specific funding support from public, private, or non-profit organizations. Author Contributions Melike Ordu: Conceptualization, study design, material preparation, data collection, project administration, formal analysis, methodology, software development, visualization, and investigation. Serife Ozlem Genc: Conceptualization, study design, data curation, manuscript writing (original draft), and review/editing of the final manuscript. Both authors have read and approved the final manuscript. References Brüggmann D, Ouassou K, Klingelhöfer D, Groneberg DA. (2020). Endometrial cancer: mapping the global landscape of research. J Transl Med. DOI Yi M, Li T, Niu M, Luo S, Chu Q, Wu K. (2021). Epidemiological trends of women's cancers from 1990 to 2019 at the global, regional, and national levels: a population-based study. Biomark Res. DOI Stelloo E, Bosse T, Nout RA, Nijman HW, Leary A, Edmondson RJ, et al. (2015). Refining prognosis and identifying targetable pathways for high-risk endometrial cancer; a TransPORTEC initiative. Mod Pathol. 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DOI Klümper N, Darr C, Büttner T, Holzwarth N, Biernath N, et al. (2024). Subgroup analysis of real-world efficacy of enfortumab vedotin in patients with metastatic/locally advanced urothelial carcinoma from a European database. J Clin Oncol. DOI Kijima T, Takada‐Owada A, Shimoda H, et al. (2025). Predictive role of ABC transporters in the efficacy of enfortumab vedotin for urothelial carcinoma. BJU Int. DOI Martini DJ, Case KB, Gratz D, Pellegrini K, Beagle E, et al. (2024). PD‐L1 and Nectin‐4 expression and genomic characterization of bladder cancer with divergent differentiation. Cancer. DOI Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6334536","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":435728284,"identity":"3b3c96a3-386d-4c6f-a717-255dde1cd799","order_by":0,"name":"Melike Ordu","email":"","orcid":"","institution":"Aksaray University Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Melike","middleName":"","lastName":"Ordu","suffix":""},{"id":435728285,"identity":"36138432-108d-4e37-8dc9-f0b9e09b0e27","order_by":1,"name":"Serife Ozlem 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14:08:10","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6334536/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6334536/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79760947,"identity":"32a379e5-f1c8-4809-963a-fd54419c6f53","added_by":"auto","created_at":"2025-04-02 11:11:50","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":54276,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eWeak cytoplasmic expression of Nectin-4 in an endometrioid endometrial carcinoma (Immunohistochemical staining, original magnification ×10).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/b2af049edde0980b26db00d6.jpeg"},{"id":79762084,"identity":"d379d983-f4a7-41c0-8c6b-fbe998f08b44","added_by":"auto","created_at":"2025-04-02 11:27:50","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":78483,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eModerate cytoplasmic expression of Nectin-4 in an endometrioid endometrial carcinoma (Immunohistochemical staining, original magnification ×10).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/8f2ea37ae8924f21118f268b.jpeg"},{"id":79760141,"identity":"a458d561-9c59-4624-aa18-e52b142c2380","added_by":"auto","created_at":"2025-04-02 11:03:50","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":87758,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eStrong cytoplasmic and membranous expression of Nectin-4 in an endometrioid endometrial carcinoma (Immunohistochemical staining, original magnification ×10).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/cf7760d6dda5a20a0f108c2c.jpeg"},{"id":79761095,"identity":"44f54da6-9785-4575-a3d2-a13d094e7783","added_by":"auto","created_at":"2025-04-02 11:19:50","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":176641,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNo loss of nuclear expression of mismatch repair (MMR) proteins in an endometrioid endometrial carcinoma (Immunohistochemical staining, original magnification ×20)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/173aed7bbc50ce8c804d0534.jpeg"},{"id":79760151,"identity":"3af53884-0429-4341-a2ad-468ce353b08f","added_by":"auto","created_at":"2025-04-02 11:03:50","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":1073124,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLoss of nuclear expression of MMR protein (Immunohistochemical staining, original magnification ×20). Positive internal control is represented by tumor-infiltrating lymphocytes with preserved nuclear staining.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/a2606d2185371f90c0693575.jpeg"},{"id":79762330,"identity":"5dda46e1-077c-43e9-8156-aa3299285002","added_by":"auto","created_at":"2025-04-02 11:35:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2305124,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6334536/v1/a4201d22-aea7-45e5-80ca-6220c91f6fa3.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nectin-4 as a Potential Prognostic Biomarker in Endometrial Adenocarcinoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndometrial adenocarcinoma is the most common gynecological malignancy in developed countries, representing a significant global health burden【1】. Histologically, endometrial cancers are broadly categorized into Type I and Type II tumors. Type I tumors, which include endometrioid adenocarcinomas, account for approximately 80% of cases and are generally associated with a favorable prognosis, being linked to estrogen exposure and microsatellite instability (MSI) or PTEN mutations【2】. In contrast, Type II tumors, such as serous carcinomas, are more aggressive and frequently exhibit p53 mutations and chromosomal instability【3】.\u003c/p\u003e\n\u003cp\u003eAdvancements in molecular biology have led to the development of genomic classifications that refine risk stratification and treatment strategies. The Cancer Genome Atlas (TCGA) classification\u0026nbsp;【4】\u0026nbsp;defines four molecular subtypes of endometrial cancer:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eDNA polymerase epsilon (POLE) mutations (associated with excellent prognosis),\u003c/li\u003e\n \u003cli\u003eMicrosatellite instability (MSI), which is linked to MMR-deficiency and Lynch syndrome\u003c/li\u003e\n \u003cli\u003ep53-mutant high copy number tumors (aggressive, poor prognosis), and\u003c/li\u003e\n \u003cli\u003eLow copy number tumors (intermediate risk).\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe Proactive Molecular Risk Classifier for Endometrial Cancer (ProMisE) further translates these genomic subtypes into clinically relevant prognostic groups, focusing on MMR deficiency (MMR-d), POLE mutations, and p53 alterations【5】. However, despite these advancements, variability in tumor behavior within molecular subtypes underscores the need for additional biomarkers to refine prognosis and guide treatment decisions.\u003c/p\u003e\n\u003cp\u003eNectin-4: A Novel Prognostic Marker in Endometrial Cancer\u003c/p\u003e\n\u003cp\u003eNectin-4, a cell adhesion molecule, has emerged as a promising biomarker in various malignancies, including breast, lung, and ovarian carcinomas【6】. It plays a key role in tumor progression, invasion, and metastasis by mediating cell-cell adhesion and interacting with oncogenic signaling pathways【7】.\u003c/p\u003e\n\u003cp\u003eRecent studies suggest that Nectin-4 expression correlates with tumor aggressiveness and is associated with poor prognosis in multiple cancer types【8】. In endometrial cancer, preliminary evidence indicates that Nectin-4 overexpression is linked to higher histological grades, p53 overexpression, and mismatch repair (MMR) protein deficiencies, making it a potential prognostic biomarker【9】.\u003c/p\u003e\n\u003cp\u003eWhy is Nectin-4 Important in Addition to Existing Prognostic Markers?\u003c/p\u003e\n\u003cp\u003eWhile p53 mutations and MMR status are commonly used to stratify endometrial tumors, they do not fully capture tumor adhesion, invasion, and metastatic potential. This is where Nectin-4 adds significant value:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eUnlike p53 mutations, which mainly reflect genomic instability, Nectin-4 is a functional transmembrane protein involved in tumor adhesion and immune evasion【6】.\u003c/li\u003e\n \u003cli\u003eMMR-deficient tumors exhibit high mutation burden, but Nectin-4 expression identifies tumors with more invasive potential, independent of genetic instability (9)\u003c/li\u003e\n \u003cli\u003eUnlike p53 mutations, which are difficult to target, Nectin-4 is a surface protein, making it an ideal candidate for antibody-drug conjugates (ADCs) such as enfortumab vedotin, which has shown success in bladder cancer therapy (10)\u003c/li\u003e\n \u003cli\u003eIf validated in endometrial cancer, Nectin-4 could help stratify patients for novel targeted therapies.【10】.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNectin-4 is part of the immunoglobulin-like adhesion molecule family, which includes E-cadherin, VE-cadherin, and ICAM-1, all of which play crucial roles in tumor invasion and metastasis.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eCompared to other adhesion molecules like E-cadherin, which is often lost in aggressive tumors, Nectin-4 is actively overexpressed in high-grade cancers【11】.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTable 1.Comparison of Nectin-4 with other adhesion molecules in cancer prognosis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"592\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003eAdhesion Molecule\u003cbr\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003eMain Function in Cancer\u003cbr\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003ePrognostic Role\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\u003cbr\u003e\n \u003cp\u003eTherapeutic Potential\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eNectin-4 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eTumor adhesion, immune evasion, promotes metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eStrong predictor of poor prognosis in bladder, breast, and ovarian cancer\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eAntibody-drug conjugates (e.g., enfortumab vedotin) in clinical use\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eE-cadherin (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eCell-cell adhesion, tumor suppression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eLoss of E-cadherin linked to increased metastasis in gastric and breast cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eUnder study for targeted therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eVE-Cadherin (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eEndothelial adhesion, vascular invasion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eIncreased expression linked to tumor angiogenesis in melanoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eTargeted in anti-angiogenic therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eICAM-1 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eImmune cell interaction, metastasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eHigh expression correlates with immune evasion and poor survival in lung cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eTargeted in immunotherapies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003eNectin-2 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 144px;\"\u003e\n \u003cp\u003eSimilar to Nectin-4, but more restricted in expression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003ePlays a role in ovarian cancer prognosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 147px;\"\u003e\n \u003cp\u003ePotential immunotherapy target\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNectin-4 has a unique role in tumor adhesion, immune evasion, and metastasis, making it a strong candidate for prognostic evaluation and targeted therapies.\u003cbr\u003e\u0026nbsp;Unlike E-cadherin, which is often lost in tumors, Nectin-4 is upregulated in aggressive cancers, making it more useful for prognosis.\u003cbr\u003e\u0026nbsp;VE-Cadherin and ICAM-1 contribute to vascular invasion and immune system evasion, but they are not as widely expressed as Nectin-4 across different tumor types.\u003cbr\u003e\u0026nbsp;Nectin-2, a close relative of Nectin-4, has been studied in ovarian cancer but lacks the same broad prognostic and therapeutic potential seen with Nectin-4.\u003c/p\u003e"},{"header":"Study Objective","content":"\u003cp\u003eThis study aims to evaluate Nectin-4 expression in endometrial adenocarcinoma and its association with histological grade, hormone receptor status, p53 expression, and MMR protein expression. By assessing its prognostic value, we seek to determine whether Nectin-4 can enhance current molecular classifications and serve as a potential therapeutic target in high-risk endometrial cancer cases.\u003c/p\u003e\n\u003cp\u003ePatient Selection and Tissue Samples\u003c/p\u003e\n\u003cp\u003eThis retrospective study was conducted on 55 formalin-fixed, paraffin-embedded (FFPE) tissue samples from patients diagnosed with endometrial adenocarcinoma, endometrial intraepithelial neoplasia, and normal endometrial tissues between 2015 and 2023. The samples were obtained from the Pathology Department archives at Aksaray University, Education and Research Hospital.\u003c/p\u003e\n\u003cp\u003e35 cases of endometrioid endometrial adenocarcinoma, categorized by the FIGO grading system:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003eGrade 1 (n=17)\u003c/li\u003e\n \u003cli\u003eGrade 2 (n=10)\u003c/li\u003e\n \u003cli\u003eGrade 3 (n=8)\u003c/li\u003e\n \u003c/ul\u003e\n \u003cli\u003e10 cases of endometrial intraepithelial neoplasia/hyperplasia.\u003c/li\u003e\n \u003cli\u003e10 normal endometrial tissues (control group).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll cases were independently reviewed by an expert pathologist to confirm the diagnosis and histological grading.\u003c/p\u003e\n\u003cp\u003eNectin-4 expression was evaluated using immunohistochemistry (IHC) on 4-\u0026mu;m formalin-fixed paraffin-embedded (FFPE) sections. The sections were deparaffinized, rehydrated, and subjected to antigen retrieval using citrate buffer (pH 6.0) at 95\u0026deg;C for 20 minutes. Endogenous peroxidase activity was blocked using 3% hydrogen peroxide for 10 minutes.\u003c/p\u003e\n\u003cp\u003eSections were incubated overnight at 4\u0026deg;C with a primary anti-Nectin-4 antibody (clone ab192033, Abcam 1/1000), Manufacturer, Dilution 1:200). After washing, sections were treated with secondary HRP-conjugated antibody and visualized using 3,3\u0026prime;-diaminobenzidine (DAB) chromogen. Counterstaining was performed with hematoxylin.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ePositive controls: Urothelial carcinoma tissue.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eA pathologist blinded to the clinical data evaluated the staining intensity and percentage of positive tumor cells. The H-score was calculated using the formula:\u003c/p\u003e\n\u003cp\u003eH-score=\u0026sum;(staining\u0026nbsp;intensity\u0026times;percentage\u0026nbsp;of\u0026nbsp;positive\u0026nbsp;cells)H\\text{-}score = \\sum (\\text{staining intensity} \\times \\text{percentage of positive cells})H-score=\u0026sum;(staining\u0026nbsp;intensity\u0026times;percentage\u0026nbsp;of\u0026nbsp;positive\u0026nbsp;cells)\u003c/p\u003e\n\u003cp\u003ewhere staining intensity was graded as:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e0 (negative)\u003c/li\u003e\n \u003cli\u003e1+ (weak)\u003c/li\u003e\n \u003cli\u003e2+ (moderate)\u003c/li\u003e\n \u003cli\u003e3+ (strong)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAssessment of Molecular Markers\u003c/p\u003e\n\u003cp\u003eTo assess potential correlations with molecular subtypes, IHC analysis was also performed for p53, mismatch repair (MMR) proteins (MLH1, PMS2, MSH2, MSH6), and hormone receptors (ER, PR).\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003ep53 expression was categorized as:\u003cul type=\"circle\" style=\"font-weight: initial;\"\u003e\n \u003cli\u003eWild-type (scattered expression pattern)\u003c/li\u003e\n \u003cli\u003eMutant-like (overexpression or complete absence)\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eMMR-deficiency (MMR-d) was defined as loss of nuclear staining in any of the four MMR proteins.\u003c/li\u003e\n \u003cli\u003eHormone receptor positivity was defined as \u0026ge;1% nuclear staining for ER or PR.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using SPSS v.26 (IBM Corp., USA). The following tests were applied:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eChi-square and Fisher\u0026rsquo;s exact test \u0026ndash; To assess associations between categorical variables (Nectin-4 expression and histological grade, p53 status, MMR status).\u003c/li\u003e\n \u003cli\u003eKruskal-Wallis and Mann-Whitney U tests \u0026ndash; To compare continuous variables (H-scores) across tumor grades.\u003c/li\u003e\n \u003cli\u003eSpearman\u0026rsquo;s correlation coefficient (r) \u0026ndash; To evaluate the relationship between Nectin-4 expression, p53 overexpression, and tumor grade.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eA p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003cp\u003eSupplementary Data\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eRepresentative images of Nectin-4 staining (low, moderate, and high expression) were included in supplementary materials.\u003c/li\u003e\n \u003cli\u003eRaw H-score values and patient characteristics are provided in Table 2.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTable 2. Analysis of demographic and clinical data according to Nectin-4 expression\u003c/p\u003e\n\u003ctable border=\"0\" cellpadding=\"0\" width=\"614\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNectin-4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eExpression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMild\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eExpression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModerate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eExpression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSevere\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eExpression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ep53 Wild\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (26.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.007*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ep53 Overexpression\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMLH1 No loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (31.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (34.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.762\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMLH1 Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 (66.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePMS2 No loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (47.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 (33.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (19.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePMS2 Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (35.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (64.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMSH2 No loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (29.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11 (32.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13 (38.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.629\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMSH2 Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMSH6 No loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 (38.46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (30.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8 (30.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.065\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMSH6 Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 (44.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (55.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge - Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.12 \u0026plusmn; 6.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.85 \u0026plusmn; 5.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68.42 \u0026plusmn; 8.93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.46 \u0026plusmn; 5.21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001**\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSurvival - Mean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.20 \u0026plusmn; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.83 \u0026plusmn; 1.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.08 \u0026plusmn; 0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.059\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cul\u003e\n \u003cli\u003e*: p\u0026lt;0,05, **: p\u0026lt;0,001\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Results","content":"\u003cp\u003eWe analyzed 55 cases, including:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e35 cases of endometrioid adenocarcinoma (17 Grade 1 [low-grade], 10 Grade 2 [intermediate-grade], and 8 Grade 3 [high-grade])\u003c/li\u003e\n \u003cli\u003e10 cases of endometrial intraepithelial neoplasia/hyperplasia\u003c/li\u003e\n \u003cli\u003e10 normal endometrial samples\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe median age of all patients was 56 years, while the median age among endometrial cancer patients was 63 years.\u003c/p\u003e\n\u003cp\u003eNectin-4 Expression and Histological Grade\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eNectin-4 was strongly expressed in high-grade (Grade 3) tumors (87.5%), while Grade 1 and 2 tumors exhibited weak-to-moderate expression (p=0.002, Chi-square test) (Fig. 1\u0026ndash;3).\u003c/li\u003e\n \u003cli\u003eNo Nectin-4 expression was detected in normal endometrial tissues or hyperplasia cases.\u003c/li\u003e\n \u003cli\u003eA significant difference was observed in PMS2 nuclear expression across histological grades (p=0.002, Fisher\u0026rsquo;s exact test), whereas no significant correlation was found between other molecular markers and FIGO histological grade (p\u0026gt;0.05) (Fig. 4-5).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNectin-4 Expression and p53 Status\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eTumors with wild-type p53 expression showed significantly lower Nectin-4 expression (p=0.007, Spearman correlation).\u003c/li\u003e\n \u003cli\u003eAll tumors with p53 overexpression exhibited strong Nectin-4 expression (100%, p=0.007, Fisher\u0026rsquo;s exact test).\u003c/li\u003e\n \u003cli\u003eA significant association was observed between PMS2 deletion and high Nectin-4 expression (64.29%, p=0.002, Table 1), but no correlation was found with MLH1, MSH2, or MSH6 expression (p\u0026gt;0.05).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAge and Nectin-4 Expression\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eNectin-4 expression severity increased significantly with age (p\u0026lt;0.001, Spearman correlation, r=0.62).\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003eEndometrial cancers exhibit biological, molecular, and morphological variations, significantly influencing their development, behavior, and prognosis. Recent classifications, such as The Cancer Genome Atlas (TCGA) and the Proactive Molecular Risk Classifier (ProMisE), categorize endometrial tumors into four subgroups with distinct prognoses and therapeutic implications【1】.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNectin-4 Expression and Its Prognostic Role\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNectin-4, a cell adhesion molecule, has been implicated in tumor proliferation, metastasis, and immune evasion【6】Nectin-4 expression is highly upregulated in high-grade endometrial cancers while being absent in normal endometrial tissues and precursor lesions (endometrial intraepithelial neoplasia/hyperplasia). These findings align with prior studies showing that Nectin-4 overexpression is a strong predictor of tumor aggressiveness in multiple cancers (Liu et al., 2023) [8].\u0026nbsp;Furthermore, emerging evidence suggests that Nectin-4 is a key driver of tumor progression in genitourinary malignancies, including bladder and ovarian cancers (Marandino et al., 2024) [18]. This highlights its potential pan-cancer significance, reinforcing the need for further validation in endometrial carcinoma cohorts.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This study investigated Nectin-4\u0026rsquo;s role in distinguishing benign from malignant endometrial lesions, its staining patterns across molecular subtypes and histological grades, and its prognostic significance. We found that Nectin-4 expression increased with histological grade and was most prominent in advanced-stage endometrial cancers, whereas normal endometrial tissue and precursor lesions (endometrial intraepithelial neoplasia/hyperplasia) exhibited minimal or no Nectin-4 expression.\u0026nbsp;Accordingly, in curettage specimens where there is diagnostic ambiguity between EIN/endometrial hyperplasia and endometrial carcinoma, strong Nectin-4 expression may serve as an ancillary diagnostic marker supporting a diagnosis of adenocarcinoma.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation Between Nectin-4 and p53 Status\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe TP53 gene, located on chromosome 17p13.1, encodes the p53 tumor suppressor protein, which plays a crucial role in cell cycle arrest, senescence, and apoptosis in response to cellular stress【19】. TP53 mutations are the most frequent genetic alterations in human cancers, including high-grade endometrial carcinomas. The PORTEC-3 trial identified a p53-mutant group within endometrial cancers, reinforcing its prognostic relevance【20】.\u003c/p\u003e\n\u003cp\u003eOur findings indicate that all p53-overexpressing tumors exhibited strong Nectin-4 expression (100%), suggesting a potential molecular interaction between these two markers in aggressive tumor phenotypes (Grade 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMismatch Repair (MMR) Deficiency and Nectin-4 Expression\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMMR status determination is critical for prognostic assessment and guiding adjuvant therapy in endometrial carcinoma (Chang et al., 2023)【9】. The MLH1, PMS2, MSH2, and MSH6 genes encode proteins essential for DNA mismatch repair, and their dysfunction leads to microsatellite instability (MSI). In sporadic endometrial carcinoma, MLH1 promoter hypermethylation is the leading cause of MSI, accounting for 20-30% of cases (Hashmi et al., 2019)【21】.\u003c/p\u003e\n\u003cp\u003eOur study found that PMS2 loss was significantly associated with strong Nectin-4 expression (p=0.002). This aligns with previous reports indicating that Nectin-4 expression is enriched in tumors with defective DNA repair mechanisms (Chang et al., 2023) [9]. Additionally, recent investigations suggest that Nectin-4-mediated cell adhesion may interact with MMR-deficient pathways to facilitate immune evasion in aggressive tumors (Ozay et al., 2024) [22].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic and Therapeutic Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMicrosatellite instability in endometrial cancer can be evaluated through both immunohistochemical (IHC) and molecular methods. We utilized IHC analysis, which is widely preferred due to its cost-effectiveness and ease of implementation in clinical settings (Berg et al., 2023)【23】. Several multicenter studies comparing diagnostic biopsies and hysterectomy specimens have reported 96% sensitivity and 95% specificity for IHC-based MMR testing compared to genetic analysis (Vermij et al., 2020)【24】.\u003c/p\u003e\n\u003cp\u003eOur findings further support that isolated PMS2 loss is a strong indicator of Lynch syndrome, consistent with other reports (Dudley et al., 2015)【25】. In our cohort, MLH1/PMS2 loss was detected in three cases, two of which were classified as sporadic (due to MLH1 hypermethylation), while one Grade 3 tumor was confirmed as Lynch syndrome-related.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNectin-4 as a Therapeutic Target\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigh Nectin-4 expression is associated with poor prognosis in multiple cancers, including breast, ovarian, and lung cancers (Soysal et al., 2019)【15】. Importantly, Nectin-4 has been identified as a therapeutic target in urothelial carcinoma, where enfortumab vedotin (an FDA-approved Nectin-4-directed antibody-drug conjugate) has shown significant efficacy (Hoffman-Censits \u0026amp; Maldonado, 2022)【26】Notably, Nectin-4 positivity has been identified as a biomarker for ADC response in multiple cancers (Rodler et al., 2022) [10]..\u003c/p\u003e\n\u003cp\u003eGiven that our study confirms high Nectin-4 expression in high-grade endometrial carcinomas, these findings open new avenues for adapting ADC-based therapies in endometrial cancer. Further clinical trials are warranted to evaluate whether Nectin-4-targeting drugs (e.g., enfortumab vedotin) can be repurposed for advanced or recurrent endometrial cancer (Nakamura et al., 2025) [27].\u003c/p\u003e\n\u003cp\u003eMoreover, recent research has explored the potential synergistic effects of Nectin-4 ADCs with immune checkpoint inhibitors (ICIs) in bladder cancer (Kl\u0026uuml;mper et al., 2024) [28]. If similar interactions occur in endometrial cancer, combination therapy strategies could be investigated, particularly in MMR-deficient tumors, which already demonstrate sensitivity to immunotherapy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary limitations of our study include:\u003c/p\u003e\n\u003cp\u003eCross-sectional design, which restricts causal inference.\u003c/p\u003e\n\u003cp\u003eSmall sample size, which may limit the generalizability of the findings.\u003c/p\u003e\n\u003cp\u003eLack of long-term follow-up, preventing a detailed analysis of survival outcomes.\u003c/p\u003e\n\u003cp\u003eFuture research should focus on large-scale, multi-institutional cohorts to confirm our findings and investigate the functional mechanisms underlying Nectin-4-mediated tumor progression.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study highlights Nectin-4 as a promising prognostic biomarker in endometrial adenocarcinoma, particularly in MMR-deficient and p53-mutant tumors. Its strong association with tumor aggressiveness and potential as a therapeutic target suggest that Nectin-4 may enhance personalized treatment approaches in high-risk endometrial cancer patients.\u003c/p\u003e\n\u003cp\u003eFuture investigations should focus on:\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eElucidating the molecular pathways linking Nectin-4, MMR deficiency, and immune evasion.\u003c/li\u003e\n \u003cli\u003eExploring ADC-based therapies (e.g., enfortumab vedotin) in endometrial cancer clinical trials (Kijima et al., 2025) [29].\u003c/li\u003e\n \u003cli\u003eAssessing the role of Nectin-4 in combination immunotherapy strategies for advanced disease (Martini et al., 2024) [30].\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eBy integrating Nectin-4 into molecular classification frameworks, we may refine risk stratification and optimize treatment strategies for endometrial cancer patients in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics Approval and Consent to Participate\u003c/p\u003e\n\u003cp\u003eThis study was conducted in compliance with the Declaration of Helsinki and was approved by the Aksaray University Clinical Research Ethics Committee (Decision No:\u0026nbsp;2022/18-04).\u003cbr\u003eAll participants provided written informed consent before their inclusion in the study.\u003c/p\u003e\n\u003cp\u003eAvailability of Data and Materials\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during this study are not publicly available due to patient privacy restrictions. However, they are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing financial or non-financial interests related to this study.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis research was conducted without any specific funding support from public, private, or non-profit organizations.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eMelike Ordu: Conceptualization, study design, material preparation, data collection, project administration, formal analysis, methodology, software development, visualization, and investigation.\u003c/li\u003e\n \u003cli\u003eSerife Ozlem Genc: Conceptualization, study design, data curation, manuscript writing (original draft), and review/editing of the final manuscript.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eBoth authors have read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBr\u0026uuml;ggmann D, Ouassou K, Klingelh\u0026ouml;fer D, Groneberg DA. 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DOI\u003c/li\u003e\n \u003cli\u003eTakano A, Ishikawa N, Nishino R, Masuda K, Yasui W, Inai K, et al. (2009). Identification of Nectin-4 oncoprotein as a diagnostic and therapeutic target for lung cancer. Cancer Res. DOI\u003c/li\u003e\n \u003cli\u003eChatterjee S, Sinha S, Kundu CN. (2021). Nectin cell adhesion molecule-4 (NECTIN-4): a potential target for cancer therapy. Eur J Pharmacol. DOI\u003c/li\u003e\n \u003cli\u003eLiu R, Zhao K, Wang K, et al. (2023). Prognostic value of Nectin-4 in human cancers: a meta-analysis. Front Oncol. DOI\u003c/li\u003e\n \u003cli\u003eChang HK, Park YH, Choi JA, et al. (2023). Nectin-4 as a Predictive Marker for Poor Prognosis of Endometrial Cancer with Mismatch Repair Impairment. Cancers. DOI\u003c/li\u003e\n \u003cli\u003eRodler S, Eismann L, Schlenker B, et al. (2022). Expression of Nectin-4 in Variant Histologies of Bladder Cancer and Its Prognostic Value\u0026mdash;Need for Biomarker Testing in High-Risk Patients? Cancers. DOI\u003c/li\u003e\n \u003cli\u003eMa J, Sheng ZY, Lv Y, et al. (2016). Expression and clinical significance of Nectin-4 in hepatocellular carcinoma. OncoTargets Ther.\u003c/li\u003e\n \u003cli\u003eLi K, Zhou Y, Zang M, Jin X, Li X. (2024). Therapeutic prospects of Nectin-4 in cancer: applications and value. Front Oncol. DOI\u003c/li\u003e\n \u003cli\u003eNishiwada S, Sho M, Yasuda S, Shimada K, et al. (2015). Nectin-4 expression contributes to tumor proliferation, angiogenesis, and patient prognosis in human pancreatic cancer. J Exp Clin Cancer Res. DOI\u003c/li\u003e\n \u003cli\u003eTanaka Y, Murata M, Tanegashima K, Oda Y, Ito T. (2022). Nectin-4 regulates angiogenesis through Src signaling and serves as a novel therapeutic target in angiosarcoma. Sci Rep. DOI\u003c/li\u003e\n \u003cli\u003eSoysal SD, Piscuoglio S, Ng CKY, et al. (2019). Nectin-4 expression is an independent prognostic biomarker and associated with better survival in triple-negative breast cancer. Front Med. DOI\u003c/li\u003e\n \u003cli\u003eBoylan KLM, Buchanan PC, Manion RD, et al. (2016). The expression of Nectin-4 on the surface of ovarian cancer cells alters their ability to adhere, migrate, aggregate, and proliferate. Oncotarget. DOI\u003c/li\u003e\n \u003cli\u003eAlexa M, Hasenburg A, Battista MJ. The TCGA molecular classification of endometrial cancer and its possible impact on adjuvant treatment decisions. Cancers. 2021;13(6):1478. https://doi.org/10.3390/cancers13061478\u003c/li\u003e\n \u003cli\u003eMarandino L, Crupi E, Costa de Padua T, et al. (2024). Nectin-4 positivity in genitourinary malignancies: A systematic review. J Precis Oncol. DOI\u003c/li\u003e\n \u003cli\u003eSchultheis AM, Martelotto LG, De Filippo MR, Piscuglio S, Ng CK, Hussein YR, et al. TP53 mutational spectrum in endometrioid and serous endometrial cancers. Int J Gynecol Pathol. 2016;35(4):289-300. https://doi.org/10.1097/PGP.0000000000000243\u003c/li\u003e\n \u003cli\u003eVermij L, L\u0026eacute;on-Castillo A, Singh N, Powell ME, Edmondson RJ, Genestie C, et al. p53 immunohistochemistry in endometrial cancer: clinical and molecular correlates in the PORTEC-3 trial. Mod Pathol. 2022;35(10):1475-83. https://doi.org/10.1038/s41379-022-01102-x\u003c/li\u003e\n \u003cli\u003eHashmi AA, Mudassir G, Hashmi RN, Irfan M, Asif H, Khan EY, et al. Microsatellite instability in endometrial carcinoma by immunohistochemistry, association with clinical and histopathologic parameters. APJCP. 2019;20(9):2601. https://doi.org/10.31557/APJCP.2019.20.9.2601\u003c/li\u003e\n \u003cli\u003eOzay ZI, Chehade CH, Agarwal N, et al. (2024). Assessing Nectin-4 as a Predictive Biomarker in Urothelial Carcinoma and Other Genitourinary Malignancies. J Precis Oncol. 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Targeted treatment of locally advanced and metastatic urothelial cancer: enfortumab vedotin in context. Onco Targets Ther. 2022;15:1519. https://doi.org/10.2147/OTT.S370900\u003c/li\u003e\n \u003cli\u003eNakamura Y, Tanaka H, Numao N, et al. (2025). Enfortumab vedotin for metastatic urothelial carcinoma: Comprehensive treatment outcomes and prognostic insights from a multicenter real-world study (YUSHIMA). Clin Genitourin Cancer. DOI\u003c/li\u003e\n \u003cli\u003eKl\u0026uuml;mper N, Darr C, B\u0026uuml;ttner T, Holzwarth N, Biernath N, et al. (2024). Subgroup analysis of real-world efficacy of enfortumab vedotin in patients with metastatic/locally advanced urothelial carcinoma from a European database. J Clin Oncol. DOI\u003c/li\u003e\n \u003cli\u003eKijima T, Takada‐Owada A, Shimoda H, et al. (2025). Predictive role of ABC transporters in the efficacy of enfortumab vedotin for urothelial carcinoma. BJU Int. DOI\u003c/li\u003e\n \u003cli\u003eMartini DJ, Case KB, Gratz D, Pellegrini K, Beagle E, et al. (2024). PD‐L1 and Nectin‐4 expression and genomic characterization of bladder cancer with divergent differentiation. Cancer. DOI\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nectin-4, Endometrial Adenocarcinoma, Prognostic Biomarker, Immunohistochemistry, p53, Mismatch Repair Deficiency","lastPublishedDoi":"10.21203/rs.3.rs-6334536/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6334536/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eEndometrial adenocarcinoma is the most prevalent gynecologic malignancy in developed countries. While molecular classifications such as TCGA and ProMisE have enhanced prognostic stratification by incorporating genetic alterations like p53 mutations and mismatch repair (MMR) deficiency, these systems may not fully capture tumor invasiveness and immune evasion potential. Nectin-4, a transmembrane cell adhesion molecule, has recently gained attention as a prognostic and therapeutic target in various cancers. However, its role in endometrial adenocarcinoma remains unclear.\u003c/p\u003e\u003ch2\u003eAims:\u003c/h2\u003e \u003cp\u003eThis study aims to investigate the expression pattern of Nectin-4 in endometrial adenocarcinoma and assess its correlation with tumor grade, hormone receptor status, p53 expression, and MMR protein expression, in order to evaluate its potential as a prognostic biomarker.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eIn this retrospective study, 55 formalin-fixed, paraffin-embedded (FFPE) tissue samples collected between 2015 and 2023 were analyzed, including endometrial adenocarcinoma (n\u0026thinsp;=\u0026thinsp;35), endometrial intraepithelial neoplasia (n\u0026thinsp;=\u0026thinsp;10), and normal endometrial tissues (n\u0026thinsp;=\u0026thinsp;10). Immunohistochemistry (IHC) was performed to assess Nectin-4, p53, estrogen/progesterone receptors, and MMR proteins (MLH1, PMS2, MSH2, MSH6). Staining was scored using the H-score method. Statistical correlations were evaluated using Chi-square or Fisher\u0026rsquo;s exact test for categorical variables, and Spearman\u0026rsquo;s correlation for continuous variables.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eNectin-4 expression was significantly associated with higher histological grades of endometrial adenocarcinoma (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). All Grade III tumors showed strong Nectin-4 positivity, while Grades I and II demonstrated variable expression. No Nectin-4 expression was observed in normal endometrium, and only mild expression in intraepithelial neoplasia. Strong Nectin-4 expression was significantly correlated with p53 overexpression (p\u0026thinsp;=\u0026thinsp;0.007) and PMS2 loss (p\u0026thinsp;=\u0026thinsp;0.002), but not with other MMR proteins or hormone receptor status. Nectin-4 expression also showed a positive correlation with increasing patient age (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eNectin-4 expression is strongly associated with high-grade endometrial adenocarcinoma, p53 overexpression, and PMS2 loss, suggesting its potential utility as a prognostic biomarker. These findings highlight the need for further large-scale studies to validate Nectin-4\u0026rsquo;s clinical relevance and investigate its role as a potential therapeutic target in endometrial cancer.\u003c/p\u003e","manuscriptTitle":"Nectin-4 as a Potential Prognostic Biomarker in Endometrial Adenocarcinoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 11:03:45","doi":"10.21203/rs.3.rs-6334536/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88f353e2-99a1-4490-8274-4b4235948f52","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-02T11:03:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-02 11:03:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6334536","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6334536","identity":"rs-6334536","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}