Frequency of Endometrial Cancer Precursors Associated with Lynch Syndrome

Frequency of Endometrial Cancer Precursors Associated with Lynch Syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Frequency of Endometrial Cancer Precursors Associated with Lynch Syndrome Kathryn Kennedy, Jennifer Gaertner-Otto, Eav Lim This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3964746/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : To identify the rate of mismatch repair deficiency in women with endometrial hyperplasia compared with the rate in endometrial cancer. Patients and Methods : A retrospective cohort pilot study was conducted to identify the frequency of mismatch repair deficiency in endometrial hyperplasia specimens, and compare to the known rate in endometrial cancer. A keyword search of the medical record at a single institution was performed to identify 1300 endometrial tissue blocks either from biopsy, curettage, or hysterectomy. After exclusion, cohort of 91 women with endometrial hyperplasia were included for analysis. Patient characteristics for both those with normal and abnormal MMR results were analyzed using the Mann-Whitney U test and Fisher exact test. Immunohistochemical staining was performed to test for mismatch repair deficiency. Results : Among the 91 women with known endometrial hyperplasia specimens who met inclusion criteria, 4 specimens exhibited mismatch repair deficiency. The observed rate of mismatch repair deficiency in hyperplasia (4.4%), was found to be significantly less than that of mismatch repair deficiency seen in endometrial cancer (25%, p< 0.0001). Conclusions : Based on the data, dMMR is not identified at a similar rate in endometrial hyperplasia compared to endometrial cancer. Currently there is no rationale to recommend immunohistochemical staining for mismatch repair deficiency on hyperplasia specimens, and further investigation is recommended to advance screening guidelines for Lynch syndrome. Mismatch repair deficiency dMMR Lynch Syndrome Hereditary endometrial cancer Introduction In 25% of endometrial tumors, one of the four proteins of the DNA mismatch repair (MMR) system is defective. 1 The implications are twofold. First, mismatch repair deficiency (dMMR) is a targetable molecular finding; MMR status renders patients eligible or ineligible for specific cancer therapies. Second, the presence of a dMMR tumor indicates the patient may carry a germline mutation in the genes encoding for one or more of these four proteins, in which case she is diagnosed with Lynch Syndrome, an autosomal dominant inherited disorder. Lynch Syndrome is the most common cause of hereditary colon and endometrial malignancies, 2,3 and portends a lifetime risk of colorectal cancer of 50%-70%, a 40%-60% risk of endometrial cancer, and elevated risk for other malignancies. For these reasons, when endometrial cancer is diagnosed on a tissue specimen, that tissue is also tested for the four MMR proteins MLH1, MSH2, MSH6, and PMS2. 4,5 It is well established that endometrial hyperplasia, an overgrowth of the normal endometrium, is a premalignant lesion. Complex hyperplasia with atypia is associated with a greater than a 30% risk of development of endometrial cancer, and a 40% risk of already-present concurrent occult endometrial cancer. 6,7,8 It is unknown whether hyperplasia carries similar rates of dMMR as endometrial cancer, but if so, this would have major ramifications for the diagnosis of Lynch Syndrome and cancer prevention strategies for patients and their families. Small studies ranging between 20 and 118 patients have supported the absence of at least 1 MMR protein in hyperplasia samples between 3% and 55% of cases. 9,10,11,12 However, follow-up data on testing for germline mutations and Lynch Syndrome is lacking. At present there is not enough evidence to support testing for dMMR in all hyperplasia specimens. The aim of this study was to compare the rate of dMMR in endometrial hyperplasia with the known rate of dMMR in endometrial cancer. If the rates were the same, it would provide a basis for expanding universal MMR testing of endometrial tumors to include testing of endometrial hyperplasia specimens. This study was performed by identifying dMMR in endometrial hyperplasia specimens, calculating the rate of dMMR in endometrial hyperplasia, then comparing it with the known rate of dMMR in endometrial cancers in the literature. It was hypothesized that the rate of dMMR in hyperplasia would be the same as the rate of dMMR in endometrial cancer. Methods A retrospective cohort pilot study was performed. The protocol was reviewed by the WellSpan Health Institutional Review Board and approved on May 8, 2019 (IRB Number 1403922-1). Appropriate specimens were identified by performing a keyword search of the electronic medical record for “hyperplasia” on final diagnosis of pathology specimens from 5/1/2014- 6/30/2022. Pathology endometrial tissue blocks labeled with the diagnosis of hyperplasia were identified. For each specimen, pathology review by a single pathologist was performed to confirm the hyperplasia diagnosis. Any specimens with unclear diagnosis were verified by a second pathologist. Females aged 18 and older with a specimen of endometrial tissue from biopsy, curettage, or hysterectomy with hyperplasia of any type were included. Women less than 18 years of age or with a known diagnosis of endometrial cancer on previous or subsequent pathology were excluded. Those patients with a final diagnosis of cancer were excluded because of the risk that cancer was already present contemporaneously at the time of the hyperplasia diagnosis and would confound the results. Sample size determination was made based on a desired power of 80% and alpha = 0.05. A calculated 1782 cases were required to exclude a difference between the groups, i.e. present of dMMR in hyperplasia specimens was equivalent to that of endometrial cancer cases (25%). Given the resources available, a pilot study of approximately 5% of this population, around 89 samples, was sought. Informed consent was obtained via telephone. Participants who met criteria were given the option of a follow up phone call with their results. A copy of the consent form was sent to all participants. No compensation was provided. Chart review was performed for demographic data including age, BMI, race, ethnicity, and personal or family history of endometrial or colon cancer. IHC testing for MLH1, PMS2, MSH2, or MSH 6 was performed and analyzed by a single pathologist. Equivocal results were reviewed with a second pathologist. Women who desired their results were notified of them via phone call. If testing revealed dMMR, those women were counseled by a Gynecologic Oncology fellow and recommended for genetic counseling and testing. Referrals to a licensed genetic counselor for Oncology at the WellSpan institution were placed if the patients were amenable. Patient characteristics for both normal and abnormal MMR results were analyzed using the Mann-Whitney U test (for continuous variables) and Fisher exact test (for categorical variables). The rate of dMMR was computed in this patient population. A z-test of proportion with a significance of p < 0.0001 compared it to the known incidence of dMMR in endometrial cancer from the literature. Results We identified 1300 endometrial pathology specimens collected during the study period, and after exclusion, 91 were available for analysis. Patient demographics are shown in Table 1 . Average patient age was 54.2 ± 12.8 years, and BMI 40.8 ± 10.3 kg/m 2 . By type of hyperplasia, the most common was complex hyperplasia without atypia at 37 cases (40.7%), followed by complex hyperplasia with atypia at 31 cases (34.1%), and simple hyperplasia without atypia with 23 cases (25.3%). There were no cases of simple hyperplasia with atypia (0%). Table 1 Patient Demographics and Mismatch Repair Protein Expression from Endometrial Hyperplasia Specimens Collected May 1, 2014 until June 30, 2022 Patient Characteristic All Patients (N = 91) MMR Proficient (N = 87) MMR Deficient (N = 4) P-Value Age in years, mean (SD) 54.2 (12.8) 53.9 (12.9) 59.3 (11.3) 0.531 BMI in kg/m 2 , mean (SD) 40.8 (10.3) 40.6 (10.2) 44.2 ( 15 ) 0.787 Race-Caucasian, N (%) 89 (97.8%) 85 (97.7%) 4 (100%) 1.000 Race- Black, N (%) 2 (2.2%) 2 (2.3%) 0 (0%) 1.000 Ethnicity- Hispanic, N (%) 3 (3.3%) 3 (3.4%) 0 (0%) 1.000 Ethnicity- Non Hispanic, N (%) 88 (96.7%) 84 (96.6%) 4 (100%) 1.000 Family History of Colon or Endometrial Cancer, N (%) 10 (11.0%) 9 (10.3%) 1 (25%) 0.377 Complex Hyperplasia with Atypia, N (%) 31 (34.1%) 31 (35.6%) 0 (0%) 0.295 Simple with Atypia, N (%) 0 (0%) 0 (0%) 0 (0%) N/A Complex Hyperplasia without Atypia, N (%) 37 (40.7%) 35 (40.2%) 2 (50%) 1.000 Simple without Atypia, N (%) 23 (25.3%) 21 (24.1%) 2 (50%) 0.264 MMR = Mismatch Repair Protein. MMR Deficiency is equivalent to lack of expression of the mismatch repair protein. MMR Proficient indicates expression of the mismatch repair protein. P-value significant < 0.05. Overall, 87 patients demonstrated MMR proficiency on immunohistochemical staining of their endometrial tissue, while 4 patients showed MMR deficiency. Per Table 1 , there were no significant differences in the demographics, family histories, or breakdown by type of hyperplasia in the MMR proficient and deficient patients. With 4 out of 91 specimens demonstrating dMMR, the rate of dMMR for endometrial hyperplasia in this group of subjects was 4.4%. This was significant different (p < 0.0001) when comparing the rate of dMMR for endometrial adenocarcinoma of 25% (22–28%) in the literature based on a meta-analysis of over 5,000 women. 9 The 4 specimens with dMMR varied in the specific proteins absent on immunohistochemical staining. Table 2 details the breakdown of proteins absent. As shown, no two endometrial hyperplasia specimens with dMMR showed the same pattern of protein absence. Table 2 Breakdown of Mismatch Repair Proteins Absent in the Four Deficient Endometrial Hyperplasia Specimens MLH1 MSH2 MSH6 PMS2 Specimen 1 x Specimen 2 x Specimen 3 x x Specimen 4 x x Only 1 of the 4 patients with dMMR found on their endometrial hyperplasia specimen underwent germline testing. This patient had formal genetic counseling followed by germline testing using a commercial test for 47 gene mutations, and none were identified. Discussion Analysis of this cohort revealed a significant difference in the rate of dMMR between endometrial hyperplasia (4.4%) and endometrial cancer (25%, p < 0.0001). The exact sample size required was not reached in this pilot study to determine whether we failed to support our hypothesis, that the rates of dMMR in endometrial hyperplasia and carcinoma are equivalent. However, to the best of our knowledge and from the procured data, there is no definitive evidence that exists to support the rates are similar. Earlier studies examined the possibility of detecting dMMR in endometrial hyperplasia specimens. Currently there is not sufficient evidence for routine testing in precancerous lesions. A handful of small studies have supported the absence of at least 1 MMR protein occurring in hyperplasia samples; these studies have sample sizes ranging from 20 to 118 patients, and demonstrate MMR deficiency in endometrial hyperplasia between 3% and 55%. 9, 10, 11, 12 Our results fall within this range,` with the rate of 4.4% dMMR in hyperplasia. There is biologic plausibility for dMMR rates to be similar between hyperplasia and endometrial cancer– though this may only apply to a subset of patients who have a germline mutation leading to dMMR. A previous case study of serial tissue samples obtained over time from a Japanese woman with a family history of Lynch Syndrome revealed the loss of MSH2 when she had only a diagnosis of hyperplasia, 7 months prior to her endometrial cancer diagnosis. 13 It is important to note, not all of the above previous studies on dMMR in endometrial hyperplasia reported follow-up germline testing. The very limited data available is conflicting; some studies show a high level of concordance between somatic dMMR in hyperplasia specimens and dMMR present in germline testing, while others suggest less than 1% of patients with somatic dMMR in hyperplasia specimens harbor a germline mutation for dMMR (namely Lynch Syndrome). 12, 14 Our study was not powered to assess germline testing, but the one hyperplasia patient whose specimen had dMMR and underwent germline testing was negative for 47 germline mutations, including Lynch Syndrome. The study was strong in utilizing a thoroughly maintained database in the electronic medical record, allowing for comprehensive chart review. There was consistency in the pathologic review of specimens and in clinical follow up for significant results. While the study was intended as a pilot investigation, it was limited by its single-institution design and small sample size. The resources available did not allow for review of all endometrial tissue specimens by multiple pathologists. Therefore unless there was a question of diagnosis, a single pathologist reviewed the slides. Of note, the original protocol allowed for use of a keyword search for ‘endometrial intraepithelial neoplasia’ in the electronic medical record. However this verbiage was not utilized by the pathology department within the study time period, consequently this keyword was abandoned. And since the term ‘endometrial intraepithelial neoplasia' is now recommended terminology by the Society for Gynecologic Oncology and the American College of Obstetricians and Gynecologists, over the 1994 World Health Organization schema used in this study, this may render our report less generalizable long-term. 17 Further, this investigation did not focus on other known risk factors for hyperplasia including BMI, age, and ovulatory status; future examination of known risks factors in the setting of endometrial hyperplasia may set a threshold for additional screening. Clinical/Research Implications : Although the outcomes of this study do not suggest practice changes based on the diagnosis of hyperplasia, it does create opportunity for further study. The absence of MMR proteins results in genomic instability, with the insertion or deletion of noncoding single nucleotide and dinucleotide repeats called microsatellites. The finding of these altered microsatellites is termed microsatellite instability which is a marker of Lynch Syndrome associated tumors. 15 While immunohistochemical staining for MMR proteins and polymerase chain reaction testing for microsatellite instability are typically correlated, the findings of this study could be either verified or expanded upon through testing for microsatellite instability. Based on The Cancer Genome Atlas study on endometrial cancer, the outlook on the pathophysiology of this disease is changing. The new genomic categories of POLE ultra-mutated, microsatellite instability hypermutated, copy number low, and copy number high for endometrial cancer prompt follow up questions related to this current study. 16 While dMMR is typically associated with microsatellite instability, what does this mean for those cancers with precursor lesions of endometrial hyperplasia? Is the loss of expression of one of the four MMR proteins a step along the pathway to the microsatellite instability hypermutated subtype of endometrial cancer– and if so, is that only not reflected here because of the exclusion of patients with a final diagnosis of endometrial cancer? Further investigation into the genomic mutations of endometrial cancer precursor lesions is warranted to better understand the treatment and prevention of this disease. Conclusion In summary, because the rate of dMMR between endometrial hyperplasia was significantly less than that of dMMR known in endometrial carcinoma, the findings of this study do not support universal screening for dMMR on endometrial hyperplasia specimens, compared to Lynch Syndrome screening in the setting of known endometrial cancer for the purpose of targeted therapy. However, this study does highlight the need for further exploration of the genomics of endometrial cancer precursor lesions to more effectively prevent and treat endometrial cancer in the future. Declarations Conflict of Interest Statement The authors have no conflicts of interest to disclose. Contribution to Authorship Kathryn Kennedy M.D.: conceived and designed the analysis, data collection and result interpretation, manuscript preparation Eav Lim D.O. FACOOG: principal investigator, conceived and designed the analysis, result interpretation, manuscript preparation and revision Jennifer Gaertner-Otto D.O.: manuscript preparation and revision Acknowledgements / Disclosures Grant funding for this research was provided by: The George L Laverty Foundation Trustee U/W Grant, The incidence of Lynch Syndrome in endometrial hyperplasia. Verbie C Emig Trust Grant, Frequency of endometrial cancer precursor associated with Lynch Syndrome. March 2019 The Lake Erie College of Osteopathic Medicine. March 2019 References Lorenzi, M., Amonkar, M., Zhang, J. et al. Epidemiology of Microsatellite Instability High (MSI-H) and Deficient Mismatch Repair (dMMR) in Solid Tumors: A Structured Literature Review. (2020) Journal of Oncology. Article ID 1807929. https://doi.org/10.1155/2020/1807929 Steinke, V., Engel, C., Buttner, R., Schackert, H. K., Schmiegel, W. H., & Propping, P. Hereditary Nonpolyposis Colorectal Cancer (HNPCC)/Lynch Syndrome. (2013) Dtscg Arztebl Int, 110(3), 32-38. doi: 10.3238/arztebl.2013.0032 Ryan, N. A., Blake, D., Cabera-Dandy, M., Glaire, M. A., Evans, G., & Crosbie, E. J. The Prevalence of Lynch Syndrome in women with endometrial cancer: A systematic review Protocol. (2018) Systematic Reviews;7(1):121. doi: 10.1186/s13643-018-0792-8 Huang , M., Djordjevic, B., Yates , M. S., Urbauer, D., Sun, C., Burzawa, J., et al. Molecular pathogenesis of endometrial cancers in Lynch Syndrome. (2013) Cancer, 119(16), 3027-3033. doi: 10.1002/cncr.28152. Sehgal, R., Sheahan, K., O'connell, P. R., Hanly, A. M., Martin, S. T., & Winter, D. C. (2014). Lynch Syndrome: An Updated Review. (2014) Genes 5(3):497-507. doi: 10.3390/genes5030497 Kurman, R. J., Kaminski, P. f., & Norris, H. J. The Behavior of Endometrial Hyperplasia, A long-term study of "untreated" hyperplasia in 170 patients. (1985) Cancer, 56(2):403-12. doi: 10.1002/1097-0142(19850715)56:23.0.co;2-x. Mutter GL, Kauderer J, Baak JP, Alberts D. Biopsy histomorphometry predicts uterine myoinvasion by endometrial carcinoma: a Gynecologic Oncology Group study. Gynecologic Oncology Group. (2008) Human Pathology, 39(6):866-74. doi: 10.1016/j.humpath.2007.09.023. Trimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ2nd, et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. (2006) Cancer; 106(4):812-9. doi: 10.1002/cncr.21650 Lucas, E., Chen, H., Molberg, K., Castrillon, D. H., Rivera Colon, G., Li, l., at al. Mismatch repair protein expression in endometrioid intraepithelial neoplasia / atypical hyperplasia: Should we screen for Lynch Syndrome in precancerous lesions? (2018) International Journal of Gynecological Pathology, 38(6): 533-542. Han, S., & Kim, M. Clinical Significance of mismatch repair genes immunohistochemical expression of complex endometrial hyperplasia. (2015) Obstetrics and Gynecology Science, 58(2), 106-111. doi: 10.5468/ogs.2015.58.2.106. Niskakoski, A., Pasanen, A., Lassus, H., Renkonen-Sinisalo, L., Kaur, S., Mecklin, J.-P., et al. Molecular changes preceding endometrial and ovarian cancer: a study of consecutive endometrial specimens from Lynch Syndrome surveillance. (2018) Modern Pathology, 31(8):1291-1301. doi: 10.1038/s41379-018-0044-4 Vierkoetter, K. R., Kagami, L. A., Ahn, H., Shimzu, D. M., & Terada, K. Y. Loss of Mismatch Repair Protein expression in unselected endometrial Adenocarcinoma Precursor Lesions. (2016) International Journal of Gynecological Cancer, 26(2), 228-232. doi: 10.1097/IGC.0000000000000606 Ichikawa, Y., Tsunoda, H., Takano, K., Oki, A., & Yoshikawa, H. Microsatellite instability and immunohistochemical analysis of MLH1 and MSH2 in normal endometrium, endometrial hyperplasia and endometrial cancer from a hereditary nonpolyposis colorectal cancer patient. (2002) Japanese Journal of Clinical Oncology, 32(3), 110-112. doi: 10.1093/jjco/hyf026 Berends MJ, Hollema H, Wu Y, van Der Sluis T, Mensink RG, ten Hoor KA, Sijmons RH, de Vries EG, Pras E, Mourits MJ, Hofstra RM, Buys CH, Kleibeuker JH, van Der Zee AG. MLH1 and MSH2 protein expression as a pre-screening marker in hereditary and non-hereditary endometrial hyperplasia and cancer. Int J Cancer. 2001 May 1;92(3):398-403. doi: 10.1002/ijc.1206 de Leeuw, W. F., Dierssen, J., Vasen, H. F., Wijnen, J. T., Kenter, G. G., Meijers-Heiboer, H., Brocker-Vriends A, Stormorken A, Moller P, Menko F, Cornelisse CJ, Morreau H. Prediction of a mismatch repair gene defect by microsatellite instability and immunohistochemical analysis in endometrial tumors from HNPCC patients. (2000) Journal of Pathology, 192(3):328-35. doi: 10.1002/1096-9896(2000)9999:99993.0.CO;2-2 Cancer Genome Atlas Research Network, Kandoth C, Schultz N, Cherniack AD, Akbani R, Liu Y, Shen H, Robertson AG, Pashtan I, Shen R, Benz CC, Yau C, Laird PW, Ding L, Zhang W, Mills GB, Kucherlapati R, Mardis ER, Levine DA. Integrated genomic characterization of endometrial carcinoma. (2013) Nature, 497(7447):67-73. doi: 10.1038/nature12113 Committee Opinion No. 631: Endometrial Intraepithelial Neoplasia. (2015) Obstetrics & Gynecology 125(5):p 1272-1278. DOI: 10.1097/01.AOG.0000465189.50026.20 Additional Declarations No competing interests reported. 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First, mismatch repair deficiency (dMMR) is a targetable molecular finding; MMR status renders patients eligible or ineligible for specific cancer therapies. Second, the presence of a dMMR tumor indicates the patient may carry a germline mutation in the genes encoding for one or more of these four proteins, in which case she is diagnosed with Lynch Syndrome, an autosomal dominant inherited disorder. Lynch Syndrome is the most common cause of hereditary colon and endometrial malignancies,\u003csup\u003e2,3\u003c/sup\u003e and portends a lifetime risk of colorectal cancer of 50%-70%, a 40%-60% risk of endometrial cancer, and elevated risk for other malignancies. For these reasons, when endometrial cancer is diagnosed on a tissue specimen, that tissue is also tested for the four MMR proteins MLH1, MSH2, MSH6, and PMS2. \u003csup\u003e4,5\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIt is well established that endometrial hyperplasia, an overgrowth of the normal endometrium, is a premalignant lesion. Complex hyperplasia with atypia is associated with a greater than a 30% risk of development of endometrial cancer, and a 40% risk of already-present concurrent occult endometrial cancer.\u003csup\u003e6,7,8\u003c/sup\u003e It is unknown whether hyperplasia carries similar rates of dMMR as endometrial cancer, but if so, this would have major ramifications for the diagnosis of Lynch Syndrome and cancer prevention strategies for patients and their families. Small studies ranging between 20 and 118 patients have supported the absence of at least 1 MMR protein in hyperplasia samples between 3% and 55% of cases.\u003csup\u003e9,10,11,12\u003c/sup\u003e However, follow-up data on testing for germline mutations and Lynch Syndrome is lacking. At present there is not enough evidence to support testing for dMMR in all hyperplasia specimens.\u003c/p\u003e \u003cp\u003eThe aim of this study was to compare the rate of dMMR in endometrial hyperplasia with the known rate of dMMR in endometrial cancer. If the rates were the same, it would provide a basis for expanding universal MMR testing of endometrial tumors to include testing of endometrial hyperplasia specimens. This study was performed by identifying dMMR in endometrial hyperplasia specimens, calculating the rate of dMMR in endometrial hyperplasia, then comparing it with the known rate of dMMR in endometrial cancers in the literature. It was hypothesized that the rate of dMMR in hyperplasia would be the same as the rate of dMMR in endometrial cancer.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective cohort pilot study was performed. The protocol was reviewed by the WellSpan Health Institutional Review Board and approved on May 8, 2019 (IRB Number 1403922-1).\u003c/p\u003e \u003cp\u003eAppropriate specimens were identified by performing a keyword search of the electronic medical record for \u0026ldquo;hyperplasia\u0026rdquo; on final diagnosis of pathology specimens from 5/1/2014- 6/30/2022. Pathology endometrial tissue blocks labeled with the diagnosis of hyperplasia were identified. For each specimen, pathology review by a single pathologist was performed to confirm the hyperplasia diagnosis. Any specimens with unclear diagnosis were verified by a second pathologist.\u003c/p\u003e \u003cp\u003eFemales aged 18 and older with a specimen of endometrial tissue from biopsy, curettage, or hysterectomy with hyperplasia of any type were included. Women less than 18 years of age or with a known diagnosis of endometrial cancer on previous or subsequent pathology were excluded. Those patients with a final diagnosis of cancer were excluded because of the risk that cancer was already present contemporaneously at the time of the hyperplasia diagnosis and would confound the results.\u003c/p\u003e \u003cp\u003eSample size determination was made based on a desired power of 80% and alpha\u0026thinsp;=\u0026thinsp;0.05. A calculated 1782 cases were required to exclude a difference between the groups, i.e. present of dMMR in hyperplasia specimens was equivalent to that of endometrial cancer cases (25%). Given the resources available, a pilot study of approximately 5% of this population, around 89 samples, was sought.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ewas obtained via telephone. Participants who met criteria were given the option of a follow up phone call with their results. A copy of the consent form was sent to all participants. No compensation was provided.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eChart review was performed for demographic data including age, BMI, race, ethnicity, and personal or family history of endometrial or colon cancer. IHC testing for MLH1, PMS2, MSH2, or MSH 6 was performed and analyzed by a single pathologist. Equivocal results were reviewed with a second pathologist. Women who desired their results were notified of them via phone call. If testing revealed dMMR, those women were counseled by a Gynecologic Oncology fellow and recommended for genetic counseling and testing. Referrals to a licensed genetic counselor for Oncology at the WellSpan institution were placed if the patients were amenable.\u003c/p\u003e \u003cp\u003ePatient characteristics for both normal and abnormal MMR results were analyzed using the Mann-Whitney U test (for continuous variables) and Fisher exact test (for categorical variables). The rate of dMMR was computed in this patient population. A z-test of proportion with a significance of p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001 compared it to the known incidence of dMMR in endometrial cancer from the literature.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe identified 1300 endometrial pathology specimens collected during the study period, and after exclusion, 91 were available for analysis. Patient demographics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Average patient age was 54.2\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;12.8 years, and BMI 40.8\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;10.3 kg/m\u003csup\u003e2\u003c/sup\u003e. By type of hyperplasia, the most common was complex hyperplasia without atypia at 37 cases (40.7%), followed by complex hyperplasia with atypia at 31 cases (34.1%), and simple hyperplasia without atypia with 23 cases (25.3%). There were no cases of simple hyperplasia with atypia (0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient Demographics and Mismatch Repair Protein Expression from Endometrial Hyperplasia Specimens Collected May 1, 2014 until June 30, 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll Patients (N\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMMR Proficient (N\u0026thinsp;=\u0026thinsp;87)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMMR Deficient (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.2 (12.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.9 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e59.3 (11.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.531\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI in kg/m\u003csup\u003e2\u003c/sup\u003e, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40.8 (10.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.6 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.2 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.787\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace-Caucasian, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e89 (97.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (97.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace- Black, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (2.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (2.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity- Hispanic, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity- Non Hispanic, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (96.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (96.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily History of Colon or Endometrial Cancer, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (11.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (10.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (25%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.377\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex Hyperplasia with Atypia, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (34.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (35.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimple with Atypia, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplex Hyperplasia without Atypia, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (40.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (40.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimple without Atypia, N (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (25.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (24.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.264\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eMMR\u0026thinsp;=\u0026thinsp;Mismatch Repair Protein. MMR Deficiency is equivalent to lack of expression of the mismatch repair protein. MMR Proficient indicates expression of the mismatch repair protein. P-value significant\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOverall, 87 patients demonstrated MMR proficiency on immunohistochemical staining of their endometrial tissue, while 4 patients showed MMR deficiency. Per Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, there were no significant differences in the demographics, family histories, or breakdown by type of hyperplasia in the MMR proficient and deficient patients.\u003c/p\u003e \u003cp\u003eWith 4 out of 91 specimens demonstrating dMMR, the rate of dMMR for endometrial hyperplasia in this group of subjects was 4.4%. This was significant different (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) when comparing the rate of dMMR for endometrial adenocarcinoma of 25% (22\u0026ndash;28%) in the literature based on a meta-analysis of over 5,000 women.\u003csup\u003e9\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe 4 specimens with dMMR varied in the specific proteins absent on immunohistochemical staining. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e details the breakdown of proteins absent. As shown, no two endometrial hyperplasia specimens with dMMR showed the same pattern of protein absence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBreakdown of Mismatch Repair Proteins Absent in the Four Deficient Endometrial Hyperplasia Specimens\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMLH1\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eMSH2\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eMSH6\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ePMS2\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecimen 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecimen 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecimen 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecimen 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOnly 1 of the 4 patients with dMMR found on their endometrial hyperplasia specimen underwent germline testing. This patient had formal genetic counseling followed by germline testing using a commercial test for 47 gene mutations, and none were identified.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAnalysis of this cohort revealed a significant difference in the rate of dMMR between endometrial hyperplasia (4.4%) and endometrial cancer (25%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). The exact sample size required was not reached in this pilot study to determine whether we failed to support our hypothesis, that the rates of dMMR in endometrial hyperplasia and carcinoma are equivalent. However, to the best of our knowledge and from the procured data, there is no definitive evidence that exists to support the rates are similar.\u003c/p\u003e \u003cp\u003eEarlier studies examined the possibility of detecting dMMR in endometrial hyperplasia specimens. Currently there is not sufficient evidence for routine testing in precancerous lesions. A handful of small studies have supported the absence of at least 1 MMR protein occurring in hyperplasia samples; these studies have sample sizes ranging from 20 to 118 patients, and demonstrate MMR deficiency in endometrial hyperplasia between 3% and 55%.\u003csup\u003e9, 10, 11, 12\u003c/sup\u003e Our results fall within this range,` with the rate of 4.4% dMMR in hyperplasia. There is biologic plausibility for dMMR rates to be similar between hyperplasia and endometrial cancer\u0026ndash; though this may only apply to a subset of patients who have a germline mutation leading to dMMR. A previous case study of serial tissue samples obtained over time from a Japanese woman with a family history of Lynch Syndrome revealed the loss of MSH2 when she had only a diagnosis of hyperplasia, 7 months prior to her endometrial cancer diagnosis.\u003csup\u003e13\u003c/sup\u003e It is important to note, not all of the above previous studies on dMMR in endometrial hyperplasia reported follow-up germline testing. The very limited data available is conflicting; some studies show a high level of concordance between somatic dMMR in hyperplasia specimens and dMMR present in germline testing, while others suggest less than 1% of patients with somatic dMMR in hyperplasia specimens harbor a germline mutation for dMMR (namely Lynch Syndrome). \u003csup\u003e12, 14\u003c/sup\u003e Our study was not powered to assess germline testing, but the one hyperplasia patient whose specimen had dMMR and underwent germline testing was negative for 47 germline mutations, including Lynch Syndrome.\u003c/p\u003e \u003cp\u003eThe study was strong in utilizing a thoroughly maintained database in the electronic medical record, allowing for comprehensive chart review. There was consistency in the pathologic review of specimens and in clinical follow up for significant results.\u003c/p\u003e \u003cp\u003eWhile the study was intended as a pilot investigation, it was limited by its single-institution design and small sample size. The resources available did not allow for review of all endometrial tissue specimens by multiple pathologists. Therefore unless there was a question of diagnosis, a single pathologist reviewed the slides.\u003c/p\u003e \u003cp\u003eOf note, the original protocol allowed for use of a keyword search for \u0026lsquo;endometrial intraepithelial neoplasia\u0026rsquo; in the electronic medical record. However this verbiage was not utilized by the pathology department within the study time period, consequently this keyword was abandoned. And since the term \u0026lsquo;endometrial intraepithelial neoplasia' is now recommended terminology by the Society for Gynecologic Oncology and the American College of Obstetricians and Gynecologists, over the 1994 World Health Organization schema used in this study, this may render our report less generalizable long-term.\u003csup\u003e17\u003c/sup\u003e Further, this investigation did not focus on other known risk factors for hyperplasia including BMI, age, and ovulatory status; future examination of known risks factors in the setting of endometrial hyperplasia may set a threshold for additional screening.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eClinical/Research Implications\u003c/span\u003e: Although the outcomes of this study do not suggest practice changes based on the diagnosis of hyperplasia, it does create opportunity for further study. The absence of MMR proteins results in genomic instability, with the insertion or deletion of noncoding single nucleotide and dinucleotide repeats called microsatellites. The finding of these altered microsatellites is termed microsatellite instability which is a marker of Lynch Syndrome associated tumors.\u003csup\u003e15\u003c/sup\u003e While immunohistochemical staining for MMR proteins and polymerase chain reaction testing for microsatellite instability are typically correlated, the findings of this study could be either verified or expanded upon through testing for microsatellite instability.\u003c/p\u003e \u003cp\u003eBased on The Cancer Genome Atlas study on endometrial cancer, the outlook on the pathophysiology of this disease is changing. The new genomic categories of POLE ultra-mutated, microsatellite instability hypermutated, copy number low, and copy number high for endometrial cancer prompt follow up questions related to this current study.\u003csup\u003e16\u003c/sup\u003e While dMMR is typically associated with microsatellite instability, what does this mean for those cancers with precursor lesions of endometrial hyperplasia? Is the loss of expression of one of the four MMR proteins a step along the pathway to the microsatellite instability hypermutated subtype of endometrial cancer\u0026ndash; and if so, is that only not reflected here because of the exclusion of patients with a final diagnosis of endometrial cancer? Further investigation into the genomic mutations of endometrial cancer precursor lesions is warranted to better understand the treatment and prevention of this disease.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, because the rate of dMMR between endometrial hyperplasia was significantly less than that of dMMR known in endometrial carcinoma, the findings of this study do not support universal screening for dMMR on endometrial hyperplasia specimens, compared to Lynch Syndrome screening in the setting of known endometrial cancer for the purpose of targeted therapy. However, this study does highlight the need for further exploration of the genomics of endometrial cancer precursor lesions to more effectively prevent and treat endometrial cancer in the future.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConflict of Interest Statement\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eContribution to Authorship\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eKathryn Kennedy M.D.: conceived and designed the analysis, data collection and result interpretation, manuscript preparation\u003c/li\u003e\n \u003cli\u003eEav Lim D.O. FACOOG: principal investigator, conceived and designed the analysis, result interpretation, manuscript preparation and revision\u003c/li\u003e\n \u003cli\u003eJennifer Gaertner-Otto D.O.: manuscript preparation and revision\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements / Disclosures\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGrant funding for this research was\u0026nbsp;provided by:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe George L Laverty Foundation Trustee U/W Grant, The incidence of Lynch Syndrome in endometrial hyperplasia.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eVerbie C Emig Trust Grant, Frequency of endometrial cancer precursor associated with Lynch Syndrome. March 2019\u003c/li\u003e\n \u003cli\u003eThe Lake Erie College of Osteopathic Medicine. March 2019\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLorenzi, M., Amonkar, M., Zhang, J. et al. Epidemiology of Microsatellite Instability High (MSI-H) and Deficient Mismatch Repair (dMMR) in Solid Tumors: A Structured Literature Review. (2020) Journal of Oncology. Article ID 1807929. https://doi.org/10.1155/2020/1807929\u003c/li\u003e\n\u003cli\u003eSteinke, V., Engel, C., Buttner, R., Schackert, H. K., Schmiegel, W. H., \u0026amp; Propping, P. Hereditary Nonpolyposis Colorectal Cancer (HNPCC)/Lynch Syndrome. (2013) Dtscg Arztebl Int, 110(3), 32-38. doi: 10.3238/arztebl.2013.0032\u003c/li\u003e\n\u003cli\u003eRyan, N. A., Blake, D., Cabera-Dandy, M., Glaire, M. A., Evans, G., \u0026amp; Crosbie, E. J. The Prevalence of Lynch Syndrome in women with endometrial cancer: A systematic review Protocol. (2018) Systematic Reviews;7(1):121. doi: 10.1186/s13643-018-0792-8\u003c/li\u003e\n\u003cli\u003eHuang , M., Djordjevic, B., Yates , M. S., Urbauer, D., Sun, C., Burzawa, J., et al. Molecular pathogenesis of endometrial cancers in Lynch Syndrome. (2013) Cancer, 119(16), 3027-3033. doi: 10.1002/cncr.28152.\u003c/li\u003e\n\u003cli\u003eSehgal, R., Sheahan, K., O\u0026apos;connell, P. R., Hanly, A. M., Martin, S. T., \u0026amp; Winter, D. C. (2014). Lynch Syndrome: An Updated Review. (2014) Genes 5(3):497-507. doi: 10.3390/genes5030497\u003c/li\u003e\n\u003cli\u003eKurman, R. J., Kaminski, P. f., \u0026amp; Norris, H. J. The Behavior of Endometrial Hyperplasia, A long-term study of \u0026quot;untreated\u0026quot; hyperplasia in 170 patients. (1985) Cancer, 56(2):403-12. doi: 10.1002/1097-0142(19850715)56:2\u0026lt;403::aid-cncr2820560233\u0026gt;3.0.co;2-x. \u003c/li\u003e\n\u003cli\u003eMutter GL, Kauderer J, Baak JP, Alberts D. Biopsy histomorphometry predicts uterine myoinvasion by endometrial carcinoma: a Gynecologic Oncology Group study. Gynecologic Oncology Group. (2008) Human Pathology, 39(6):866-74. doi: 10.1016/j.humpath.2007.09.023.\u003c/li\u003e\n\u003cli\u003eTrimble CL, Kauderer J, Zaino R, Silverberg S, Lim PC, Burke JJ2nd, et al. Concurrent endometrial carcinoma in women with a biopsy diagnosis of atypical endometrial hyperplasia: a Gynecologic Oncology Group study. (2006) Cancer; 106(4):812-9. doi: 10.1002/cncr.21650\u003c/li\u003e\n\u003cli\u003eLucas, E., Chen, H., Molberg, K., Castrillon, D. H., Rivera Colon, G., Li, l., at al. Mismatch repair protein expression in endometrioid intraepithelial neoplasia / atypical hyperplasia: Should we screen for Lynch Syndrome in precancerous lesions? (2018) International Journal of Gynecological Pathology, 38(6): 533-542.\u003c/li\u003e\n\u003cli\u003eHan, S., \u0026amp; Kim, M. Clinical Significance of mismatch repair genes immunohistochemical expression of complex endometrial hyperplasia. (2015) Obstetrics and Gynecology Science, 58(2), 106-111. doi: 10.5468/ogs.2015.58.2.106. \u003c/li\u003e\n\u003cli\u003eNiskakoski, A., Pasanen, A., Lassus, H., Renkonen-Sinisalo, L., Kaur, S., Mecklin, J.-P., et al. Molecular changes preceding endometrial and ovarian cancer: a study of consecutive endometrial specimens from Lynch Syndrome surveillance. (2018) Modern Pathology, 31(8):1291-1301. doi: 10.1038/s41379-018-0044-4\u003c/li\u003e\n\u003cli\u003eVierkoetter, K. R., Kagami, L. A., Ahn, H., Shimzu, D. M., \u0026amp; Terada, K. Y. Loss of Mismatch Repair Protein expression in unselected endometrial Adenocarcinoma Precursor Lesions. (2016) International Journal of Gynecological Cancer, 26(2), 228-232. doi: 10.1097/IGC.0000000000000606\u003c/li\u003e\n\u003cli\u003eIchikawa, Y., Tsunoda, H., Takano, K., Oki, A., \u0026amp; Yoshikawa, H. 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DOI: 10.1097/01.AOG.0000465189.50026.20\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"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":"Mismatch repair deficiency, dMMR, Lynch Syndrome, Hereditary endometrial cancer","lastPublishedDoi":"10.21203/rs.3.rs-3964746/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3964746/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To identify the rate of mismatch repair deficiency in women with endometrial hyperplasia compared with the rate in endometrial cancer.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients and Methods\u003c/strong\u003e: A retrospective cohort pilot study was conducted to identify the frequency of mismatch repair deficiency in endometrial hyperplasia specimens, and compare to the known rate in endometrial cancer. A keyword search of the medical record at a single institution was performed to identify 1300 endometrial tissue blocks either from biopsy, curettage, or hysterectomy. After exclusion, cohort of 91 women with endometrial hyperplasia were included for analysis. Patient characteristics for both those with normal and abnormal MMR results were analyzed using the Mann-Whitney U test and Fisher exact test. Immunohistochemical staining was performed to test for mismatch repair deficiency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Among the 91 women with known endometrial hyperplasia specimens who met inclusion criteria, 4 specimens exhibited mismatch repair deficiency. The observed rate of mismatch repair deficiency in hyperplasia (4.4%), was found to be significantly less than that of mismatch repair deficiency seen in endometrial cancer (25%, p\u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Based on the data, dMMR is not identified at a similar rate in endometrial hyperplasia compared to endometrial cancer. Currently there is no rationale to recommend immunohistochemical staining for mismatch repair deficiency on hyperplasia specimens, and further investigation is recommended to advance screening guidelines for Lynch syndrome.\u003c/p\u003e","manuscriptTitle":"Frequency of Endometrial Cancer Precursors Associated with Lynch Syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-21 11:38:26","doi":"10.21203/rs.3.rs-3964746/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":"7ac26d15-8c42-4c88-b86c-90fb411f594b","owner":[],"postedDate":"February 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-06T12:28:39+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-21 11:38:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3964746","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3964746","identity":"rs-3964746","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}