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Durable response in a woman with recurrent low-grade endometrioid endometrial cancer and a germline BRCA2 mutation treated with a PARP inhibitor

      Abstract

      A 42-year-old woman with a germline BRCA2 mutation and recurrent low-grade endometrioid endometrial adenocarcinoma experienced clinical and radiographic response to the poly (ADP ribose) polymerase (PARP) inhibitor, olaparib. Molecular and treatment factors are discussed.

      1. Presentation of case

      A 42-year-old G4P3 with a body mass index of 43 kg/m2 presented with abnormal vaginal bleeding and underwent an endometrial biopsy which revealed grade 1 endometrioid adenocarcinoma of the endometrium. She underwent a total laparoscopic hysterectomy (TLH) and final pathology revealed a stage IA (T1A Nx M0) grade 1 endometrioid endometrial adenocarcinoma. The tumor measured 3.1 cm and did not invade the myometrium. There was no lymphovascular space invasion. Immunohistochemistry revealed intact MMR expression. She received no further treatment.
      The patient's genetic history is notable for a germline BRCA2 mutation [c.5946delT (p.S1982Rfs*22), exon 11 corresponding to a 6174delT mutation]; she underwent genetic testing after her mother was diagnosed with breast cancer at the age of 45. The patient previously underwent a prophylactic bilateral salpingo-oopherectomy (BSO) at the age of 39. She had declined prophylactic breast surgery at that time and started treatment with tamoxifen. She was taking tamoxifen for 3 years at the time of her endometrial cancer diagnosis.
      Three years after her TLH and diagnosis of endometrial cancer, she developed vaginal bleeding, a 1 cm lesion on the vaginal apex was biopsied, and pathology confirmed endometrioid adenocarcinoma consistent with her prior endometrial cancer. Pelvic magnetic resonance imaging (MRI) revealed peripheral enhancement of the vaginal apex measuring 2.7 × 1.6 cm on the right and 2.7 × 2.0 cm on the left. She was treated with external beam radiation (4500cGY delivered to the pelvis in 25 fractions). Repeat pelvic MRI at the end of radiation treatment revealed an interval decrease of these lesions to 2.3 × 1.7 cm and 2.1 × 1.7 cm, respectively. The vaginal cuff was too deep to be adequately treated with interstitial brachytherapy, and therefore she was treated with stereotactic radiotherapy over 5 fractions with 600 cGy per fraction. After radiation therapy, she was followed closely with MRIs every 3–6 months.
      Two years after her radiation treatment and five years after her initial diagnosis, a pelvic MRI revealed a 2.5 × 1.4 cm enhancing left pelvic lesion, and a subsequent positron emission computed tomography (PET-CT) scan revealed fluorodeoxyglucose (FDG) avidity in this area medial to the external iliac vessels. Given the isolated nature of her recurrence and her prior history of radiation therapy, she returned to the operating room for resection of the mass. At the time of surgery, the mass was noted to be invasive into the pelvic sidewall, the parametrial tissue and the base of the bladder; complete resection was not achievable. Pelvic exenteration was considered, however the extent of the pelvic sidewall disease prohibited achieving negative margins. She then received 5 cycles of carboplatin and paclitaxel. Following chemotherapy a PET-CT showed interval decrease of a FDG-avid left pelvic nodule. During treatment, she also had targeted next-generation sequencing testing performed (using our in-house assay) [
      • Sholl L.M.
      • et al.
      Institutional implementation of clinical tumor profiling on an unselected cancer population.
      ,
      • Wagle N.
      • et al.
      High-throughput detection of actionable genomic alterations in clinical tumor samples by targeted, massively parallel sequencing.
      ] which revealed both the known germline BRCA2 mutation and a different somatic frameshift BRCA2 mutation [c.7639delA (p.K2547Nfs*4)] [
      • Garcia E.P.
      • et al.
      Validation of OncoPanel: a targeted next-generation sequencing assay for the detection of somatic variants in cancer.
      ]. She was started on anastrozole for maintenance therapy following a partial response to chemotherapy.
      She continued with routine surveillance until an MRI scan 14 months after completing chemotherapy revealed an enlarging left pelvic sidewall mass which involved the sigmoid colon, left lateral bladder wall, and left external iliac vein measuring 4.0 × 2.5 cm. New lesions were present on the left lateral vagina with extension to the base of the bladder. At this point anastrozole was discontinued. Given her partial response to prior platinum-based chemotherapy and that the combination of platinum and gemcitabine has shown activity in recurrent endometrial cancer [
      • Smith J.A.
      • et al.
      Determination of the mechanism of gemcitabine modulation of cisplatin drug resistance in panel of human endometrial cancer cell lines.
      ,
      • Brown J.
      • et al.
      Combination of gemcitabine and cisplatin is highly active in women with endometrial carcinoma: results of a prospective phase 2 trial.
      ], she was treated with carboplatin and gemcitabine. Following her third cycle, pelvic MRI revealed essentially stable disease with only slight progression of the left adnexal mass to 5.6 × 3.9 cm.(Fig. 1) She received a fourth cycle of gemcitabine and carboplatin but developed an allergy to carboplatin.
      Fig. 1
      Fig. 1Pelvic MRI prior to treatment with olaparib.
      Following the third cycle of gemcitabine and carboplatin, pelvic MRI revealed slight progression of the left adnexal mass to 5.6 × 3.9 cm.
      Given her germline and somatic BRCA2 mutations, the team discussed the potential efficacy of the poly (ADP-ribose) (PARP) inhibitor, olaparib. Once approved by her insurance company, she initiated the Food and Drug Administration (FDA) recommended dose of 300 mg PO BID and was followed closely. A pelvic MRI 10 months after olaparib initiation demonstrated a decrease in adnexal mass now measuring 2.2 × 1.5 cm as compared to prior study. (Fig. 2) She has since continued olaparib with close clinical follow-up every 2 months, having completed 15+ months of olaparib with stable disease in her most recent PET/CT and MRI.
      Fig. 2
      Fig. 2Pelvic MRI following 10 months of treatment with olaparib.
      Pelvic MRI 10 months after olaparib initiation demonstrated decrease in adnexal mass now measuring 2.2 × 1.5 cm as compared to prior study.

      2. Pathology of endometrial cancer

      Gross examination of the initial hysterectomy specimen revealed a 3.1 cm polypoid lesion in the posterior endometrium. Microscopic examination showed a tumor partially involving an endometrial polyp. Although the endomyometrial junction was irregular, there was no myometrial invasion (Fig. 3A ). On higher power, the tumor was composed of back-to-back glands with columnar, stratified nuclei (Fig. 3B). The nuclei were hyperchromatic, slightly enlarged, and had preserved polarity. There was a background of endometrial intraepithelial neoplasia (EIN, or atypical hyperplasia). These pathologic features are diagnostic of endometrial endometrioid carcinoma, grade 1. There was no lymphovascular space invasion. Immunohistochemical staining for mismatch repair proteins MLH1, MSH2, MSH6, and PMS2 showed positive (intact) nuclear staining in tumor cells. A biopsy of the vaginal apex three years after the patient's hysterectomy showed adenocarcinoma, which was morphologically similar to the previous endometrial endometrioid adenocarcinoma.
      Fig. 3
      Fig. 3(A) The endomyometrial junction is irregular, but there is no myometrial invasion of the adenocarcinoma. (B) Higher power shows back-to-back glands composed of stratified, columnar nuclei with low-grade cytologic atypia.
      The precursor lesion of endometrioid carcinoma is endometrial intraepithelial neoplasia (EIN) or atypical hyperplasia, which may be identified adjacent to a carcinoma. At most centers, immunohistochemistry for mismatch repair proteins is performed reflexively on all endometrial carcinomas to screen for Lynch syndrome, the most common cause of inherited endometrial cancer [
      • Mills A.M.
      • et al.
      Lynch syndrome screening should be considered for all patients with newly diagnosed endometrial cancer.
      ]. In ovarian high-grade serous carcinoma, there are morphologic features including Solid, pseudoEndometrioid, and Transitional (so-called SET) patterns which have been associated with germline and somatic abnormalities in BRCA1 and BRCA2 [
      • Soslow R.A.
      • et al.
      Morphologic patterns associated with BRCA1 and BRCA2 genotype in ovarian carcinoma.
      ]. However, there are no known morphologic correlates of BRCA1 and BRCA2 mutations in endometrial carcinoma.
      Endometrial biopsies in patients taking tamoxifen most commonly show inactive/atrophic endometrium [
      • Deligdisch L.
      • et al.
      Endometrial histopathology in 700 patients treated with tamoxifen for breast cancer.
      ]. However, tamoxifen use is associated with a variety of endometrial pathologies, including polyps, hyperplasia, and rarely malignancy [
      • Deligdisch L.
      • et al.
      Endometrial histopathology in 700 patients treated with tamoxifen for breast cancer.
      ]. Some studies have suggested that tamoxifen-associated endometrial carcinomas present at a higher stage and are more likely to be of high-risk histology (carcinosarcoma, grade 3 endometrioid, serous, and clear cell) compared to those which occur in women who have never used tamoxifen [
      • Bland A.E.
      • et al.
      Relationship between tamoxifen use and high risk endometrial cancer histologic types.
      ]. However, there are no specific histopathologic features which suggest that a given tumor may have been caused by tamoxifen use.

      3. Phenotype of endometrial cancer in BRCA mutation carriers

      The risk of endometrial cancer among BRCA carriers remains an area of controversy. The risks may be different between BRCA 1 and 2 carriers. A large cohort study found that women with BRCA1 mutations had an increased rate of uterine cancer as compared to expected population cancer rates while BRCA2 patients in this cohort did not have an elevated rate of uterine cancer. [
      ] [
      • Thompson D.
      • Easton D.F.
      Cancer incidence in BRCA1 mutation carriers.
      ] Although BRCA1 carriers tend to develop ovarian and breast cancers earlier than BRCA2 carriers (approximately 8 and 4 years earlier respectively), no data support that such trend exists for endometrial cancer. [
      • Chen S.
      • Parmigiani G.
      Meta-analysis of BRCA1 and BRCA2 penetrance.
      ] There is evidence that patients with a BRCA gene mutation may be at a greater risk of developing papillary serous endometrial cancer (UPSC). A study of 27 patients with UPSC found that 4(20%) of the patients had a germline BRCA1 mutation, suggesting that UPSC may be a manifestation of the BRCA mutation syndrome [
      • Lavie O.
      • et al.
      BRCA germline mutations in Jewish women with uterine serous papillary carcinoma.
      ]. In a pathologic study of 27 cases with uterine serous carcinoma, three tumors exhibited loss of BRCA1 expression by immunohistochemistry; two of these had a known germline mutation in BRCA1 suggesting that in these cases there was loss of heterozygosity leading to complete loss of expression of BRCA1 protein [
      • Hecht J.L.
      • et al.
      Immunohistochemical loss of BRCA1 protein in uterine serous carcinoma.
      ]. However, another study of 56 UPSC patients found that none of patients exhibited BRCA mutations based on blood specimen testing for four common mutations [
      • Goshen R.
      • et al.
      Is uterine papillary serous adenocarcinoma a manifestation of the hereditary breast-ovarian cancer syndrome?.
      ]. Additionally, a survey-based study of 154 women who underwent a risk-reducing salpingo-oopherectomy found that only 4 patients required subsequent hysterectomy and none of them for malignancy [
      • Villella J.A.
      • et al.
      Role of prophylactic hysterectomy in patients at high risk for hereditary cancers.
      ]. A recent multi-institutional prospective study by Shu et al. of over 1000 BRCA 1 and 2 carriers found 8 uterine cancers as compared to 4.3 cases expected. Although the overall risk of uterine cancer was not increased, there were five cases of UPSC observed, 4 of which were in BRCA1 women, which significantly exceeded the expected rate among BRCA1 women (O:E ratio 22.2, p < 0.001) [
      • Shu C.A.
      • et al.
      Uterine cancer after risk-reducing salpingo-oophorectomy without hysterectomy in women with BRCA mutations.
      ]. The authors suggested that the potential risks and benefits of hysterectomy should be discussed at the time of risk-reducing salpingo-oopherectomy in women with an underlying germline BRCA1 mutation, however this remains a controversial practice given the small number of patients involved in these studies.
      Beyond potential differences in histology, there is also evidence that patients with germline BRCA mutations and endometrial cancer may have an improved prognosis as compared to endometrial cancer patients without BRCA mutations. A population database study of germline BRCA mutation carriers identified 3 women with BRCA1 mutations who presented with FIGO stage IVB endometrial cancer (2 with papillary serous carcinoma and one with sarcomatoid carcinoma) who were alive without recurrence of disease during a follow -up period of 3.3–12.6 years [
      • Kwon J.S.
      • et al.
      Prolonged survival among women with BRCA germline mutations and advanced endometrial cancer: a case series.
      ].

      4. Tamoxifen in BRCA mutation carriers who have an intact uterus and retained breast tissue

      Tamoxifen is often used as chemoprevention in patients with BRCA mutations who have retained breast tissue or as adjuvant treatment of breast cancer since it has an anti-estrogen effect on breast tissue at the estrogen receptor. [
      • Reimers L.L.
      • et al.
      Breast cancer chemoprevention among high-risk women and those with ductal carcinoma in situ.
      ] However, not all BRCA patients derive equal benefit from tamoxifen. BRCA1 patients tend to develop tumors that lack estrogen receptors while BRCA2 patients more often express estrogen receptors [
      • Loman N.
      • et al.
      Steroid receptors in hereditary breast carcinomas associated with BRCA1 or BRCA2 mutations or unknown susceptibility genes.
      ]. The Breast Cancer Prevention Trial (BCPT) was a randomized, double-blind study of over 13,000 women aimed at addressing whether tamoxifen use among high-risk patients altered the risk of invasive breast cancer. In this trial, tamoxifen was found to reduce the risk of invasive breast cancer [risk ratio(RR) = 0.51]. [
      • Fisher B.
      • et al.
      Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study.
      ] Follow-up genotyping was undertaken for this population and suggested that tamoxifen reduced breast cancer incidence among BRCA2 carriers by 62% but did not affect incidence among women with BRCA1 mutations [
      • King M.C.
      • et al.
      Tamoxifen and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial.
      ]. This patient did carry a known BRCA2 mutation and initiated tamoxifen prophylaxis following her prophylactic BSO in the setting of retaining her breasts.
      Tamoxifen acts as an anti-estrogen in breast tissue but acts as a partial agonist on the endometrium. The link between tamoxifen use and endometrial cancer, especially among patients harboring BRCA mutations, remains controversial. Several pre-clinical and clinical studies have suggested a potential increased risk of endometrial adenocarcinoma among tamoxifen users [
      • Wen J.
      • et al.
      Decreased BRCA1 confers tamoxifen resistance in breast cancer cells by altering estrogen receptor-coregulator interactions.
      ,
      • Davies C.
      • et al.
      Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial.
      ,
      • Sismondi P.
      • et al.
      Tamoxifen and endometrial cancer.
      ,
      • Bissett D.
      • Davis J.A.
      • George W.D.
      Gynaecological monitoring during tamoxifen therapy.
      ]; in 2004 a black box warning was issued by the FDA about the risk of uterine malignancies including uterine cancer and sarcoma associated with use of tamoxifen for chemoprevention. A case-control questionnaire-based study of over 14,000 BRCA carriers with 83 cases of endometrial cancer found an adjusted odds ratio for endometrial cancer associated with history of tamoxifen use of 3.50 (05% CI 1.51–8.10, p = 0.003) [
      • Segev Y.
      • et al.
      Risk factors for endometrial cancer among women with a BRCA1 or BRCA2 mutation: a case control study.
      ]. Retrospective reviews have suggested a link between tamoxifen use and high-risk histologies such as papillary serous endometrial carcinoma. [
      • Bland A.E.
      • et al.
      Relationship between tamoxifen use and high risk endometrial cancer histologic types.
      ,
      • Brinton L.A.
      • et al.
      Etiologic heterogeneity in endometrial cancer: evidence from a Gynecologic Oncology Group trial.
      ] In the Shu et al. study, 3 of the 5 patients with uterine papillary serous carcinoma had prior exposure to tamoxifen [
      • Shu C.A.
      • et al.
      Uterine cancer after risk-reducing salpingo-oophorectomy without hysterectomy in women with BRCA mutations.
      ]. However other studies have not supported this hypothesis [
      • Barakat R.R.
      • et al.
      Tamoxifen use in breast cancer patients who subsequently develop corpus cancer is not associated with a higher incidence of adverse histologic features.
      ]. Current recommendations for women on tamoxifen suggest routine gynecologic care and deny a role for pelvic ultrasound or endometrial biopsy for asymptomatic women on tamoxifen [
      • ACOG committee opinion
      No. 336: Tamoxifen and uterine cancer.
      ].
      In the case of our patient, she had a BRCA2 and not a BRCA1 mutation and developed a recurrent low-grade endometrioid adenocarcinoma, not a uterine papillary serous carcinoma. Her tumor is not necessarily the expected phenotype of a BRCA carrier with endometrial cancer; however her germline BRCA2 mutation, as well as the results of her targeted panel next generation sequencing, offered multiple options for therapy.

      5. Molecular events in endometrial cancer

      In addition to the germline testing that revealed the founder BRCA2 (c.5946delT) (p.S1982Rfs*22) mutation, the patient's tumor was subjected to targeted panel next-generation sequencing performed in our institution [
      • Wagle N.
      • et al.
      High-throughput detection of actionable genomic alterations in clinical tumor samples by targeted, massively parallel sequencing.
      ]. Similar targeted NGS assays are performed in other academic cancer institutions in the US, and there are a number of commercial targeted NGS assays that are currently available. Of note, as of March 16, 2018, the Centers for Medicare & Medicaid Services (CMS) covers diagnostic laboratory tests using Next Generation Sequencing (NGS) for patients with advanced cancer (i.e., recurrent, metastatic, relapsed, refractory, or stages III or IV cancer) to be used as companion diagnostics. The OncoPanel targeted sequencing test developed at the Dana-Farber Cancer Institute consists of hybrid capture sequencing of formalin-fixed tumor samples covering exons of over 300 cancer-associated genes, plus intronic regions of genes involved in somatic rearrangements [
      • Sholl L.M.
      • et al.
      Institutional implementation of clinical tumor profiling on an unselected cancer population.
      ,
      • Wagle N.
      • et al.
      High-throughput detection of actionable genomic alterations in clinical tumor samples by targeted, massively parallel sequencing.
      ,
      • Garcia E.P.
      • et al.
      Validation of OncoPanel: a targeted next-generation sequencing assay for the detection of somatic variants in cancer.
      ]. The results of OncoPanel are reviewed by molecular pathologists and report mutations, insertions/deletions, copy number variations, and structural variants in the targeted genes. This patient's tumor OncoPanel revealed the germline founder BRCA2 mutation (c.5946delT), but also revealed another BRCA2 mutation, a somatic frameshift BRCA2 mutation [c.7639delA (p.K2547Nfs*4)] which is likely deleterious.(Fig. 4) This mutation essentially deleted almost the entire C-terminal region (amino acids 2459–3190) of BRCA2 which contains the DNA-binding-domain (DBD) that represents the most conserved portion of BRCA2 across metazoans, plants, and fungal orthologs. [
      • Holloman W.K.
      Unraveling the mechanism of BRCA2 in homologous recombination.
      ] The C-terminal region also contains the nuclear localization signal (NLS), a helical domain (HD), and 3 oligonucleotide binding (OB) folds that are ssDNA-binding modules [
      • Guidugli L.
      • et al.
      Functional assays for analysis of variants of uncertain significance in BRCA2.
      ]. Due to the limitations of next generation sequencing, it is not possible to ascertain whether the variants involve the same allele. The Oncopanel performs paired end sequencing, sequencing 100 base pairs of either end of an approximately 300 bp fragmented section of DNA. The 2 BRCA2 variants are on 2 different exons which are thousands of base pairs apart. Since intervening introns are not captured, there is no contiguous stretch of DNA between the exons which could be used to build a longer sequence in order to ascertain if these variants are indeed on the same allele. While we cannot be certain that there is biallelic loss of BRCA2, the fact that the patient responded so well to PARPi therapy suggests that there indeed was.
      BRCA1 and BRCA2 mutations are commonly associated with biallelic inactivation of BRCA1 and BRCA2, both in uterine and ovarian cancers. In the TCGA ovarian cancer dataset, 81% of BRCA1 mutations and 72% of BRCA2 mutations were accompanied by heterozygous loss of BRCA1 and BRCA2 respectively, indicating that both alleles are inactivated. Recent data using advanced next generation sequencing suggests that 100% of ovarian high-grade serous carcinomas in patients with germline BRCA mutations are due to biallelic inactivation while >80% of somatic BRCA mutations have biallelic inactivation [
      • Dougherty B.A.
      • et al.
      Biological and clinical evidence for somatic mutations in BRCA1 and BRCA2 as predictive markers for olaparib response in high-grade serous ovarian cancers in the maintenance setting.
      ]. A similar phenomenon has been reported in uterine cancer [
      • Lavie O.
      • et al.
      BRCA germline mutations in Jewish women with uterine serous papillary carcinoma.
      ,
      • Hecht J.L.
      • et al.
      Immunohistochemical loss of BRCA1 protein in uterine serous carcinoma.
      ]. It is important to underscore that the absence of heterozygosity loss or of biallelic BRCA mutations does not mean that biallelic inactivation of BRCA does not exist; other mechanisms of BRCA silencing, such as epigenetic silencing via promoter hypermethylation which is not captured by NGS may still exist. Therefore, offering a PARP inhibitor would still have been prudent if the second BRCA2 mutation was not found; however, the presence of two BRCA2 mutations in this tumor may explain the excellent and durable response to olaparib as the result of biallelic inactivation of BRCA2. In this regard, new data among ovarian cancer patients has suggested that patients with biallelic inactivation of BRCA may have a more durable response rate to PARP inhibitors than patients with monoallelic inactivation [
      • Lheureux S.
      • et al.
      Somatic BRCA1/2 recovery as a resistance mechanism after exceptional response to poly (ADP-ribose) polymerase inhibition.
      ].
      Oncopanel also revealed a NRAS mutation (NRAS G12 V) which is present at a mutational hotspot of NRAS.(Fig. 4) Although NRAS mutations in endometrial adenocarcinoma are relatively rare, KRAS mutations are common, and activation of the RAS-MAPK pathway likely contributes to tumorigenesis [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ], especially in low-grade endometrioid tumors.
      Endometrial cancers are classified into two major histological types [
      • Bokhman J.V.
      Two pathogenetic types of endometrial carcinoma.
      ]. Type I endometrial tumors exhibit endometrioid histology and commonly express estrogen (ER) and progesterone (PR) receptors while type II endometrial cancers have non-endometrioid histology (mainly uterine papillary serous cancers) and are associated with inferior prognosis, with an overall survival rate of 55% at five years [
      • Morice P.
      • et al.
      Endometrial cancer.
      ]. Type II endometrial cancers are not associated with estrogen exposure, are frequently ER/PR negative, and do not respond to endocrine therapy. Type I endometrial tumors routinely exhibit PI3K pathway alterations (mostly PTEN and PIK3CA mutations) [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ,
      • Weigelt B.
      • Banerjee S.
      Molecular targets and targeted therapeutics in endometrial cancer.
      ]. Notably, in The Cancer Genome Atlas (TCGA) dataset, 92% of endometrioid ECs harbored PI3K pathway mutations suggesting the potential for targeted therapy with PI3K pathway inhibitors, although PI3K pathway inhibitor monotherapy has shown minimal activity in this disease [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ]. Other commonly mutated genes in type I tumors include FGFR2, ARID1A, CTNNB1, PIK3CA, PIK3R1 and KRAS. While microsatellite instability (MSI) is also frequently found in approximately one-third of type I tumors, it is infrequent in type II tumors [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ]. Furthermore, 7% of endometrioid endometrial cancers in the TCGA dataset were ultramutated due to mutations in the exonuclease domain of POLE, and were associated with an improved progression-free survival [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ]. Currently, based on the TCGA findings, endometrial cancers are molecularly classified into four groups based on nucleotide substitution frequencies and patterns, MSI status, and copy-number changes; these four groups include POLE ultramutated, microsatellite instability hypermutated, copy-number low, and copy-number high groups.
      Contrary to type I endometrial cancers, type II uterine serous carcinomas exhibit significantly higher rates of mutations in TP53, reportedly in >90% of cases [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ]. Approximately half (i.e. 48%) of serous carcinomas harbor PIK3CA mutations and/or amplifications of PIK3CA. ERBB2 amplification and Her2 overexpression have been reported in 17–28% and 42% of serous carcinomas respectively. Furthermore, mutations or deletions of FBXW7 and amplification of CCNE1 (a known substrate for FBXW7) occur frequently in endometrial serous cancers. Finally, PPP2R1A mutations have been reported in as high as 50% of the uterine serous tumors [
      • Kandoth C.
      • et al.
      Integrated genomic characterization of endometrial carcinoma.
      ].
      In this patient, the findings of the targeted panel next generation sequencing were consistent with molecular events seen in the pathologic diagnosis of low-grade endometrioid endometrial cancer (type I cancer); there was no TP53 mutation, while the NRAS mutation is consistent with the common activation of the RAS-MAPK pathway in type I tumors. There was a single copy deletion of 10q23.31 involving exon 6 and intron 6 of PTEN, predicted to lead to loss of function and leading to possible activation of the PI3K pathway. However, it is unlikely that this alteration explains the excellent response to olaparib.
      Finally, it is important to underscore that the low grade endometrioid histology encountered in this tumor is not considered typical of BRCA1/2-mutated endometrial cancers (which are commonly associated with high grade serous histology). On the contrary, the low-grade endometrioid histology suggests that this patient's endometrial cancer may have been more likely related to her obesity and prior tamoxifen exposure.

      6. Treatment options for this patient

      There have been several randomized studies performed to ascertain the optimal chemotherapy in patients with recurrent or metastatic endometrial cancer. GOG-0209 was a randomized phase III trial which compared doxorubicin, paclitaxel, and cisplatin (TAP) to paclitaxel and carboplatin (CT). At the reported interim analysis, the median OS was 32 months vs. 38 months in patients treated with CT vs. TAP (not significant, HR, 1.01). CT was also better tolerated than TAP and was established as the standard of care chemotherapy regimen for the treatment of recurrent and metastatic endometrial cancer [
      • Miller D.
      • F. V.
      • Flemin G.
      • Mannel R.
      • Cohn D.
      • Matsumoto T.
      • Tewari K.
      • DiSilvestro P.
      • Pearl M.
      • Zaino R.
      Randomized phase III noninferiority trial of first line chemotherapy for metastatic or recurrent endometrial carcinoma: A Gynecologic Oncology Group study.
      ]. However, once this initial therapy has been delivered, there are no established standard options in the second line setting. Various cytotoxic agents have been used including paclitaxel, docetaxel, liposomal doxorubicin, topotecan, oxaliplatin, ixabepilone, pemetrexed, gemcitabine with response rates of 4–27%, with only paclitaxel having a response rate > 20% [
      • Fleming G.F.
      Second-line therapy for endometrial cancer: the need for better options.
      ].
      Besides chemotherapy, hormonal/endocrine therapies, such as progestins, antiestrogens and estrogen modulators, when given to chemotherapy-naïve patients, can result in response rates of up to 33%, but responses are of short duration (median PFS of approximately 3 months) [
      • Thigpen T.
      • et al.
      Tamoxifen in the treatment of advanced or recurrent endometrial carcinoma: a Gynecologic Oncology Group study.
      ,
      • Thigpen J.T.
      • et al.
      Oral medroxyprogesterone acetate in the treatment of advanced or recurrent endometrial carcinoma: a dose-response study by the Gynecologic Oncology Group.
      ,
      • Lentz S.S.
      • et al.
      High-dose megestrol acetate in advanced or recurrent endometrial carcinoma: a Gynecologic Oncology Group Study.
      ]. However, some patients may derive durable benefit for extended periods of time, occasionally exceeding two years [
      • Whitney C.W.
      • et al.
      Phase II study of medroxyprogesterone acetate plus tamoxifen in advanced endometrial carcinoma: a Gynecologic Oncology Group study.
      ]. Positive expression of ER and PR, which is most common in low-grade tumors, has been associated with response to endocrine treatment, though the data are not consistent [
      • Markman M.
      Hormonal therapy of endometrial cancer.
      ,
      • Singh M.
      • et al.
      Relationship of estrogen and progesterone receptors to clinical outcome in metastatic endometrial carcinoma: a Gynecologic Oncology Group Study.
      ]. ER/PR testing was not performed for our patients because tissue was not available; furthermore, it is not our standard practice to check ER/PR by IHC for grade 1 endometrioid tumors because >90% of grade 1 tumors are hormonally positive and in the 10% of cases that they are negative by IHC, patients often are still challenged with hormonal therapy.
      mTOR inhibitors such as rapalogs (everolimus, ridaforolimus and temsirolimus), which target mTORC1, a downstream target of AKT, have shown some modest activity in phase II trials with both objective responses as well as clinically significant disease stabilization [
      • Oza A.M.
      • et al.
      Phase II study of erlotinib in recurrent or metastatic endometrial cancer: NCIC IND-148.
      ,
      • Colombo N.
      • et al.
      Ridaforolimus as a single agent in advanced endometrial cancer: results of a single-arm, phase 2 trial.
      ,
      • Slomovitz B.M.
      • et al.
      A phase 2 study of the oral mammalian target of rapamycin inhibitor, everolimus, in patients with recurrent endometrial carcinoma.
      ]; however, responses are again usually of brief duration (median duration of 3.5 months). Interestingly, combination of endocrine therapy using the aromatase inhibitor letrozole in combination with the mTOR inhibitor everolimus has shown a promising clinical benefit rate (response or stable disease) of 40% in a phase II study in patients with recurrent, incurable endometrial cancer [
      • Slomovitz B.M.
      • et al.
      Phase II study of everolimus and letrozole in patients with recurrent endometrial carcinoma.
      ]. Furthermore, in a recently reported, non-comparative, randomized phase II study of everolimus and letrozole versus hormonal therapy with medroxyprogesterone acetate/tamoxifen in advanced, persistent or recurrent endometrial carcinoma, the response rate for the combination of everolimus/letrozole was comparable to hormonal therapy, but progression-free survival (PFS) was more favorable with everolimus/letrozole [
      • Slomovitz B.
      • Filiaci V.L.
      • Coleman R.L.
      • et al.
      GOG 3007, a randomized phase II (RP2) trial of everolimus and letrozole (EL) or hormonal therapy (medroxyprogesterone acetate/tamoxifen, PT) in women with advanced, persistent or recurrent endometrial carcinoma (EC): a GOG Foundation study.
      ]. Of note, patients who had not received prior chemotherapy had a response rate of 53% with everolimus/letrozole, which compares favorably to results from some of the best chemotherapy trials with PFS in these patients being over 21 months.
      Several other targeted agents (e.g. trastuzumab, gefitinib, lapatinib) and antiangiogenic drugs (bevacizumab, thalidomide and brivanib) have also been evaluated in endometrial cancer. Of these agents, GOG-229E suggested bevacizumab was well tolerated and active based on PFS at 6 months (13.5% ORR and 40.4% PFS6, i.e. surviving progression free at 6 months). The combination of temsirolimus and bevacizumab was active based on both objective tumor response and PFS at 6 months (24.5% ORR and 46.9% PFS 6) in recurrent or persistent endometrial tumors but was associated with significant toxicity [
      • Alvarez E.A.
      • et al.
      Phase II trial of combination bevacizumab and temsirolimus in the treatment of recurrent or persistent endometrial carcinoma: a Gynecologic Oncology Group study.
      ,
      • Aghajanian C.
      • et al.
      Phase II trial of bevacizumab in recurrent or persistent endometrial cancer: a Gynecologic Oncology Group study.
      ]. Bevacizumab has also been evaluated in a phase II trial for advanced/recurrent endometrial cancer patients in combination with carboplatin and paclitaxel. This trial included 15 patients and reported a 93% PFS at 6 months as well as 5 complete responses and 6 partial responses [
      • Simpkins F.
      • et al.
      A phase II trial of paclitaxel, carboplatin, and bevacizumab in advanced and recurrent endometrial carcinoma (EMCA).
      ].
      Finally, immune checkpoint inhibitors have also been evaluated in endometrial cancer. Pembrolizumab, an anti-PD-1 antibody, is currently FDA approved in MSI/mismatch repair (MMR) deficient tumors, including endometrial cancers, which have failed standard treatment options. Le et al. evaluated pembrolizumab in a phase II study of patients with or without mismatch repair deficiency. This study enrolled nine patients with non-colorectal mismatch repair-deficient tumors, and in this cohort, which included two endometrial cancer patients, there was an objective response rate of 71% (five out of seven) patients [
      • Le D.T.
      • et al.
      PD-1 blockade in tumors with mismatch-repair deficiency.
      ]. In the multicenter phase II study of pembrolizumab in patients with non-colorectal MSI-H tumors (KEYNOTE-158) [], which included 4 endometrial cancer patients, the overall response rate was 42.9% with a disease control rate of 66.7% with 8 confirmed partial responses, and 1 complete response among the 21 MSI-H non-colorectal cancer cases. Among 14 total patients with MSI/MMR deficient endometrial cancer, there have been 5 objective responses to pembrolizumab (ORR = 36%) with a duration of response of 4.2+ months to 17.6+ months. However, outside MSI/MMR deficient endometrial cancers, the response to pembrolizumab in microsatellite stable (MSS) tumors has been modest. Specifically, in the endometrial cancer cohort of the KEYNOTE-28 pembrolizumab study which selected endometrial cancer patients with positive PD-L1 expression, the objective response rate among tumors with confirmed MSS status was modest, with only 1 of 18 tumors (5%) exhibiting an objective response [
      • Ott P.A.
      • et al.
      Safety and antitumor activity of pembrolizumab in advanced programmed death ligand 1-positive endometrial cancer: results from the KEYNOTE-028 Study.
      ].
      This patient has an MMR proficient tumor by immunohistochemistry, so the anticipated response to immune checkpoint blockade is low. Retesting of the recurrent tumor for MMR status can be considered although it is not a standard practice. Surgical resection was not feasible, and patient was not a candidate for re-irradiation therapy due to her having completed curative-dose therapy. She had already progressed through hormonal therapy. Since there is no evidence of cross resistance to hormonal therapy, alternative endocrine therapies such as tamoxifen, progestins or an aromatase inhibitor with or without everolimus could also be considered. However, given of the possibility of response to olaparib, rechallenge with endocrine therapy was deferred.
      Furthermore, given that her tumor was adherent to the bladder and was associated with hematuria, she was not a candidate for bevacizumab or any other anti-vascular therapy. The patient had already received first line carboplatin/paclitaxel chemotherapy but her disease relapsed and although she had stable disease to second line chemotherapy with carboplatin/gemcitabine, she developed allergy to carboplatin. Given the absence of any meaningful alternative standard therapies, we discussed off-label use of a PARP-inhibitor in the setting of her germline BRCA2 mutation status (known pathogenic founder BRCA2 c.5946delT mutation). Of note, our targeted next generation sequencing assay revealed another BRCA2 mutation, a somatic frameshift BRCA2 mutation [c.7639delA (p.K2547Nfs*4)] which was likely deleterious as it essentially deleted almost the entire C-terminal region (amino acids 2459–3190) of BRCA2. The presence of gemline and somatic BRCA2 mutations suggested that both BRCA2 alleles may be dysfunctional therefore raising the possibility of a good response to PARP-inhibitor therapy, a hypothesis which was confirmed in our patient as she has had a durable anti-cancer response to olaparib lasting >15+ months and has tolerated the agent well.

      7. PARP-inhibitor treatment in BRCA-mutated tumors

      BRCA1 and BRCA2 germline mutations confer a 40% and 20% lifetime risk of ovarian cancer and a 65% and 50% lifetime risk of breast cancer, respectively [
      • Walsh T.
      • et al.
      Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing.
      ,
      • Antoniou A.
      • et al.
      Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: a combined analysis of 22 studies.
      ,
      • Kuchenbaecker K.B.
      • et al.
      Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers.
      ]. Germline BRCA1 and BRCA2 mutations are present in up to approximately 15% of all epithelial ovarian cancers (EOCs) [
      • Alsop K.
      • et al.
      BRCA mutation frequency and patterns of treatment response in BRCA mutation-positive women with ovarian cancer: a report from the Australian Ovarian Cancer Study Group.
      ,
      • Pal T.
      • et al.
      BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases.
      ] and as high as 22.6% of high grade serous ovarian cancers (HGSOC) [
      • Alsop K.
      • et al.
      BRCA mutation frequency and patterns of treatment response in BRCA mutation-positive women with ovarian cancer: a report from the Australian Ovarian Cancer Study Group.
      ,
      • Pal T.
      • et al.
      BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases.
      ,
      ], while somatic BRCA1 and BRCA2 mutations have been identified in 6–7% of HGSOC [
      ,
      • Hennessy B.T.
      • et al.
      Somatic mutations in BRCA1 and BRCA2 could expand the number of patients that benefit from poly (ADP ribose) polymerase inhibitors in ovarian cancer.
      ]. Importantly, the majority of BRCA1 and BRCA2 mutations (81% of BRCA1 and 72% of BRCA2 mutations) are accompanied by heterozygous loss [
      • TCGA
      Integrated genomic analyses of ovarian carcinoma.
      ] indicating that in HGSOC both alleles are inactivated, as predicted by Knudson's two-hit hypothesis.
      The BRCA genes are central to repairing double strand DNA breaks through the homologous recombination repair (HRR) pathway and BRCA1/2 mutations confer HRR deficiency. However, besides BRCA1 and BRCA2 germline and somatic mutations, HRR deficiency can also occur in ovarian cancer via several alternative ways including mutations in Fanconi Anemia (FA) genes [e.g. PALB2 (FANCN), BRIP1 (FANCJ)], core RAD genes (e.g. RAD51C, RAD51D) and other genes involved in HRR either directly (e.g. BARD1, NBN and ATM) or indirectly such as CDK12 which is involved in regulation of transcription of several HRR genes including BRCA1. Furthermore, pathogenic germline mutations associated with ovarian cancer have been found in other HRR genes including BRIP1, RAD51C, RAD51D, PALB2 and BARD1 [
      • Norquist B.M.
      • et al.
      Inherited mutations in women with ovarian carcinoma.
      ]. HRR deficiency may also occur via BRCA1 promoter hypermethylation which exists in approximately 10–20% of EOCs and is mutually exclusive of BRCA1/2 mutations highlighting the strong selective pressure to inactivate BRCA via either epigenetic silencing or mutation in this disease [
      • TCGA
      Integrated genomic analyses of ovarian carcinoma.
      ,
      • Baldwin R.L.
      • et al.
      BRCA1 promoter region hypermethylation in ovarian carcinoma: a population-based study.
      ,
      • Esteller M.
      • et al.
      Promoter hypermethylation and BRCA1 inactivation in sporadic breast and ovarian tumors.
      ]. Besides BRCA1, RAD51C is also epigenetically silenced via promoter hypermethylation in about 2% of HGSOC cases in the TCGA dataset [
      • Bernards S.S.
      • et al.
      Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma.
      ].
      Poly (ADP-ribose) polymerase (PARP1) is a DNA repair enzyme utilized in the base excision repair and single-strand break repair pathways. If PARP1 is blocked in cells with BRCA mutations or HRR deficiency, double strand DNA breaks occur, ultimately inducing synthetic lethality since loss of homologous recombination and base excision repair forces the tumor to use more error-prone DNA repair pathways which ultimately lead to cell death [
      • Farmer H.
      • et al.
      Targeting the DNA repair defect in BRCA mutant cells as a therapeutic strategy.
      ,
      • Ashworth A.
      A synthetic lethal therapeutic approach: poly(ADP) ribose polymerase inhibitors for the treatment of cancers deficient in DNA double-strand break repair.
      ]. In addition to inhibition of base excision repair (due to blocking of PARP enzymes), trapping of PARP-DNA complexes at the replication fork is another mechanism of PARP inhibitor (PARPis) activity. Other proposed mechanisms include enhancement of toxic non-homologous end joining in PARP1-deficient cells, and inhibition of PARP1/Polθ-mediated alternative end joining [
      • Konstantinopoulos P.A.
      • et al.
      Homologous recombination deficiency: exploiting the fundamental vulnerability of ovarian cancer.
      ].
      Three PARPis, (olaparib, rucaparib and niraparib), have received FDA approval as monotherapy for ovarian cancer treatment, either in patients with germline or somatic BRCA1/2 mutations or as maintenance therapy after platinum-based chemotherapy in platinum-sensitive recurrent EOC, regardless of BRCA mutation status. Specifically, olaparib is FDA approved for recurrent germline BRCA-mutated ovarian cancer with 3 or more prior lines of chemotherapy, while rucaparib is FDA approved for patients with BRCA-mutated ovarian cancer (either deleterious tumor or germline BRCA mutation) who have received at least 2 prior lines of chemotherapy.
      Besides ovarian cancer, HRR alterations have also been identified, albeit less frequently, in other human malignancies including triple negative breast cancer, melanoma, prostate and pancreatic cancers, which has prompted evaluation of PARPis in other clinical contexts beyond ovarian cancer. Olaparib is now FDA approved for patients with germline BRCA-mutated HER2-negative metastatic breast cancer previously treated with chemotherapy and has been designated as breakthrough therapy for the treatment of BRCA or ATM gene–mutated castration-resistant metastatic prostate cancer. In endometrial cancer, although HRR alterations have been reported in association with BRCA1/2 mutations in high-grade serous endometrial cancers, PARPis are currently not FDA approved for this indication and no trials of PARP inhibitors for endometrial cancer patients with BRCA mutations have been reported.

      8. PARP-inhibitor treatment in endometrial cancer

      Although there are no published clinical trials for PARP inhibitors in endometrial cancer patients, there is some evidence that PARP inhibitors may have efficacy in a variety of tumors with HRR defects, including a subset of endometroid endometrial adenocarcinomas [
      • Reinbolt R.E.
      • Hays J.L.
      The role of PARP inhibitors in the treatment of gynecologic malignancies.
      ]. For example, deficiency of the tumor suppressor gene PTEN is associated with homologous recombination defects, similar to BRCA mutations. When exposed to PARP inhibitors, PTEN deficient cells suffer synthetic lethality similar to the mechanism triggered in BRCA-deficient cells treated with PARP inhibitors [
      • Mendes-Pereira A.M.
      • et al.
      Synthetic lethal targeting of PTEN mutant cells with PARP inhibitors.
      ]. In ovarian cancer, a focal deletion region at 10q23.31 that includes only PTEN has been found in approximately 7% of HGSOCs. These tumors exhibit homozygous PTEN deletion which is also associated with downregulation of PTEN at the mRNA level [
      • TCGA
      Integrated genomic analyses of ovarian carcinoma.
      ]. PTEN deficiency has been shown to be synthetically lethal with PARP inhibition or compound PARP-PI3K inhibition [
      • Dedes K.J.
      • et al.
      PTEN deficiency in endometrioid endometrial adenocarcinomas predicts sensitivity to PARP inhibitors.
      ,
      • Bian X.
      • et al.
      PTEN deficiency sensitizes endometrioid endometrial cancer to compound PARP-PI3K inhibition but not PARP inhibition as monotherapy.
      ], and one of the proposed mechanisms is transcriptional downregulation of RAD51 [
      • Mendes-Pereira A.M.
      • et al.
      Synthetic lethal targeting of PTEN mutant cells with PARP inhibitors.
      ,
      • Shen W.H.
      • et al.
      Essential role for nuclear PTEN in maintaining chromosomal integrity.
      ]. Specifically, in an in-vitro study, deficiency of the tumor suppressor PTEN in endometrioid endometrial cancer cell lines was associated with increased sensitivity to olaparib [
      • Dedes K.J.
      • et al.
      PTEN deficiency in endometrioid endometrial adenocarcinomas predicts sensitivity to PARP inhibitors.
      ]. Furthermore, in a case report of a 58-year-old woman who presented with metastatic endometrioid endometrial adenocarcinoma and had several platinum-sensitive relapses, olaparib treatment (as part of a phase 1 trial) was associated with significant reduction in the size of her brain metastases and subjective improvement in her symptoms after 10 weeks. At 8 months the patient had progression of her tumor and a biopsy at that time revealed intact somatic BRCA 1 and 2 but a loss of PTEN [
      • Forster M.D.
      • et al.
      Treatment with olaparib in a patient with PTEN-deficient endometrioid endometrial cancer.
      ]. However, another study showed that PTEN-deficient endometrioid endometrial cancer cells are not responsive to PARP inhibitor olaparib monotherapy, but instead show superior sensitivity to compound inhibition with the PI3K inhibitor BKM120 [
      • Bian X.
      • et al.
      PTEN deficiency sensitizes endometrioid endometrial cancer to compound PARP-PI3K inhibition but not PARP inhibition as monotherapy.
      ]. These apparently conflicting data indicate that the association of PTEN deficiency with HRR deficiency and response to PARP-inhibitors is likely context-specific. Taken together, outside of these studies, PARP inhibitors have not been formally and specifically evaluated in endometrial cancer patients, including BRCA-mutated, PTEN-deficient and HRR deficient subsets.

      9. Conclusion

      We report a 42-year-old woman with a germline BRCA2 mutation and recurrent low-grade endometrioid endometrial adenocarcinoma with no meaningful remaining standard treatment options, who has experienced durable clinical and radiographic response to the poly (ADP-ribose) polymerase (PARP) inhibitor olaparib. This study exemplifies that PARP-inhibitors may have activity in endometrial cancer in the setting of the deleterious BRCA1/2-mutations, especially if biallelic inactivation of BRCA1/2 occurs. Targeted sequencing may be a valuable tool for the clinical management of patients with endometrial cancer.

      Conflict of interest

      Dr. Konstantinopoulos reports other from Astrazeneca, other from Merck, other from Pfizer, outside the submitted work.
      Dr. Matulonis reports other from Astrazeneca, outside the submitted work.
      All other authors have no conflicts of interest to declare.

      References

        • Sholl L.M.
        • et al.
        Institutional implementation of clinical tumor profiling on an unselected cancer population.
        JCI Insight. 2016; 1: e87062
        • Wagle N.
        • et al.
        High-throughput detection of actionable genomic alterations in clinical tumor samples by targeted, massively parallel sequencing.
        Cancer Discov. 2012; 2: 82-93
        • Garcia E.P.
        • et al.
        Validation of OncoPanel: a targeted next-generation sequencing assay for the detection of somatic variants in cancer.
        Arch. Pathol. Lab. Med. 2017; 141: 751-758
        • Smith J.A.
        • et al.
        Determination of the mechanism of gemcitabine modulation of cisplatin drug resistance in panel of human endometrial cancer cell lines.
        Gynecol. Oncol. 2006; 103: 518-522
        • Brown J.
        • et al.
        Combination of gemcitabine and cisplatin is highly active in women with endometrial carcinoma: results of a prospective phase 2 trial.
        Cancer. 2010; 116: 4973-4979
        • Mills A.M.
        • et al.
        Lynch syndrome screening should be considered for all patients with newly diagnosed endometrial cancer.
        Am. J. Surg. Pathol. 2014; 38: 1501-1509
        • Soslow R.A.
        • et al.
        Morphologic patterns associated with BRCA1 and BRCA2 genotype in ovarian carcinoma.
        Mod. Pathol. 2012; 25: 625-636
        • Deligdisch L.
        • et al.
        Endometrial histopathology in 700 patients treated with tamoxifen for breast cancer.
        Gynecol. Oncol. 2000; 78: 181-186
        • Bland A.E.
        • et al.
        Relationship between tamoxifen use and high risk endometrial cancer histologic types.
        Gynecol. Oncol. 2009; 112: 150-154
      1. J. Natl. Cancer Inst. 1999; 91: 1310-1316
        • Thompson D.
        • Easton D.F.
        Cancer incidence in BRCA1 mutation carriers.
        J. Natl. Cancer Inst. 2002; 94: 1358-1365
        • Chen S.
        • Parmigiani G.
        Meta-analysis of BRCA1 and BRCA2 penetrance.
        J. Clin. Oncol. 2007; 25: 1329-1333
        • Lavie O.
        • et al.
        BRCA germline mutations in Jewish women with uterine serous papillary carcinoma.
        Gynecol. Oncol. 2004; 92: 521-524
        • Hecht J.L.
        • et al.
        Immunohistochemical loss of BRCA1 protein in uterine serous carcinoma.
        Int. J. Gynecol. Pathol. 2014; 33: 282-287
        • Goshen R.
        • et al.
        Is uterine papillary serous adenocarcinoma a manifestation of the hereditary breast-ovarian cancer syndrome?.
        Gynecol. Oncol. 2000; 79: 477-481
        • Villella J.A.
        • et al.
        Role of prophylactic hysterectomy in patients at high risk for hereditary cancers.
        Gynecol. Oncol. 2006; 102: 475-479
        • Shu C.A.
        • et al.
        Uterine cancer after risk-reducing salpingo-oophorectomy without hysterectomy in women with BRCA mutations.
        JAMA Oncol. 2016; 2: 1434-1440
        • Kwon J.S.
        • et al.
        Prolonged survival among women with BRCA germline mutations and advanced endometrial cancer: a case series.
        Int. J. Gynecol. Cancer. 2008; 18: 546-549
        • Reimers L.L.
        • et al.
        Breast cancer chemoprevention among high-risk women and those with ductal carcinoma in situ.
        Breast J. 2015; 21: 377-386
        • Loman N.
        • et al.
        Steroid receptors in hereditary breast carcinomas associated with BRCA1 or BRCA2 mutations or unknown susceptibility genes.
        Cancer. 1998; 83: 310-319
        • Fisher B.
        • et al.
        Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study.
        J. Natl. Cancer Inst. 1998; 90: 1371-1388
        • King M.C.
        • et al.
        Tamoxifen and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial.
        JAMA. 2001; 286: 2251-2256
        • Wen J.
        • et al.
        Decreased BRCA1 confers tamoxifen resistance in breast cancer cells by altering estrogen receptor-coregulator interactions.
        Oncogene. 2009; 28: 575-586
        • Davies C.
        • et al.
        Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial.
        Lancet. 2013; 381: 805-816
        • Sismondi P.
        • et al.
        Tamoxifen and endometrial cancer.
        Ann. N. Y. Acad. Sci. 1994; 734: 310-321
        • Bissett D.
        • Davis J.A.
        • George W.D.
        Gynaecological monitoring during tamoxifen therapy.
        Lancet. 1994; 344: 1244
        • Segev Y.
        • et al.
        Risk factors for endometrial cancer among women with a BRCA1 or BRCA2 mutation: a case control study.
        Familial Cancer. 2015; 14: 383-391
        • Brinton L.A.
        • et al.
        Etiologic heterogeneity in endometrial cancer: evidence from a Gynecologic Oncology Group trial.
        Gynecol. Oncol. 2013; 129: 277-284
        • Barakat R.R.
        • et al.
        Tamoxifen use in breast cancer patients who subsequently develop corpus cancer is not associated with a higher incidence of adverse histologic features.
        Gynecol. Oncol. 1994; 55: 164-168
        • ACOG committee opinion
        No. 336: Tamoxifen and uterine cancer.
        Obstet. Gynecol. 2006; 107: 1475-1478
        • Holloman W.K.
        Unraveling the mechanism of BRCA2 in homologous recombination.
        Nat. Struct. Mol. Biol. 2011; 18: 748-754
        • Guidugli L.
        • et al.
        Functional assays for analysis of variants of uncertain significance in BRCA2.
        Hum. Mutat. 2013; 35: 151-164
        • Dougherty B.A.
        • et al.
        Biological and clinical evidence for somatic mutations in BRCA1 and BRCA2 as predictive markers for olaparib response in high-grade serous ovarian cancers in the maintenance setting.
        Oncotarget. 2017; 8: 43653-43661
        • Lheureux S.
        • et al.
        Somatic BRCA1/2 recovery as a resistance mechanism after exceptional response to poly (ADP-ribose) polymerase inhibition.
        J. Clin. Oncol. 2017; 35: 1240-1249
        • Kandoth C.
        • et al.
        Integrated genomic characterization of endometrial carcinoma.
        Nature. 2013; 497: 67-73
        • Bokhman J.V.
        Two pathogenetic types of endometrial carcinoma.
        Gynecol. Oncol. 1983; 15: 10-17
        • Morice P.
        • et al.
        Endometrial cancer.
        Lancet. 2016; 387: 1094-1108
        • Weigelt B.
        • Banerjee S.
        Molecular targets and targeted therapeutics in endometrial cancer.
        Curr. Opin. Oncol. 2012; 24: 554-563
        • Miller D.
        • F. V.
        • Flemin G.
        • Mannel R.
        • Cohn D.
        • Matsumoto T.
        • Tewari K.
        • DiSilvestro P.
        • Pearl M.
        • Zaino R.
        Randomized phase III noninferiority trial of first line chemotherapy for metastatic or recurrent endometrial carcinoma: A Gynecologic Oncology Group study.
        Gynecol. Oncol. 2012; 125: 771
        • Fleming G.F.
        Second-line therapy for endometrial cancer: the need for better options.
        J. Clin. Oncol. 2015; 33: 3535-3540
        • Thigpen T.
        • et al.
        Tamoxifen in the treatment of advanced or recurrent endometrial carcinoma: a Gynecologic Oncology Group study.
        J. Clin. Oncol. 2001; 19: 364-367
        • Thigpen J.T.
        • et al.
        Oral medroxyprogesterone acetate in the treatment of advanced or recurrent endometrial carcinoma: a dose-response study by the Gynecologic Oncology Group.
        J. Clin. Oncol. 1999; 17: 1736-1744
        • Lentz S.S.
        • et al.
        High-dose megestrol acetate in advanced or recurrent endometrial carcinoma: a Gynecologic Oncology Group Study.
        J. Clin. Oncol. 1996; 14: 357-361
        • Whitney C.W.
        • et al.
        Phase II study of medroxyprogesterone acetate plus tamoxifen in advanced endometrial carcinoma: a Gynecologic Oncology Group study.
        Gynecol. Oncol. 2004; 92: 4-9
        • Markman M.
        Hormonal therapy of endometrial cancer.
        Eur. J. Cancer. 2005; 41: 673-675
        • Singh M.
        • et al.
        Relationship of estrogen and progesterone receptors to clinical outcome in metastatic endometrial carcinoma: a Gynecologic Oncology Group Study.
        Gynecol. Oncol. 2007; 106: 325-333
        • Oza A.M.
        • et al.
        Phase II study of erlotinib in recurrent or metastatic endometrial cancer: NCIC IND-148.
        J. Clin. Oncol. 2008; 26: 4319-4325
        • Colombo N.
        • et al.
        Ridaforolimus as a single agent in advanced endometrial cancer: results of a single-arm, phase 2 trial.
        Br. J. Cancer. 2013; 108: 1021-1026
        • Slomovitz B.M.
        • et al.
        A phase 2 study of the oral mammalian target of rapamycin inhibitor, everolimus, in patients with recurrent endometrial carcinoma.
        Cancer. 2010; 116: 5415-5419
        • Slomovitz B.M.
        • et al.
        Phase II study of everolimus and letrozole in patients with recurrent endometrial carcinoma.
        J. Clin. Oncol. 2015; 33: 930-936
        • Slomovitz B.
        • Filiaci V.L.
        • Coleman R.L.
        • et al.
        GOG 3007, a randomized phase II (RP2) trial of everolimus and letrozole (EL) or hormonal therapy (medroxyprogesterone acetate/tamoxifen, PT) in women with advanced, persistent or recurrent endometrial carcinoma (EC): a GOG Foundation study.
        in: Oral presentation at: 2018 Society of Gynecologic Oncology Annual Meeting on Women's Cancer; March 24–27, 2018. 2018 (New Orleans, LA)
        • Alvarez E.A.
        • et al.
        Phase II trial of combination bevacizumab and temsirolimus in the treatment of recurrent or persistent endometrial carcinoma: a Gynecologic Oncology Group study.
        Gynecol. Oncol. 2012; 129: 22-27
        • Aghajanian C.
        • et al.
        Phase II trial of bevacizumab in recurrent or persistent endometrial cancer: a Gynecologic Oncology Group study.
        J. Clin. Oncol. 2011; 29: 2259-2265
        • Simpkins F.
        • et al.
        A phase II trial of paclitaxel, carboplatin, and bevacizumab in advanced and recurrent endometrial carcinoma (EMCA).
        Gynecol. Oncol. 2015; 136: 240-245
        • Le D.T.
        • et al.
        PD-1 blockade in tumors with mismatch-repair deficiency.
        N. Engl. J. Med. 2015; 372: 2509-2520
      2. (Pembrolizumab: Package Insert)
        • Ott P.A.
        • et al.
        Safety and antitumor activity of pembrolizumab in advanced programmed death ligand 1-positive endometrial cancer: results from the KEYNOTE-028 Study.
        J. Clin. Oncol. 2017; 35: 2535-2541
        • Walsh T.
        • et al.
        Mutations in 12 genes for inherited ovarian, fallopian tube, and peritoneal carcinoma identified by massively parallel sequencing.
        Proc. Natl. Acad. Sci. U. S. A. 2011; 108: 18032-18037
        • Antoniou A.
        • et al.
        Average risks of breast and ovarian cancer associated with BRCA1 or BRCA2 mutations detected in case series unselected for family history: a combined analysis of 22 studies.
        Am. J. Hum. Genet. 2003; 72: 1117-1130
        • Kuchenbaecker K.B.
        • et al.
        Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers.
        JAMA. 2017; 317: 2402-2416
        • Alsop K.
        • et al.
        BRCA mutation frequency and patterns of treatment response in BRCA mutation-positive women with ovarian cancer: a report from the Australian Ovarian Cancer Study Group.
        J. Clin. Oncol. 2012; 30: 2654-2663
        • Pal T.
        • et al.
        BRCA1 and BRCA2 mutations account for a large proportion of ovarian carcinoma cases.
        Cancer. 2005; 104: 2807-2816
      3. Nature. 2012; 474: 609-615
        • Hennessy B.T.
        • et al.
        Somatic mutations in BRCA1 and BRCA2 could expand the number of patients that benefit from poly (ADP ribose) polymerase inhibitors in ovarian cancer.
        J. Clin. Oncol. 2010; 28: 3570-3576
        • TCGA
        Integrated genomic analyses of ovarian carcinoma.
        Nature. 2011; 474: 609-615
        • Norquist B.M.
        • et al.
        Inherited mutations in women with ovarian carcinoma.
        JAMA Oncol. 2016; 2: 482-490
        • Baldwin R.L.
        • et al.
        BRCA1 promoter region hypermethylation in ovarian carcinoma: a population-based study.
        Cancer Res. 2000; 60: 5329-5333
        • Esteller M.
        • et al.
        Promoter hypermethylation and BRCA1 inactivation in sporadic breast and ovarian tumors.
        J. Natl. Cancer Inst. 2000; 92: 564-569
        • Bernards S.S.
        • et al.
        Clinical characteristics and outcomes of patients with BRCA1 or RAD51C methylated versus mutated ovarian carcinoma.
        Gynecol. Oncol. 2017; 148: 281-285
        • Farmer H.
        • et al.
        Targeting the DNA repair defect in BRCA mutant cells as a therapeutic strategy.
        Nature. 2005; 434: 917-921
        • Ashworth A.
        A synthetic lethal therapeutic approach: poly(ADP) ribose polymerase inhibitors for the treatment of cancers deficient in DNA double-strand break repair.
        J. Clin. Oncol. 2008; 26: 3785-3790
        • Konstantinopoulos P.A.
        • et al.
        Homologous recombination deficiency: exploiting the fundamental vulnerability of ovarian cancer.
        Cancer Discov. 2015; 5: 1137-1154
        • Reinbolt R.E.
        • Hays J.L.
        The role of PARP inhibitors in the treatment of gynecologic malignancies.
        Front. Oncol. 2013; 3: 237
        • Mendes-Pereira A.M.
        • et al.
        Synthetic lethal targeting of PTEN mutant cells with PARP inhibitors.
        EMBO Mol. Med. 2009; 1: 315-322
        • Dedes K.J.
        • et al.
        PTEN deficiency in endometrioid endometrial adenocarcinomas predicts sensitivity to PARP inhibitors.
        Sci. Transl. Med. 2010; 2: 53ra75
        • Bian X.
        • et al.
        PTEN deficiency sensitizes endometrioid endometrial cancer to compound PARP-PI3K inhibition but not PARP inhibition as monotherapy.
        Oncogene. 2018; 37: 341-351
        • Shen W.H.
        • et al.
        Essential role for nuclear PTEN in maintaining chromosomal integrity.
        Cell. 2007; 128: 157-170
        • Forster M.D.
        • et al.
        Treatment with olaparib in a patient with PTEN-deficient endometrioid endometrial cancer.
        Nat. Rev. Clin. Oncol. 2011; 8: 302-306