Endometrial cancer — FIGO 2023 staging with molecular classification and the ESGO 2025 management ladder

Also known as Endometrial carcinoma · Uterine cancer · FIGO 2023 endometrial staging · POLEmut · MMRd endometrial cancer · p53abn endometrial cancer · ProMisE classifier · PORTEC trials

FRANZCOG-exhaustive treatment of endometrial cancer building on the MBBS foundation: the FIGO 2023 (Berek) staging system reproduced verbatim including its four molecular subgroups (POLEmut, MMRd, NSMP, p53abn) and their stage modifiers, the 2025 ESGO-ESTRO-ESP risk-stratified management ladder, the full surgical and adjuvant ladder with trial evidence (PORTEC-1/2/3, FIRES, Fader 2018), fertility-sparing management, and survival by stage and molecular subgroup. ANZ-primary, globally tagged to MRCOG, ABOG, FRCSC and MRCPI.

high14 referencesUpdated 27 July 202612 min readVerification in progress

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14 MCQs

One-line fellowship answer

Endometrial cancer is the most common gynaecological malignancy in developed countries; 90 per cent present with postmenopausal bleeding, which is cancer until proven otherwise. Stage it with the FIGO 2023 (Berek) system — the anatomic ladder (IA1–IC, IIA–IIC, IIIA–IIIC, IVA–IVC) plus the four molecular subgroups (POLEmut, MMRd, NSMP, p53abn), recorded as an "m" subscript, with POLEmut stage IA–IB down-staged and p53abn stage IA with myometrial invasion up-staged. Treat with total hysterectomy and BSO plus sentinel lymph node biopsy, then walk the 2025 ESGO-ESTRO-ESP risk ladder: low = observation; intermediate = vault brachytherapy (PORTEC-2); high = chemoradiotherapy (PORTEC-3); advanced = carboplatin-paclitaxel ± hormonal ± immunotherapy ± trastuzumab. Five-year survival is 85 to 95 per cent in stage I, falling to 15 to 25 per cent in stage IV; molecular subgroup drives prognosis — POLEmut 98 per cent, p53abn 48 per cent five-year recurrence-free survival.^[1]^[2]^[5]

A 62-year-old woman with obesity and type 2 diabetes sits in your clinic after a single episode of postmenopausal bleeding. Her endometrial thickness on transvaginal ultrasound is 9 mm; the pipelle returns grade 1 endometrioid carcinoma. The questions a fellowship candidate must answer are sharp and few: what stage, what molecular class, what surgery, what adjuvant therapy, and what survival can she be offered. The 2023 FIGO revision and the 2025 ESGO update have moved the centre of gravity of this answer toward molecular classification — every candidate must know them.^[1]^[2]

Overview — why this page exists beside the MBBS page

The MBBS endometrial cancer page covers the foundation: the Bokhman dualistic model, the hyperplasia-to-carcinoma sequence, the diagnostic pathway (TVUS, pipelle, hysteroscopy), the FIGO 2009 staging, and the broad management principles. This FRANZCOG page builds on that foundation and goes deeper on the four things a fellowship answer is graded on: the FIGO 2023 staging reproduced verbatim with its molecular classification, the 2025 ESGO-ESTRO-ESP risk-stratified management ladder, the surgical and adjuvant decision tree with trial evidence, and survival by stage and molecular subgroup. Read the MBBS page for the groundwork; this page for the exam.^[1]^[2]^[13]

Endometrial cancer — the numbers a candidate must know

~90%Present with postmenopausal bleedingthe cardinal symptom and the diagnostic window

70-75%Diagnosed at stage Ifive-year survival 85 to 95 per cent

~3%Lifetime risk in a developed countryroughly 1 in 30 women

98%POLEmut 5-yr recurrence-free survivalLeon-Castillo PORTEC-3 2020 — de-escalate adjuvant therapy

48%p53abn 5-yr recurrence-free survivalthe worst subgroup — benefit most from chemoradiotherapy

^[2] ^[5]

References14Show

[1]Berek JS, Matias-Guiu X, Creutzberg C, et al. FIGO staging of endometrial cancer: 2023. Int J Gynaecol Obstet, 2023.PMID 37337978
[2]Concin N, Matias-Guiu X, Cibula D, et al. ESGO-ESTRO-ESP guidelines for the management of patients with endometrial carcinoma: update 2025. Lancet Oncol, 2025.PMID 40744042
[3]Concin N, Matias-Guiu X, Vergote I, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. Int J Gynecol Cancer, 2021.PMID 33397713
[4]Kandoth C, Schultz N, Cherniack AD, et al. Integrated genomic characterization of endometrial carcinoma. Nature, 2013.PMID 23636398
[5]León-Castillo A, de Boer SM, Powell ME, et al. Molecular Classification of the PORTEC-3 Trial for High-Risk Endometrial Cancer: Impact on Prognosis and Benefit From Adjuvant Therapy. J Clin Oncol, 2020.PMID 32749941
[6]de Boer SM, Powell ME, Mileshkin L, et al. Adjuvant chemoradiotherapy versus radiotherapy alone for women with high-risk endometrial cancer (PORTEC-3): final results of an international, open-label, multicentre, randomised, phase 3 trial. Lancet Oncol, 2018.PMID 29449189
[7]Nout RA, Smit VT, Putter H, et al. Vaginal brachytherapy versus pelvic external beam radiotherapy for patients with endometrial cancer of high-intermediate risk (PORTEC-2): an open-label, non-inferiority, randomised trial. Lancet, 2010.PMID 20206777
[8]Creutzberg CL, van Putten WL, Koper PC, et al. Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma. Lancet, 2000.PMID 10791524
[9]Keys HM, Roberts JA, Brunetto VL, et al. A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study. Gynecol Oncol, 2004.PMID 14984936
[10]Rossi EC, Kowalski LD, Scalici J, et al. A comparison of sentinel lymph node biopsy to lymphadenectomy for endometrial cancer staging (FIRES trial): a multicentre, prospective, cohort study. Lancet Oncol, 2017.PMID 28159465
[11]Fader AN, Roque DM, Siegel E, et al. Randomized Phase II Trial of Carboplatin-Paclitaxel Versus Carboplatin-Paclitaxel-Trastuzumab in Uterine Serous Carcinomas That Overexpress Human Epidermal Growth Factor Receptor 2/neu. J Clin Oncol, 2018.PMID 29584549
[12]Ramirez PT, Frumovitz M, Bodurka DC, et al. Hormonal therapy for the management of grade 1 endometrial adenocarcinoma: a literature review. Gynecol Oncol, 2004.PMID 15385122
[13]Braun MM, Overbeek-Wager EA, Grumbo RJ Diagnosis and Management of Endometrial Cancer. Am Fam Physician, 2016.PMID 26977831
[14]Post CCB, de Boer SM, Powell ME, et al. Adjuvant chemoradiotherapy versus radiotherapy alone in women with high-risk endometrial cancer (PORTEC-3): 10-year clinical outcomes. Lancet Oncol, 2025.PMID 40921169