GENERAL DISCUSSION 193 8 Proposition diagnostic algorithm adjuvant treatment of endometrial cancer For the diagnostic algorithm of adjuvant treatment, molecular subgroup analysis is needed. The large prospective RAINBO trial has recently started to evaluated different treatment strategies for the different molecular subgroups.61, 93 Unfortunately, patients characteristics, tumor grade, L1CAM expression and both hormonal biomarkers are lacking in the four trails defining treatment strategies. In my opinion, first determination of FIGO stage, grade and histology should be performed and molecular analysis can be used to further refine adjuvant treatment in highrisk EC. In low-grade early stage EC the benefit of molecular classification as well as treatment strategy needs to be elucidated. In addition, it needs to be clarified what the effect is of different adjuvant treatment strategies in the disparities of patient characteristics e.g. performing a study taking into consideration anemia and/or race, in relation to the molecular subgroups to define adjuvant treatment strategies. Future development must also include shared decision making with the patient since most patients with EC are vulnerable and unable to tolerate each type of adjuvant treatment. The revised ENDORISK-model could provide additional information, by including the adjuvant treatment to analyze the 5-year recurrence-free survival risk (Figure 3). Figure 3. Revised ENDORISK-model including adjuvant treatment (circled in purple) to analyze the 5-year recurrence free survival risk. Abbreviations: L1CAM, L1 cell adhesion molecule; TP53, tumor protein 53; POLE, polymerase epsilon; MS, microsatellite; MMR, mismatch repair; TVU, transvaginal ultrasound; MRI, magnetic resonance imaging; LNM, lymph node metastasis; CA125, cancer antigen; BMI, Body mass index; LVSI, lympho-vascular space invasion
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