Impact of 2025 ESGO guidelines on the management of patients with endometrial cancer: reviewing retrospective data in an expert center.

OBJECTIVE: To assess the potential impact of the latest European society of Gynaecological Oncology (ESGO) molecular classification on the management of endometrial cancer in a French cohort. METHOD: All patients surgically treated for an endometrial cancer at a tertiary referral center between January 2015 and November 2024 were retrospectively included. Pathological and molecular characteristics were reviewed, and tumors were reclassified according to the 2023 International Federation of Gynecology and Obstetrics (FIGO) staging system and the 2025 ESGO guidelines. The impact of the latest 2025 ESGO guidelines was assessed regarding risk groups classification, neo-adjuvant therapy, surgical management, adjuvant therapy and overall survival. A sensitivity analysis was performed among patients treated from 2022 onwards, for whom POLE status was systematically available. RESULTS: Out of 374 patients included, 37 (9.9%) were reclassified according to the 2025 ESGO guidelines: 16 (4.3%) to a lower-risk group, 16 (4.3%) to a higher-risk group, and 5 (1.3%) to the indeterminate category. Agreement between initial and 2025 classifications was high (unweighted Cohen's κ = 0.86, 95% CI 0.82-0.90; weighted κ = 0.93, 95% CI 0.90-0.97, after exclusion of indeterminate cases). In the sensitivity analysis restricted to patients with systematically available POLE status (n = 110), the reclassification rate was similar (10.0%). Sentinel lymph node mapping indication increased from 59% to 83%, while pelvic lymphadenectomy decreased from 39% to 10% (both p < 0.001). Active surveillance increased from 33% to 39% (p < 0.01), while radiotherapy increased from 41% to 59% (p < 0.001). Overall survival differed significantly across 2025 risk groups (log-rank p < 0.001), with poorer outcomes in high-risk and metastatic disease. CONCLUSION: The 2025 ESGO guidelines enable more precise, molecularly informed risk stratification in endometrial cancer, leading to meaningful modifications in adjuvant management for a subset of patients.