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. 2023 Oct 24;44(Suppl 2):61–70. doi: 10.1007/s00292-023-01208-2

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© The Author(s) 2023

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Fig. 5 — Immunohistochemical complex findings (group 4 according to Jaffrelot et al. [10]). Uterus with well-differentiated endometrial cancer and subclonal loss of MLH1 (a) and PMS2 (b) in the same tumor area and focal loss of MSH6 in different areas (d) while MSH2 is retained throughout the tumor (c). Explanation: Focal geographic loss of the MLH1/PMS2 heterodimer (affecting approx. 60% of the tumor). MSI-PCR is positive for MSI‑H and MLH1 promotor methylation is detected as the cause for the subclonal loss of MLH1/PMS2. Therefore, there is no further germline genetics work-up (see algorithm Fig. 6). Due to a secondary frame shift mutation in an intragenic C₈ microsatellite in the MSH6 gene, a focal loss of MSH6 protein occurs in parts of the tumor (clearly demarcated unlike the staining gradients due to fixation variations, see inset). This cancer was classified as dMMR and is potentially suitable for ICI therapy in the event of metastasis or relapse (recommendation: re-biopsy and re-testing)