Article | Published:

TIM-3 in endometrial carcinomas: an immunotherapeutic target expressed by mismatch repair-deficient and intact cancers


The checkpoint molecule TIM-3 is a target for emerging immunotherapies and has been identified on a variety of malignancies. Mismatch repair-deficient endometrial carcinomas have demonstrated durable responses to other checkpoint inhibitors due to high neoantigen loads and robust tumor-associated immune responses. However, little is known about TIM-3 expression in this tumor type. Tumor-associated immune and tumoral expression of TIM-3 were evaluated by immunohistochemistry on 75 endometrial carcinomas [25 MLH1 promoter hypermethylated (MLH1-hypermethylated), 25 non-hypermethylated mismatch repair-deficient, and 25 mismatch repair-intact]. All cases showed at least focal immune staining, but moderate and robust immune cell expression were more often observed in mismatch repair-deficient vs intact cases [66 vs 12%, P = 0.00002]. While the majority (77%) of endometrial cancers showed ≥1% tumoral TIM-3 expression, the MLH1-hypermethylated subset was more likely to demonstrate >5% tumoral staining when compared to both mismatch repair-intact and non-methylated mismatch repair-deficient cancers [64 vs. 28% and 32%, respectively; P = 0.02 and P = 0.05]. Within the non-methylated mismatch repair-deficient subset, high-level expression was most often associated with MSH6 loss. Across mismatch repair subgroups, tumoral TIM-3 expression was more common among intermediate and high-grade vs. low-grade tumors using both the 1% (P = 0.02) and 5% expression cut-offs (P = 0.02). In conclusion, tumoral TIM-3 expression is common in both mismatch repair-intact and deficient endometrial cancers, with particularly high levels of expression identified in the setting of MLH1-hypermethylation, MSH6 loss, and intermediate to high histologic grade. Although focal immune cell expression was seen in all tumors, robust expression was significantly more common in the context of mismatch repair deficiency. These data support a potential role for checkpoint inhibitors targeting TIM-3 in a subset of endometrial cancers, including some mismatch repair-intact tumors which are not currently considered immunotherapy candidates.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


  1. 1.

    Le DT, Durham JN, Smith KN, Wang H, Bartlett BR, Aulakh LK, et al. Mismatch repair deficiency predicts response of solid tumors to PD-1 blockade. Science. 2017;357:409.

  2. 2.

    Lee V, Le DT. Efficacy of PD-1 blockade in tumors with MMR deficiency. Immunotherapy. 2016;8:1–3.

  3. 3.

    Lee V, Murphy A, Le DT, Diaz LA Jr. Mismatch repair deficiency and response to immune checkpoint blockade. Oncologist. 2016;21:1200–11.

  4. 4.

    Le DT, Uram JN, Wang H, Bartlett BR, Kemberling H, Eyring AD, et al. PD-1 blockade in tumors with mismatch-repair deficiency. N Engl J Med. 2015;372:2509–20.

  5. 5.

    Santin AD, Bellone S, Buza N, Choi J, Schwartz PE, Schlessinger J, Lifton RP. Regression of chemotherapy-resistant polymerase Ε (POLE) ultra-mutated and MSH6 hyper-mutated endometrial tumors with Nivolumab. Clin Cancer Res. 2016;22:5682–7.

  6. 6.

    Liu J, Liu Y, Wang W, Wang C, Che Y. Expression of immune checkpoint molecules in endometrial carcinoma. Exp Ther Med. 2015;10:1947–52.

  7. 7.

    Howitt BE, Shukla SA, Sholl LM, Ritterhouse LL, Watkins JC, Rodig S, et al. Association of polymerase-e-mutated and microsatellite-instable endometrial cancers with neoantigen load, number of tumor-infiltrating lymphocytes, and expression of PD-1 and PD-L1. JAMA Oncol. 2015;1:1319–23.

  8. 8.

    Sloan EA, Ring KL, Willis BC, Modesitt SC, Mills AM. PD-L1 Expression in mismatch repair-deficient endometrial carcinomas, including Lynch syndrome-associated and MLH1 promoter hypermethylated tumors. Am J Surg Pathol. 2017;41:326–33.

  9. 9.

    Vanderstraeten A, Luyten C, Verbist G, Tuyaerts S, Amant F. Mapping the immunosuppressive environment in uterine tumors: implications for immunotherapy. Cancer Immunol Immunother. 2014;63:545–57.

  10. 10.

    Mills A, Zadeh S, Sloan E, Chinn Z, Modesitt SC, Ring KL. Indoleamine 2,3-dioxygenase in endometrial cancer: a targetable mechanism of immune resistance in mismatch repair-deficient and intact endometrial carcinomas. Mod Pathol. 2018;31:1282–90.

  11. 11.

    Tougeron D, Fauquembergue E, Rouquette A, Le Pessot F, Sesboue R, Laurent M, et al. Tumor-infiltrating lymphocytes in colorectal cancers with microsatellite instability are correlated with the number and spectrum of frameshift mutations. Mod Pathol. 2009;22:1186.

  12. 12.

    Llosa NJ, Cruise M, Tam A, Wicks, EC, Hechenbleikner EM, Taube JM, et al. The vigorous immune microenvironment of microsatellite instable colon cancer is balanced by multiple counter-inhibitory checkpoints. Cancer Discov. 2014;5:43–51.

  13. 13.

    Friedman K, Brodsky AS, Lu S, Wood S, Gill AJ, Lombardo K, Yang D, Resnick MB. Medullary carcinoma of the colon: a distinct morphology reveals a distinctive immunoregulatory microenvironment. Mod Pathol. 2016;29:528.

  14. 14.

    Dempke WCM, Fenchel K, Uciechowski P, Dale SP. Second- and third-generation drugs for immuno-oncology treatment—The more the better? Eur J Cancer. 2017;74:55–72.

  15. 15.

    Hellmann MD, Friedman CF, Wolchok JD. Combinatorial cancer immunotherapies. Adv Immunol. 2016;130:251–77.

  16. 16.

    Topalian SL, Hodi FS, Brahmer JR, Gettinger SN, Smith DC, McDermott DF, et al. Safety, activity, and immune correlates of anti–PD-1 antibody in cancer. N Engl J Med. 2012;366:2443–54.

  17. 17.

    Taube JM, Klein A, Brahmer JR, Xu H, Pan X, Kim JH, et al. Association of PD-1, PD-1 ligands, and other features of the tumor immune microenvironment with response to anti-PD-1 therapy. Clin Cancer Res. 2014;20:5064–74.

  18. 18.

    Ott PA, Bang Y-J, Berton-Rigaud D, Elez E, Pishvaian MJ, Rugo HS, et al. Pembrolizumab in advanced endometrial cancer: preliminary results from the phase Ib KEYNOTE-028 study. J Clin Oncol. 2016;34:5581–5581.

  19. 19.

    Li X, Hu W, Zheng X, Zheng C, Du P, Zheng Z, et al. Emerging immune checkpoints for cancer therapy. Acta Oncol. 2015;54:1706–13.

  20. 20.

    Koyama S, Akbay EA, Li YY, Herter-Sprie GS, Buczkowski KA, Richards WG, et al. Adaptive resistance to therapeutic PD-1 blockade is associated with upregulation of alternative immune checkpoints. Nat Commun. 2016;7:10501.

  21. 21.

    Nirschl CJ, Drake CG. Molecular pathways: coexpression of immune checkpoint molecules: signaling pathways and implications for cancer immunotherapy. Clin Cancer Res. 2013;19:4917–24.

  22. 22.

    Hughes PE, Caenepeel S, Wu LC. Targeted therapy and checkpoint immunotherapy combinations for the treatment of cancer. Trends Immunol. 2016;37:462–76.

  23. 23.

    Baitsch L, Legat A, Barba L, Fuertes Marraco SA, Rivals JP, Baumgaertner P, et al. Extended co-expression of inhibitory receptors by human CD8 T-cells depending on differentiation, antigen-specificity and anatomical localization. PLoS ONE. 2012;7:e30852.

  24. 24.

    Zhu C, Anderson AC, Schubart A, Xiong H, Imitola J, Khoury SJ, et al. The TIM-3 ligand galectin-9 negatively regulates T helper type 1 immunity. Nat Immunol. 2005;6:1245.

  25. 25.

    Du W, Yang M, Turner A, Xu C, Ferris RL, Huang J, Kane LP, Lu B. TIM-3 as a target for cancer immunotherapy and mechanisms of action. Int J Mol Sci. 2017;18:645.

  26. 26.

    Sánchez-Fueyo A, Tian J, Picarella D, Domenig C, Zheng XX, Sabatos CC, et al. TIM-3 inhibits T helper type 1-mediated auto- and alloimmune responses and promotes immunological tolerance. Nat Immunol. 2003;4:1093.

  27. 27.

    Das M, Zhu C, Kuchroo VK. TIM-3 and its role in regulating anti-tumor immunity. Immunol Rev. 2017;276:97–111.

  28. 28.

    Rangachari M, Zhu C, Sakuishi K, Xiao S, Karman J, Chen A, et al. Bat3 promotes T cell responses and autoimmunity by repressing TIM-3-mediated cell death and exhaustion. Nat Med. 2012;18:1394–1400.

  29. 29.

    Sakuishi K, Jayaraman P, Behar SM, Anderson AC, Kuchroo VK. Emerging TIM-3 functions in antimicrobial and tumor immunity. Trends Immunol. 2011;32:345–9.

  30. 30.

    Dardalhon V, Anderson AC, Karman J, Apetoh L, Chandwaskar R, Lee DH, et al. TIM-3/galectin-9 pathway: regulation of Th1 immunity through promotion of CD11b(+)Ly-6G(+) myeloid cells. J Immunol. 2011;185:1383–92.

  31. 31.

    Yan J, Zhang Y, Zhang JP, Liang J, Li L, Zheng L. TIM-3 expression defines regulatory T cells in human tumors. PLoS ONE Electron Resour. 2013;8:e58006.

  32. 32.

    Cao Y, Zhou X, Huang X, Li Q, Gao L, Jiang L, Huang M, Zhou J. TIM-3 Expression in cervical cancer promotes tumor metastasis. PLoS ONE. 2012;8:e53834.

  33. 33.

    Jiang J, Jin M-S, Kong F, Cao D, Ma HX, Jia Z, Wang YP, Suo J, Cao X. Decreased galectin-9 and increased TIM-3 expression are related to poor prognosis in gastric cancer. PLoS ONE. 2013;8:e81799.

  34. 34.

    Morgado M, Datar I, Wang J, Sanmamed MF, McEachern K, Jenkins D, et al. Abstract 1681: Simultaneous measurement and significance of PD-1, LAG-3 and TIM-3 expression in human solid tumors. Cancer Res. 2018;78:1681.

  35. 35.

    Yuan J, Jiang B, Zhao H, Huang Q. Prognostic implication of TIM-3 in clear cell renal cell carcinoma. Neoplasma. 2014;61:35–40.

  36. 36.

    Sloan EA, Moskaluk CA, Mills AM. Mucinous differentiation with tumor infiltrating lymphocytes is a feature of sporadically methylated endometrial carcinomas. Int J Gynecol Pathol. 2017;36:205–16.

  37. 37.

    Mills AM, Longacre TA. Lynch syndrome screening in the gynecologic tract: current state of the art. Am J Surg Pathol. 2016;40:e35–e44.

  38. 38.

    Mills AM, Liou S, Ford JM, Berek JS, Pai RK, Longacre TA. Lynch syndrome screening should be considered for all patients with newly diagnosed endometrial cancer. Am J Surg Pathol. 2014;38:1501–9.

  39. 39.

    Büttner R, Gosney JR, Skov BG, Adam J, Motoi N, Bloom KJ, et al. Programmed death-ligand 1 immunohistochemistry testing: a review of analytical assays and clinical implementation in non–small-cell lung cancer. J Clin Oncol. 2017;35:3867–76.

  40. 40.

    Kulangara K, Zhang N, Corigliano E, Guerrero L, Waldroup S, Jaiswal D, et al. Clinical utility of the combined positive score for programmed death ligand-1 expression and the approval of Pembrolizumab for treatment of gastric cancer. Arch Pathol Lab Med. 2018.

  41. 41.

    Salhab M, Migdady Y, Donahue M, Xiong Y, Dresser K, Walsh W, Chen BJ, Liebmann J. Immunohistochemical expression and prognostic value of PD-L1 in extrapulmonary small cell carcinoma: a single institution experience. J Immunother Cancer. 2018;6:42. -018-0359–1

  42. 42.

    Chung HC, Schellens JHM, Delord J-P, Perets R, Italiano A, Shapira-Fromer R, et al. Pembrolizumab treatment of advanced cervical cancer: Updated results from the phase 2 KEYNOTE-158 study. J Clin Oncol. 2018;36:5522–5522.

  43. 43.

    Overman MJ, Lonardi S, Wong KYM, Lenz HJ, Gelsomino F, Aglietta M, et al. Durable clinical benefit with Nivolumab plus Ipilimumab in DNA mismatch repair–deficient/microsatellite instability–high metastatic colorectal cancer. J Clin Oncol. 2018;36:773–9.

  44. 44.

    Fader AN, Diaz LA, Armstrong DK, Tanner EJ, Uram J, Eyring A, et al. Preliminary results of a phase II study: PD-1 blockade in mismatch repair–deficient, recurrent or persistent endometrial cancer. Gynecol Oncol. 2016;141:206–7.

  45. 45.

    Ramos A, Fortin SAM, Melchert V, Jenkins D, Borger DR, Growdon WB. Checkpoint inhibitor signatures across endometrial carcinoma histologic subtypes. Gynecol Oncol. 2018;149:621.

  46. 46.

    Bonadona V, Bonaïti B, Olschwang S, Grandjouan S, Huiart L, Longy M, et al. Cancer risks associated with germline mutations in MLH1, MSH2, and MSH6 genes in lynch syndrome. JAMA. 2011;305:2304–10.

  47. 47.

    Fashoyin-Aje L, Donoghue M, Chen H, He K, Veerarghavan J, Goldberg KB, et al. FDA Approval Summary: Pembrolizumab for recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma expressing PD-L1. Oncologist. 2019;24:103–9.

  48. 48.

    Frenel J-S, Le Tourneau C, O’Neil B, Ott PA, Piha-Paul SA, Gomez-Roca C, et al. Safety and efficacy of pembrolizumab in advanced, programmed death ligand 1–positive cervical cancer: results from the phase Ib KEYNOTE-028 trial. J Clin Oncol. 2017;35:4035–41.

  49. 49.

    Sakuishi K, Apetoh L, Sullivan JM, Blazar BR, Kuchroo VK, Anderson AC. Targeting TIM-3 and PD-1 pathways to reverse T cell exhaustion and restore anti-tumor immunity. J Exp Med. 2010;207:2187–94.

  50. 50.

    Fourcade J, Sun Z, Benallaoua M, Guillaume P, Luescher IF, Sander C, et al. Upregulation of TIM-3 and PD-1 expression is associated with tumor antigen-specific CD8(+) T cell dysfunction in melanoma patients. J Exp Med. 2010;207:2175–86.

  51. 51.

    Zhou Q, Munger ME, Veenstra RG, Weigel BJ, Hirashima M, Munn DH, et al. Coexpression of TIM-3 and PD-1 identifies a CD8+ T-cell exhaustion phenotype in mice with disseminated acute myelogenous leukemia. Blood. 2011;117:4501–10.

  52. 52.

    Ngiow SF, Teng MWL, Smyth MJ. Prospects for TIM3-targeted antitumor immunotherapy. Cancer Res. 2011;71:6567–71.

  53. 53.

    Wolchok JD, Kluger H, Callahan MK, Postow MA, Rizvi NA, Lesokhin AM, et al. Nivolumab plus Ipilimumab in advanced melanoma. N Engl J Med. 2013;369:122–33.

  54. 54.

    Kandoth C, McLellan MD, Vandin F, Ye K, Niu B, Lu C, et al. Mutational landscape and significance across 12 major cancer types. Nature. 2013;502:333.

  55. 55.

    Talhouk A, McConechy MK, Leung S, Li-Chang HH, Kwon JS, Melnyk N, et al. A clinically applicable molecular-based classification for endometrial cancers. Br J Cancer. 2015;113:299.

  56. 56.

    Meng B, Hoang LN, McIntyre JB, Duggan MA, Nelson GS, Lee CH, Köbel M. POLE exonuclease domain mutation predicts long progression-free survival in grade 3 endometrioid carcinoma of the endometrium. Gynecol Oncol. 2014;134:15–19.

  57. 57.

    Bosse T, Nout RA, McAlpine JN, McConechy MK, Britton H, Huessein YR, et al. Molecular classification of grade 3 endometrioid endometrial cancers identifies distinct prognostic subgroups. Am J Surg Pathol. 2018;42:561–8.

  58. 58.

    Mills AM, Sloan EA, Thomas M, Modesitt SC, Stoler MH, Atkins KA, Moskaluk CA. Clinicopathologic comparison of Lynch syndrome–associated and “Lynch-like” endometrial carcinomas identified on universal screening using mismatch repair protein immunohistochemistry. Am J Surg Pathol. 2016;40:155–65.

  59. 59.

    Haraldsdottir S, Hampel H, Tomsic J, Frankel WL, Pearlman R, de la Chapelle A, Pritchard CC. Colon and endometrial cancers with mismatch repair deficiency can arise from somatic, rather than germline, mutations. Gastroenterology. 2014;147:1308–16.

  60. 60.

    Watkins JC, EJ Yang, Muto MG, Feltmate CM, Berkowitz RS, Horowitz NS, et al. Universal screening for mismatch-repair deficiency in endometrial cancers to identify patients with Lynch syndrome and Lynch-like syndrome. Int J Gynecol Pathol. 2017;36:115–27.

Download references


The authors would like to thank the University of Virginia Biorepository and Tissue Research Facility for their skill and expertise in performing all immunohistochemical staining.

Author information

Conflict of interest

The authors declare that they have no conflict of interest.

Correspondence to Anne M. Mills.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark
Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5