Clinical-grade AI model for molecular subtyping of endometrial cancer: a multi-center cohort study in China

Accurate molecular subtyping is essential for guiding precision treatment and prognostic stratification in endometrial cancer (EC). However, current methods, based on Sanger sequencing and immunohistochemistry (IHC), are costly, time-intensive, and difficult to implement widely in routine clinical practice, particularly in resource-limited settings. To overcome these challenges, we developed a deep-learning pipeline that directly infers EC molecular subtypes from routine hematoxylin-and-eosin (H&E) whole-slide images (WSIs). The framework integrates super-resolution enhancement (SRResGAN), transformer-based lesion segmentation (MedSAM), and a ResNet-101 classifier for molecular subtype prediction, with an LSTM module for survival modeling. This retrospective study included 393 Chinese patients diagnosed between 2010 and 2018, all with ≥ 5 years of follow-up. Molecular subtypes-POLE^mut, mismatch repair-deficient (MMRd), p53abnormal (p53abn), and no specific molecular profile (NSMP)-were confirmed by Sanger sequencing and immunohistochemistry. The model achieved high classification accuracies (92% for POLE^mut and MMRd, 91% for p53abn, and 90% for NSMP), with a strong correlation between predicted and observed survival (R2 = 0.9692; MAE = 123 days). External validation on two independent cohorts (N = 35 and N = 83) confirmed robust generalizability across institutions. This study represents the first large-scale, multicenter, AI-based digital pathology model for EC molecular classification in China. The proposed workflow provides an automated, interpretable, and cost-efficient alternative to conventional molecular testing, supporting precision oncology, fertility-preserving management, and clinical decision-making in real-world practice.