The impact of obesity and bariatric surgery on the immune microenvironment of the endometrium

Background The incidence of endometrial cancer is rising in parallel with the obesity epidemic. Obesity increases endometrial cancer risk and weight loss is protective, but the underlying mechanisms are incompletely understood. We hypothesise that the immune microenvironment may influence susceptibility to malignant transformation in the endometrium. The aim of this study was to measure the impact of obesity and weight loss on the immunological landscape of the endometrium. Methods We conducted a prospective cohort study of women with class III obesity (body mass index, BMI ≥ 40 kg/m 2 ) undergoing bariatric surgery or medically-supervised low-calorie diet. We collected blood and endometrial samples at baseline, and two and 12 months after weight loss intervention. Serum was analysed for inflammatory markers CRP, IL-6 and TNF-α. Multiplex immunofluorescence was used to simultaneously identify cells positive for immune markers CD68, CD56, CD3, CD8, FOXP3 and PD-1 in formalin-fixed paraffin-embedded endometrial tissue sections. Kruskal–Wallis tests were used to determine whether changes in inflammatory and immune biomarkers were associated with weight loss. Results Forty-three women with matched serum and tissue samples at all three time points were included in the analysis. Their median age and BMI were 44 years and 52 kg/m 2 , respectively. Weight loss at 12 months was greater in women who received bariatric surgery ( n = 37, median 63.3 kg) than low-calorie diet ( n = 6, median 12.8 kg). There were significant reductions in serum CRP ( p = 3.62 × 10 −6 , r = 0.570) and IL-6 ( p = 0.0003, r = 0.459), but not TNF-α levels, with weight loss. Tissue immune cell densities were unchanged except for CD8+ cells, which increased significantly with weight loss ( p = 0.0097, r = −0.323). Tissue CD3+ cell density correlated negatively with systemic IL-6 levels ( p = 0.0376; r = −0.318). Conclusion Weight loss is associated with reduced systemic inflammation and a recruitment of protective immune cell types to the endometrium, supporting the concept that immune surveillance may play a role in endometrial cancer prevention.