Microsatellite instability (MSI) is a tumor molecular phenotype that evolves from loss of function in the mismatch repair (MMR) proteins through deleterious germline mutations, epigenetic inactivation, or somatic biallelic mutations. This phenotype is characterized by genomic hyper-mutability, increased neoantigen expression, and a favorable, immune-rich tumor microenvironment. These features confer a greater likelihood of response to treatment with the class of agents known as immune checkpoint inhibitors (ICI) and, potentially, other immune-based therapeutics. MSI as a predictive biomarker for response to treatment with ICIs ultimately led to the first tissue-agnostic approval of pembrolizumab for advanced, previously treated MSI or deficient MMR (dMMR) tumors. Nevertheless, response to ICIs in dMMR/MSI tumors is not universal. Identifying predictors of response and elucidating mechanisms of immune escape will be crucial to continued successful treatment of this subset. In this review, we aim to describe the pathogenesis and key immunologic features of dMMR/MSI tumors, provide a brief overview of the currently approved treatments, and discuss promising novel immune-based therapeutics currently under investigation.

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