Neuro-Oncology

Medulloblastoma and ependymoma are common pediatric central nervous system tumors with significant molecular and clinical heterogeneity. We collected bulk RNA sequencing data from 888 medulloblastoma and 370 ependymoma tumors to establish a comprehensive reference landscape. Following rigorous batch effect correction, normalization, and dimensionality reduction, we constructed a unified landscape to explore gene expression, signaling pathways, RNA fusions, and copy number variations. Our analysis revealed distinct clustering patterns, including two primary ependymoma compartments, EPN-E1 and EPN-E2, each with specific RNA fusions and molecular signatures. In medulloblastoma, we observed precise stratification of Group 3/4 tumors by subtype and in SHH tumors by patient age. This landscape serves as a vital resource for identifying biomarkers, refining diagnoses, and enables the mapping of new patients bulk RNA-seq data onto the reference framework to predict biology and outcome from nearest neighbor analysis facilitate accurate disease subtype identification. The landscape is accessible via Oncoscape, an interactive platform, empowering global exploration and application. One Sentence SummaryA landscape built using only Transcriptomic analysis for medulloblastoma and ependymoma reveals novel insights about subtype-specific biology.

BackgroundMedulloblastoma is the most common malignant pediatric brain tumor, and has an urgent need for novel treatment approaches. Dordaviprone (ONC201) and its chemical derivative with nanomolar potency, ONC206, induce apoptosis of cancer cells by activation of the mitochondrial caseinolytic protease P (ClpP). ONC206 is currently in Phase I clinical trials for pediatric patients with primary brain tumors. MethodsIn this study, we evaluated the preclinical therapeutic effects of ONC206 in medulloblastoma and investigated its mechanism of action. ResultsWe found evidence for high expression of ClpP at both the RNA and protein level in medulloblastoma tumors, compared to very low expression in normal brain tissue. In addition, we saw a pronounced reduction in cell viability of human Group 3 and Group 4 and murine SHH-driven and Group 3 medulloblastoma cells treated with ONC206 with low IC-50s. After treatment with ONC206, we observed an induction of integrated stress response and mitochondrial damage. To test the efficacy of ONC206 in vivo, we used murine models of SHH-driven and Group 3 medulloblastoma as well as Group 3 and Group 4 patient-derived xenografts (PDXs). ONC206 led to a significant prolongation of survival in both murine models, with the SHH mice demonstrating survival extension from 70 to 140 days. PDX-bearing mice also responded to ONC206, which led to a significant survival benefit. ConclusionOur results highlight ONC206 as a novel therapeutic option for patients with high-risk medulloblastoma and provide strong rationale for testing the efficacy of ONC206 in the treatment of these patients. Key points (2-3)ONC206 potently kills medulloblastoma cells by inducing integrated stress response and mitochondrial damage. ONC206 prolongs survival of medulloblastoma-bearing mice in both murine and patient-derived xenograft models. Importance of studyThere is an unmet need for better therapies for high-risk medulloblastoma patients. ONC201 has shown promising responses and recently received FDA approval for diffuse midline glioma. ONC206 is a chemical derivative with higher potency and better brain penetrance. In this study, we analyzed the therapeutic potential of ONC206 for high-risk medulloblastoma and found that the drug effectively killed mouse and human medulloblastoma cells with high nanomolar potency. We also saw that ONC206 very significantly prolonged survival of medulloblastoma-bearing mice, both in genetically engineered mouse models and patient-derived xenografts. Our study provides a strong rationale for testing the efficacy of ONC206 in the treatment of patients with medulloblastoma and has set the stage for a clinical trial with this agent in pediatric patients with recurrent malignant brain tumors, including medulloblastoma (NCT04732065).

In order to better understand the relationship between normal and neoplastic brain, we combined five publicly available large-scale datasets, correcting for batch effects and applying Uniform Manifold Approximation and Projection (UMAP) to RNA-seq data. We assembled a reference Brain-UMAP including 702 adult gliomas, 802 pediatric tumors and 1409 healthy normal brain samples, which can be utilized to investigate the wealth of information obtained from combining several publicly available datasets to study a single organ site. Normal brain regions and tumor types create distinct clusters and because the landscape is generated by RNA seq, comparative gene expression profiles and gene ontology patterns are readily evident. To our knowledge, this is the first meta-analysis that allows for comparison of gene expression and pathways of interest across adult gliomas, pediatric brain tumors, and normal brain regions. We provide access to this resource via the open source, interactive online tool Oncoscape, where the scientific community can readily visualize clinical metadata, gene expression patterns, gene fusions, mutations, and copy number patterns for individual genes and pathway over this reference landscape.

BackgroundMost genomic studies of adult-type diffuse gliomas have focused on predominantly European ancestry populations, limiting the generalizability of molecular classifications and precision medicine approaches. We assembled a multi-institutional glioma cohort of diverse patients to investigate how germline ancestry, molecular subtypes, and mutational processes shape tumor biology and clinical outcomes. MethodsWe analyzed 1,102 adults with WHO 2021-classified diffuse gliomas (IDH-mutant, 1p/19q-codeleted oligodendroglioma; IDH-mutant astrocytoma; IDH-wildtype glioma) from seven U.S. institutions. Whole-exome sequencing (WES) of FFPE tumors identified somatic alterations and COSMIC SBS v3.2 mutational signatures. Genetic ancestry was estimated from WES using 1000 Genomes reference populations. Overall survival was assessed using Kaplan-Meier and multivariable models. ResultsThe cohort included 66.9% European (EUR), 21.1% Admixed American/Hispanic (AMR), 10.3% Admixed African (AFR), and 1.6% Asian (AS) ancestry. Survival followed expected molecular hierarchy (median overall survival: oligodendroglioma 15.7 years, astrocytoma 10.6 years, IDH-wildtype glioma 1.9 years). Within oligodendroglioma, AMR patients showed improved survival versus EUR (HR 0.67, 95% CI 0.48-0.94; p=0.011), with similar trends across subtypes. Somatic profiling confirmed canonical subtype-defining alterations and revealed higher ATRX alterations in AFR and AMR IDH-wildtype tumors compared with EUR. ATRX alterations were associated with improved survival only in AFR (p=0.003). Mutational signature analysis identified subtype-specific signatures, including therapy-associated signatures. Chemotherapy-related signatures were more frequent in EUR and AMR than in AFR. ConclusionsThis ancestrally diverse glioma cohort confirms established molecular classifications and identifies ancestry-associated differences in survival, somatic alterations, and mutational processes, indicating the critical need for broad representation to inform precision neuro-oncology. Key PointsO_LIA multi-institutional glioma cohort validates subtype and survival patterns across ancestries. C_LIO_LITherapy-associated mutational signatures differ by ancestry, suggesting distinct treatment-related mutational processes. C_LIO_LIAdmixed American patients show improved survival, particularly in oligodendroglioma. C_LI Importance of the StudyMost genomic studies of adult-type diffuse glioma have focused on populations of predominantly European ancestry which limits the ability to examine variation in tumor biology and clinical outcomes across populations. In this study, we assembled one of the largest ancestrally diverse cohorts of molecularly characterized adult diffuse gliomas, integrating germline ancestry inference with tumor whole-exome sequencing and mutational signature analysis. We confirm that established molecular classifications and survival hierarchies remain robust across ancestry groups. However, we also identified ancestry-associated differences in survival within specific tumor subtypes, higher ATRX alteration frequencies in African American and admixed American patients with IDH-wildtype tumors, and variation in therapy-associated mutational signatures across ancestry groups. These findings highlight the importance of incorporating population differences into genomic studies of glioma and provide a resource for future multi-ancestry investigations of glioma risk, tumor evolution, and treatment response, ultimately supporting more inclusive precision neuro-oncology.

The cerebellar rhombic lip generates cerebellar progenitors and neurons that ultimately differentiate to comprise over half of all neurons in the adult human brain. Standard clustering approaches often fragment or miss rhombic lip progenitor populations entirely due to their transient nature, small size, and rapid state transitions, leaving fundamental questions unanswered about normal cerebellar development and how such processes may be hijacked in pediatric brain cancer. Medulloblastoma, the most common malignant pediatric brain tumor, affects approximately 500 children annually in the United States with overall survival rates varying dramatically by subgroup. Sonic hedgehog (SHH) medulloblastoma, comprising 25-30% of cases, arises from rhombic lip-derived granule neuron precursors (GNP) within the external granule layer (EGL) and has particularly poor outcomes in several subtypes (5-year survival [~]41%). Using our topic modeling framework on over one million fetal cerebellar nuclei, we identify proliferative rhombic lip and EGL states that bifurcate into distinct glial and neuronal lineages through intermediate progenitors and capture a portion of the developmental spectrum form outer EGL (oEGL) proliferation through inner EGL (iEGL) differentiation. These developmental signatures (topics) persist in medulloblastoma, validating GNP origins of SHH tumors and revealing age-specific molecular programs that correspond to distinct stages of EGL development within SHH subtypes. Our transferable framework enables systematic comparison of developmental and disease states across technologies without data integration, solving a fundamental challenge as genomic atlases expand.

Gliomas are complex and heterogeneous primary brain tumors with a high degree of therapeutic resistance, particularly glioblastomas, which carry a poor prognosis. Cellular plasticity and stem cell-like features, or "stemness," are increasingly recognized as key contributors to tumor progression and treatment resistance. In this study, we introduce two machine-learning-based prediction models designed to assess stemness in glioma samples using bulk gene expression data. One model captures fetal astrocyte characteristics (ASTsi), while the other identifies glioma stem cell traits (GSCsi). ASTsi was notably correlated with poor prognosis in IDHmut gliomas, whereas GSCsi was more indicative of stemness in IDHwt subtypes. Longitudinal data analysis showed that IDHwt and grade IV gliomas exhibit shifts in stemness indices upon recurrence, suggesting a phenotypic change linked to therapy resistance. Additionally, single-cell transcriptomic analysis confirmed that GSCsi can detect stem-like cell subsets in IDHwt gliomas. This approach enhances our understanding of glioma heterogeneity and reveals potential therapeutic targets.

BackgroundMutations of the isocitrate dehydrogenase (IDH) gene occur in over 80% of low-grade gliomas and secondary glioblastomas. Despite considerable efforts, endogenous in vitro IDH-mutated glioma models remain scarce. Availability of these models is key for the development of new therapeutic interventions. MethodsCell cultures were established from fresh tumor material and expanded in serum-free culture media. D-2-Hydroxyglutarate levels were determined by mass-spectrometry. Genomic and transcriptomic profiling were carried out on the Illumina Novaseq platform, methylation profiling was performed with the Infinium MethylationEpic BeadChip array. Mitochondrial respiration was measured with the Seahorse XF24 Analyzer. Drug screens were performed with an NIH FDA-approved anti-cancer drug set and two IDH-mutant specific inhibitors. ResultsA set of twelve patient-derived IDHmt cell cultures was established. We confirmed high concordance in driver mutations, copy number and methylation profiles between the tumors and derived cultures. Homozygous deletion of CDKN2A/B was observed in all cultures. IDH-mutant cultures had lower mitochondrial reserve capacity. IDH-mutant specific inhibitors did not affect cell viability or global gene expression. Screening of 107 FDA-approved anti-cancer drugs identified nine compounds with potent activity against IDHmt gliomas, including three compounds with favorable pharmacokinetic characteristics for CNS penetration: teniposide, omacetaxine mepesuccinate, and marizomib. ConclusionsOur twelve IDH-mutant cell cultures show high similarity to the parental tissues and offer a unique tool to study the biology and drug sensitivities of high-grade IDHmt gliomas in vitro. Our drug screening studies reveal lack of sensitivity to IDHmt inhibitors, but sensitivity to a set of nine available anti-cancer agents. Key pointsO_LIIDHmt glioma cultures closely resemble their parental tumors C_LIO_LIMicroscopic monitoring of early passages and colony isolation increases IDH1mt culture success C_LIO_LIDrug screening identified nine candidate repurposed drugs for IDHmt glioma C_LI Importance of the studyIDH-mutations are highly prevalent in low grade and secondary high-grade gliomas. Despite this high frequency however, very few in vitro models have been reported for IDH-mutated gliomas. In this manuscript we describe and characterize in detail twelve primary cultures from IDH-mutant astrocytomas. We show that these cultures retain most of the genetic, epigenetic and metabolic features of their respective parental tumors. Because of these similarities, these independent model systems will not only help understand the molecular defects driven by the mutation, but are also vital to identify means to target these tumors. Screening of 107 FDA-approved anti-cancer agents on these cultures identified a set of highly effective agents that may offer candidates for either systemic or assisted delivery treatment of this tumor subtype.

Glioblastoma hijacks neuronal pathways to drive tumor growth, and drugs affecting the function of these pathways may potentiate survival gains. Recent studies have suggested clinical benefits with post-diagnostic use of gabapentin. We assessed the impact of taking gabapentin after glioblastoma diagnosis utilizing an active comparator model in a population-based dataset of older adults in the United States. We leveraged a cohort of glioblastoma patients >65 years old who received resection, radiation, and temozolomide from the Surveillance, Epidemiology and End Results data paired with Medicare claims. Those receiving post-diagnostic gabapentin (TMZ+G) were compared to those receiving standard of care treatment only (TMZ), and two active comparators (duloxetine [TMZ+D], and levetiracetam [TMZ+L]). Association between medication use and overall survival was assessed using cox proportional hazards models adjusted for known prognostic factors. Out of 2,494 individuals, 797 (32%) received TMZ, 146 (5.9%) received TMZ+G, 38 (1.5%) received TMZ+D, and 1,513 (60.7%) received TMZ+L. Median survival among those receiving TMZ (10 months) as compared to all other groups (TMZ+G=16.3 months, TMZ+D=16 months; TMZ+L=13.0 months). TMZ+G was associated with 47% decrease in hazard of death (p<0.001) compared to TMZ, and a 32% decrease (p<0.001) compared to TMZ+L. Women had a 43% decrease in hazard of death (p<0.001) in TMZ+G as compared to TMZ+L, while this difference was non-significant in men (p=0.204). These results show survival benefit associated with gabapentin and supports ongoing work therapeutically targeting neuron-glioma interactions.

In contrast to most other tumors, the anatomical extent of brain tumors is not objectified and quantified through staging. Staging systems are built on the understanding of the anatomical sequence of tumor progression and its relation to histopathological dedifferentiation and survival. While major advances in the understanding of primary brain tumors at a histological, cellular and molecular level have been achieved in recent decades, our understanding at a macroscopic anatomical level is limited. The aim of this study was to describe the anatomical phenotype of the most frequent brain tumor entities based on topographic probability and growth behavior analysis. The association of anatomical tumor features with survival probability was assessed and a prototypical staging system for WHO grade II-IV glioma was proposed based on the hypothesized anatomical sequence of tumor progression. The analysis is based on data from a consecutive cohort of 1000 patients with first diagnosis of a primary or secondary brain tumor. On preoperative MRI, the relative tumor density (RTD) of different topographic, phylogenetic and ontogenetic parcellation units was derived through normalization of the relative tumor prevalence to the relative volume of the respective structure. While primary central nervous system lymphoma (PCNSL) showed a high RTD along white matter tracts, the RTD in metastases was highest along terminal arterial flow areas. Neuroepithelial tumors (NT) demonstrated a high and homogeneous RTD along all sectors of the ventriculo-cortical axis, avoiding adjacent units, consistent with a transpallial behavior within phylo-ontogenetic radial units. Additionally, the topographic probability in NT correlated with morphogenetic processes of convergence and divergence of radial units during phylo- and ontogenesis. The anatomical tumor growth behavior was analyzed by comparing pre- and postoperative MRI, showing that a ventriculofugal growth dominates in NT. With progressive histopathological dedifferentiation of NT, a gradual deviation from this neuroepithelial anatomical behavior was found. By comparing survival probability, we identified prognostically critical steps in the anatomical behavior of NT. Based on a hypothesized sequence of anatomical tumor progression, we developed a three-level prototypical staging system for WHO grade II-IV glioma. This staging system proved to be accurate across histological, molecular, radiomorphological and clinical strata based on Kaplan Meier curves and multivariable survival analysis. Similar to staging systems for other tumors, a staging system such as this one may have the potential to inform stage-adapted treatment decisions.

Somatic mutations in the isocitrate dehydrogenase genes IDH1 and IDH2 occur at high frequency in several tumour types. Even though these mutations are confined to distinct hotspots, we show that gliomas are the only tumour type with an exceptionally high percentage of IDH1R132H mutations. This high prevalence is important as IDH1R132H is presumed to be relatively poor at producing D-2-hydroxyglutarate (D-2HG) whereas high concentrations of this oncometabolite are required to inhibit TET2 DNA demethylating enzymes. Indeed, patients harbouring IDH1R132H mutated tumours have lower levels of genome-wide DNA-methylation, and an associated increased gene expression, compared to tumours with other IDH1/2 mutations ("non-R132H mutations"). This reduced methylation is seen in multiple tumour types and thus appears independent of site of origin. For 1p/19q non-codeleted glioma patients, we show that this difference is clinically relevant: in samples of the randomised phase III CATNON trial, patients harbouring non-R132H mutated tumours have better outcome (HR 0.41, 95% CI [0.24, 0.71], p=0.0013). Non-R132H mutated tumours also had a significantly lower proportion of tumours assigned to prognostically poor DNA-methylation classes (p<0.001). IDH mutation-type was independent in a multivariable model containing known clinical and molecular prognostic factors. To confirm these observations, we validated the prognostic effect of IDH mutation type on a large independent dataset. The observation that non-R132H mutated 1p/19q non-codeleted gliomas have a more favourable prognosis than their IDH1R132H mutated counterpart is clinically relevant and should be taken into account for patient prognostication. Single sentence summaryAstrocytoma patients with tumours harbouring IDH mutations other than p.R132H have increased DNA methylation levels and longer survival

BackgroundGlioblastoma (GB) is a highly aggressive and treatment-resistant brain cancer with poor prognosis. Surgical resection followed by radiotherapy (RT) with the chemotherapeutic, temozolomide (TMZ), is the standard GB treatment; yet recurrence often occurs. GB is organized hierarchically with a small population of radiation-resistant glioma-initiating cells (GICs) that self-renew and drive tumor growth. Importantly, RT can induce a subset of cells from non-tumor-initiating into glioma-initiating cells (iGICs). Both GICs and iGICs contribute to tumor recurrence and therapy resistance. Thus, without effective elimination of non-tumorigenic GB and prevention or targeting of GICs, a cure is unlikely. The objective of this study is to identify small molecules that block RT-induced phenotypic conversion to occur. MethodWe conducted a high-throughput screen of NCIs Cancer Therapy Evaluation Program (CTEP) compounds with evidence for crossing the blood-brain-barrier. To identify "stemness" or reprogramming of cells, we transduced GB cell lines representing each TCGA subtype to express a fluorescent reporter for proteasomal activity that distinguishes non-tumor-initiating cells from GICs. We tested CTEP agents at 10 different concentrations in combination with radiation. ResultsOur results identified selumetinib as a candidate compound that effectively prevents radiation-induced phenotype conversion. Furthermore, in combination with radiation, selumetinib decreased stem cell maintenance in GICs with differential effects on viability in non-tumorigenic cells. ConclusionTaken together, these findings suggest that repurposing FDA-approved compounds alongside current therapies may effectively target the cellular and molecular heterogeneity of GB--and because these agents are already clinically approved, this approach can be rapidly implemented in the clinic.

Medulloblastoma (MB) is the most common malignant primary pediatric brain tumor. Current therapies are ineffective for targeting proliferation, leptomeningeal migration, and metastasis of MB cancer cells to visceral organs and therefore, novel treatments are needed. The small GTPase, RAC1, has emerged as an important regulator of actin cytoskeletal dynamics, proliferation, and migration in several cancers. However, it has not been characterized in MB and no clinical drug candidates have been described for RAC1 in MB. Here we demonstrate that RAC1 levels are higher in MB tissue relative to normal cerebellum. Further, RAC1 depletion significantly reduces proliferation and migration of Shh-MB cells in vitro. Mechanistically, RAC1 controls the mRNA and protein levels of the main transcription factors in the Shh pathway, GLI1 and GLI2. RAC1 binds to the GLI1 promoter highlighting a novel role in transcriptional regulation in Shh-dependent cancers. We demonstrate that the RAC1 inhibitor, GYS32661, is brain penetrant, and reduces MB growth and increases mouse survival in an orthotopic model of Shh-MB. Importantly, GYS32661 is a non-toxic clinical candidate, suggesting that it may be a novel potential drug for the treatment of either the pediatric or adult forms of MB. Collectively, our studies identify RAC1 as a druggable target in Shh-dependent MB. Graphical abstractRAC1 controls Shh-MB progression by binding to the GLI1 promoter. Graphical abstract demonstrating RAC1 localizes to the nucleus and binds to the GLI1 promoter and plays an important role in its transcription. RAC1 genetic or GYS32661 mediated inhibition leads to RAC1 dissociation from the GLI1 promoter and transcriptional repression of Shh-MB biomarkers GLI2, DNMT1 and UHRF1. This eventually causes inhibition of Shh-MB tumor cell proliferation and migration, which leads to a decrease in Shh-MB development. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=118 SRC="FIGDIR/small/655563v2_ufig1.gif" ALT="Figure 1"> View larger version (37K): org.highwire.dtl.DTLVardef@e4def9org.highwire.dtl.DTLVardef@1eab826org.highwire.dtl.DTLVardef@dfe68borg.highwire.dtl.DTLVardef@198efb9_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundThe current WHO classification integrates histological and molecular features of brain tumors. The aim of this study was to identify generalizable topological patterns with the potential to add an anatomical dimension to the classification of brain tumors. MethodsWe applied non-negative matrix factorization as an unsupervised pattern discovery strategy to the fine-grained topographic tumor profiles of 936 patients with primary and secondary brain tumors. From the anatomical features alone, this machine learning algorithm enabled the extraction of latent topological tumor patterns, termed meta-topologies. The optimal parts-based representation was automatically determined in 10,000 split-half iterations. We further characterized each meta-topologys unique histopathologic profile and survival probability, thus linking important biological and clinical information to the underlying anatomical patterns ResultsIn primary brain tumors, six meta-topologies were extracted, each detailing a transpallial pattern with distinct parenchymal and ventricular compositions. We identified one infratentorial, one allopallial, three neopallial (parieto-occipital, frontal, temporal) and one unisegmental meta-topology. Each meta-topology mapped to distinct histopathologic and molecular profiles. The unisegmental meta-topology showed the strongest anatomical-clinical link demonstrating a survival advantage in histologically identical tumors. Brain metastases separated to an infra- and supratentorial meta-topology with anatomical patterns highlighting their affinity to the cortico-subcortical boundary of arterial watershed areas. ConclusionsUsing a novel data-driven approach, we identified generalizable topological patterns in both primary and secondary brain tumors Differences in the histopathologic profiles and prognosis of these anatomical tumor classes provide insights into the heterogeneity of tumor biology and might add to personalized clinical decision making.

While CDKN2A loss is classically associated with cell cycle deregulation through the p16-Cdk4-Rb axis, our findings suggest an additional layer of metabolic vulnerability arising from altered NAD homeostasis in CDKN2A-deleted glioblastoma, revealing a previously unrecognized metabolic-genetic interface for rationally revisiting NAD+ targeting strategies, moving beyond the broad inhibition approaches.

BackgroundTo achieve replicative immortality, most cancers develop a telomere maintenance mechanism, such as reactivation of telomerase or alternative lengthening of telomeres (ALT). There are limited data on the prevalence and clinical significance of ALT in pediatric brain tumors, and ALT-directed therapy is not available. MethodsWe performed C-circle analysis (CCA) on 579 pediatric brain tumors that had corresponding tumor/normal whole genome sequencing through the Open Pediatric Brain Tumor Atlas (OpenPBTA). We detected ALT in 6.9% (n=40/579) of these tumors and completed additional validation by ultrabright telomeric foci in situ on a subset of these tumors. We used CCA to validate TelomereHunter for computational prediction of ALT status and focus subsequent analyses on pediatric high-grade glioma (pHGG) Finally, we examined whether ALT is associated with recurrent somatic or germline alterations. ResultsALT is common in pHGG (n=24/63, 38.1%), but occurs infrequently in other pediatric brain tumors (<3%). Somatic ATRX mutations occur in 50% of ALT+ pHGG and in 30% of ALT-pHGG. Rare pathogenic germline variants in mismatch repair (MMR) genes are significantly associated with an increased occurrence of ALT. Conclusions: We demonstrate that ATRX is mutated in only a subset of ALT+ pHGG, suggesting other mechanisms of ATRX loss of function or alterations in other genes may be associated with the development of ALT in these patients. We show that germline variants in MMR are associated with development of ALT in patients with pHGG. Key PointsATRX alterations are frequent, but not required, for an ALT phenotype in pHGGs pHGG patients with germline mismatch repair variants have higher rate of ALT + tumors TelomereHunter is validated to predict ALT in pHGGs Importance of the StudyWe performed orthogonal molecular and computational analyses to detect the presence of alternative lengthening of telomeres in a highly characterized cohort of pediatric brain tumors. We demonstrate that many pHGG utilize ALT without a mutation in ATRX, suggesting either loss of function of ATRX via an alternative mechanism or an alternate means of development of ALT. We show that germline variants in MMR genes are significantly associated with ALT in pHGG. Our work adds to the biological understanding of the development of ALT and provides an approach to stratify patients who may benefit from future ALT-directed therapies in this patient population.

BackgroundDespite intensive therapies, outcomes for high-risk pediatric brain tumors (PBTs) remain dismal, prompting the search for novel treatments. DNA methyltransferase inhibitors (DNMTi) have been shown to prime tumors to improve response to checkpoint inhibition. The aim of this study was to investigate the potential of decitabine (DAC), in combination with a PD-1 inhibitor, to improve survival in pediatric high-risk brain tumor models. MethodsAnalysis of human PBT datasets was performed to determine gene expression levels of immune cell associated markers. Tumor response to DAC, with or without a PD-1 inhibitor, was tested in murine models representing H3-wildtype diffuse intrinsic pontine glioma (DIPG), H3K27-mutant diffuse midline glioma (DMG), atypical teratoid rhabdoid tumor (ATRT), and medulloblastoma (MB). CyTOF analysis of allograft tumors was performed to characterize changes within the tumor microenvironment. ResultsAnalysis of PBT subtypes revealed heterogeneous expression of immune cell markers, checkpoint receptors, and MHC molecules. DAC treatment decreased DNA methylation and increased neoantigen expression in human and mouse tumor cells. DAC alone or in combination with a PD-1 inhibitor resulted in prolonged survival in syngeneic mouse models of DIPG and ATRT but not DMG and MB models. CyTOF analysis of mouse tumors revealed changes in local immune cell infiltration upon combination treatment. ConclusionsDAC in combination with a PD-1 inhibitor can alter the immune microenvironment in mouse tumor models. Changes were observed in H3-wildtype DIPG and ATRT models, suggesting that certain tumor subtypes may respond to checkpoint blockade after immune augmentation with DNMTi. Key PointsO_LIPBTs show heterogenous expression of immune cell infiltrates C_LIO_LIDAC or DAC plus a PD-1 inhibitor shows extension of survival in H3-wildtype DIPG and ATRT mouse models C_LIO_LIMyeloid-derived suppressor cell abundance could be a major contributing factor to treatment response C_LI Importance of the StudyChildren with high-risk PBTs face dismal outcomes. Immune checkpoint inhibitor (ICI) successes have been demonstrated in a variety of adult malignancies; however, such beneficial outcomes have not been realized in PBTs. Here we investigate single and combination treatment of DNMTi and PD-1 checkpoint inhibition in syngeneic mouse models of high-risk PBTs. Our results suggest that some H3-wildtype DIPG and ATRT tumor types may be responsive to checkpoint therapy post immunomodulation and warrant further investigation.

BackgroundGliomas, particularly high-grade variants such as glioblastoma, remain therapeutically challenging with poor survival outcomes. Current biomarkers inadequately stratify patients for therapy selection, monitoring, and early detection of progression. The FOXO transcription factors and Tribbles pseudokinases, key regulators of the PI3K/AKT pathway, have been implicated in cancer progression but their prognostic value in gliomas is unclear. The aim of this study was to determine whether transcriptional profiles of FOXO and Tribbles family members predict survival in glioma patients better than established biomarkers. MethodsUsing RNA-seq data from The Cancer Genome Atlas (TCGA, n = 705) and Chinese Glioma Genome Atlas (CGGA, n = 1018), along with microarray datasets (REMBRANDT, n = 552; Gravendeel, n = 268), we analyzed mRNA levels of FOXO1/3/4/6 and TRIB1/2/3. Survival analysis was performed via Kaplan-Meier curves, log-rank tests, and concordance indices. Gene expression differences across tumor grades and molecular subgroups were assessed using Students t-test. ResultsHigh FOXO1 and low FOXO3/4 mRNA levels, combined with elevated TRIB1/2/3 expression, formed a signature significantly associated with worse survival across all cohorts. This signature stratifies grade 4 gliomas, with a median survival difference of 4.5 months. Grade 4 tumors exhibited elevated FOXO1 and TRIB1/2/3 but reduced FOXO3/4 levels compared to lower-grade gliomas. ConclusionsThe FOXO/Tribbles transcriptional signature robustly predicts survival in glioma patients. These findings highlight its potential as a biomarker for patient stratification and a therapeutic target for high-grade gliomas. Key PointsO_LIFOXO/Tribbles mRNA signature predicts glioma survival status. Our analysis identifies a distinct transcriptional signature - characterized by high FOXO1 and TRIB1/2/3 levels along with low FOXO3 and FOXO4 - that consistently predicts poor prognosis across glioma cohorts. This FOXO/Tribbles signature demonstrates great prognostic power, particularly in grade 4 gliomas, providing an improved tool for risk stratification and clinical decision-making. C_LIO_LIHigh FOXO1 and Tribbles levels mark aggressive glioblastoma tumors. We show that elevated expression of FOXO1 and Tribbles pseudokinases is enriched in glioblastoma (GB) and grade 4 astrocytomas. These tumors, known for their aggressiveness and therapy resistance, are consistently associated with this unfavorable mRNA profile. This suggests a functional role for FOXO1 and Tribbles in glioma progression and highlights them as promising biomarkers and therapeutic targets. C_LIO_LIMulti-cohort validation (TCGA, CGGA) confirms prognostic robustness. The predictive FOXO/Tribbles expression pattern was validated across four large and independent datasets (TCGA, CGGA, REMBRANDT, and Gravendeel), demonstrating consistency despite differences in platform and population. This multi-cohort validation reinforces the robustness and generalizability of this transcriptional signature for predicting survival outcomes in glioma patients. C_LI Importance of the StudyGlioblastoma and high-grade gliomas have dismal prognoses, yet current biomarkers fail to adequately guide therapy. This study identifies a novel transcriptional signature - combining FOXO transcription factors and Tribbles pseudokinases - that robustly predicts survival in glioma patients stratifying aggressive tumors. Using multi-cohort validation (TCGA, CGGA, REMBRANDT), we demonstrate that elevated FOXO1 and Tribbles (TRIB1/2/3) levels, coupled with reduced FOXO3/4, correlate with poor outcomes in grade 4 gliomas. This signature is enriched in glioblastomas, highlighting its link to therapy resistance. Unlike prior studies focusing on individual proteins, our integrated analysis reveals their collective prognostic power, offering a pathway-specific biomarker for patient stratification. These findings provide a translational framework for targeting FOXO/Tribbles in precision oncology, addressing an urgent need for improved therapeutic strategies in neuro-oncology.

Group 3 medulloblastomas (G3MB) carry the worst prognosis among medulloblastoma subtypes, yet molecularly targeted therapies remain elusive. Standard treatments cause severe long-term morbidity in survivors. Here, we identify tumor-derived sphingosine kinase 2 (SPHK2) as an essential driver of G3MB initiation and progression. SPHK2 exacerbates local immunosuppression by suppressing cytotoxic T-cell and NK-cell activity while promoting regulatory T-cell infiltration. Genetic or pharmacologic SPHK2 inhibition using Opaganib attenuates pro-survival tumor signaling and restores anti-tumor immunity, significantly improving survival in syngeneic G3MB mouse models. Combining Opaganib with fractionated low-dose radiation (f-LDRT) further enhances antigen presentation and reprograms tumor-associated myeloid cells toward an anti-tumor phenotype. This combination therapy markedly prolongs survival without inducing significant toxicity. Overall, our study establishes SPHK2 as a previously unrecognized therapeutic target and presents a safe, effective, microenvironment-reprogramming regimen for G3MB. One Sentence SummaryDirect inhibition of tumor-derived SPHK2 overcomes local immunosuppression and downregulates pro-survival signaling in Group 3 medulloblastoma, while combination with fractionated low-dose radiation further enhances anti-tumor immunity and significantly improves survival.

Immune competent animal models are essential in preclinical glioma research. The ability to investigate tumor development with key tumor microenvironment components such as immune infiltration, stromal cells and extracellular matrix allows for the investigation of these complex tumors. However, the current range of syngeneic models of glioma possess intrinsic limitations which must be acknowledged when designing a preclinical study. To address this gap, we developed genetically engineered mouse cell line models (GEM-CLeMs) by introducing common glioma driver mutations into immortalized astrocytes. A high-grade glioma model was generated by combining Pten knockdown with RAS V12 overexpression, while a low-grade glioma model was produced through p53 knockdown with mutant IDH1R132H overexpression. The RAS/Pten GEM-CLeM tumors grew rapidly in vivo, displayed necrosis, multinucleated pleomorphisms, abundant vascularization, and showed strong enrichment for extracellular matrix remodelling and mesenchymal genes, features closely aligned with human glioblastoma. Importantly, the RAS/Pten GEM-CLeM tumors showed similar survival trends and immune infiltration patterns as a corresponding KrasG12D/PtencKO GEMM, but could be grown to larger sizes, facilitating better stromal and immune analyses. In contrast, the IDH1R132H/p53 GEM-CLeM formed slow-growing tumors with distinctive immune infiltration and vascular patterns, consistent with low-grade glioma phenotypes. Compared with the commonly used cell line GL261, the GEM-CLeM tumors had higher levels of stromal integration and immune suppression, making them a more faithful model of the glioma tumor microenvironment. This system enables rapid generation of transplantable glioma models with defined driver mutations in a low-mutational background, offering a flexible platform for dissecting glioma biology and evaluating immunotherapies. Importance of the studyWe have generated a set of customizable, modular Genetically Engineered Mouse Cell Line Models (GEM-CLeMs) of "high grade" and "low grade" glioma. They reliably form tumors when transplanted intracranially into immune-competent C57BL/6 mice, and they are cost- and time-effective at capturing the important characteristics of glioma, both mutant IDH1 low grade glioma and high grade glioblastoma. Critically these characteristics include the myeloid-rich immune suppressive tumor immune microenvironment, a key weakness of existing murine glioma cell lines like GL261. These GEM-CLeM models can be used in multiple ways. The cells are amenable to further manipulation, so therapeutic targets and drug mechanism of action can be assessed. The activity of candidate genes in tumour formation and phenotype can be determined. Most importantly the models can be used to develop effective immunotherapies, including strategies to target macrophage and myeloid cell immune suppression. Key pointsO_LICombinations of driver mutations were engineered into an immortalised mouse astrocyte. C_LIO_LIEngineered cells formed tumours on intracranial transplant into immune competent mice. C_LIO_LITumors had key histological and immune suppressive features of human glioma. C_LI

Ependymomas encompass a heterogeneous group of central nervous system (CNS) neoplasms that occur along the entire neuroaxis. In recent years, extensive (epi-)genomic profiling efforts have identified several molecular groups of ependymoma that are characterized by distinct molecular alterations and/or patterns. Based on unsupervised visualization of a large cohort of genome-wide DNA methylation data, we identified a highly distinct group of pediatric-type tumors (n = 40) forming a cluster separate from all established CNS tumor types, of which a high proportion were histopathologically diagnosed as ependymoma. RNA sequencing revealed recurrent fusions involving the pleomorphic adenoma gene-like 1 (PLAGL1) gene in 19 of 20 of the samples analyzed, with the most common fusion being EWSR1:PLAGL1 (n = 13). Five tumors showed a PLAGL1:FOXO1 fusion and one a PLAGL1:EP300 fusion. High transcript levels of PLAGL1 were noted in these tumors, with concurrent overexpression of the imprinted genes H19 and IGF2, which are regulated by PLAGL1. Histopathological review of cases with sufficient material (n = 16) demonstrated a broad morphological spectrum of largely ependymoma-like tumors. Immunohistochemically, tumors were GFAP-positive and OLIG2- and SOX10-negative. In 3/16 of the cases, a dot-like positivity for EMA was detected. Consistent with other fusion-positive ependymal groups, all tumors in our series were located in the supratentorial compartment. Median age of the patients at the time of diagnosis was 6.2 years. Analysis of time to progression or recurrence revealed survival times comparable to those of patients with ZFTA:RELA-fused ependymoma. In summary, our findings suggest the existence of a novel group of supratentorial ependymomas that are characterized by recurrent PLAGL1 fusions and enriched for pediatric patients.