Neuro-Oncology Advances

H3K27M diffuse midline gliomas (DMGs) are lethal and lack treatment options. These tumors exhibit tumor heterogeneity with aggressive oligodendrocyte precursor (OPC)- and mesenchymal (MES)-like cell states. Because all tumor cells bear H3K27M, tumor heterogeneity has been attributed to microenvironmental cues that remain obscure. H3K27M DMGs exhibit increased glycolysis and the Warburg effect to produce lactate. Lactate can directly modify histone lysines including H3K27Lac, and we hypothesized that lactate epigenetically regulates tumor cell states in H3K27M DMGs. We undertook a comprehensive and integrated analysis of H3K27M DMG cell lines, animal models, tumor tissues, and magnetic resonance spectroscopy in patients to decipher the epigenetic roles of lactate. Here, we report that H3K27M cells uniquely exhibit elevation of the activating mark H3K27Lac. We observed significant heterogeneity in lactate levels within tumors, and the addition of exogenous lactate resulted in marked increases in H3K27Lac and the expression of critical OPC- and MES- like gene signature genes, which correlates with poorer patient outcomes. Our therapeutic approach leverages the inhibition of CBP/p300, which deposits both H3K27Lac and H3K27ac. Targeting CBP/p300 effectively reduces both H3K27Lac and H3K27ac levels, suppresses key OPC- and MES-like signatures, and shows efficacy in preclinical models. Collectively, our findings identify lactate as a key player in the epigenetic regulation of tumor cell state heterogeneity and suggest that targeting this pathway offers promise for addressing the heterogeneous complexities of H3K27M DMGs.

ABSTRACT Background: High grade glioma (HGG), encompassing IDH-wildtype glioblastoma (CNS WHO grade 4), diffuse midline glioma (CNS WHO grade 4), oligodendroglioma (IDH-mutant and 1p/19q-codeleted) CNS WHO grade 3, together with IDH-mutant astrocytoma of CNS grade 3 and grade 4, represents the most lethal group of adult diffuse gliomas. Despite significant efforts, obtaining improvements in patient survival has been limited, in part, by difficulties in comprehensive ex vivo modeling of the complexities of HGG. Although organotypic slice cultures and other platforms have shown promise, existing models often fail to capture the intrinsic cellular heterogeneity, microenvironment, and architecture of HGG, restricting investigations into their fundamental biology as well as design of novel therapeutics. Methods: We developed a patient-derived HGG organotypic slice culture (GOSC) platform demonstrating long-term preservation of intrinsic tumor characteristics. Vibratome-sectioned slices were cultured in defined medium under conditions approximating those in situ: reduced oxygen (4%), low glucose (2.5 mM), and no added growth factors. The characteristics of GOSCs after 28 days in culture, including expression of immunotherapy targets, were compared to parental tumors using histological staining, immunofluorescence, multiplexed PhenoCycler (CODEX) imaging, bulk RNA-seq expression profiling, and CAR T cell killing assays. Results: GOSCs preserved the histopathology, cell heterogeneity, tumor microenvironment, and tissue architecture of their parental tumors throughout at least 28 days in culture. Importantly, GOSCs retained parental patterns of immunotherapy target expression, and CAR T cells co-cultured with GOSCs demonstrated target-specific killing consistent with parental tumors. Conclusions: This ex vivo GOSC platform offers long-term preservation of the cellular and structural properties of parental HGG tumors, thereby providing a robust tool for extended preclinical studies, and facilitating development and evaluation of advanced tumor-targeting strategies.

Background. Automated segmentation of glioma subregions on multiparametric MRI can be improved by changing either the network architecture or the information presented to the network. These two design levers are usually studied together, which makes their individual contributions difficult to see. We present an integrated analysis of two completed, independent studies, each of which isolates one lever. Methods. In the architecture-level study (Slice), SIBA-UNet - a 2D U-Net combining depthwise separable convolution, inverted-bottleneck blocks and attention-guided skip fusion - was trained on 128 x 128 multimodal slices from BraTS 2020 with a patient-level split, and a sigmoid decision threshold was selected on validation data. In the representation-level study (Subtract), CMSR-3D augmented the four standard MRI sequences with four voxel-wise cross-modal subtraction maps (T1-T1CE, T2-FLAIR, FLAIR-T1CE, T2-T1CE) and evaluated 4-, 6- and 8-channel inputs with an identical 3D U-Net on 1,251 BraTS-GLI 2023 cases (1,001/125/125 split). Results. SIBA-UNet reached an overall validation Dice of 0.8601 at a validation-selected threshold of 0.51, with reported subregion Dice of 0.8795 (necrotic core), 0.8501 (edema) and 0.9125 (enhancing tumor); the source ablation was only partially reported. With the architecture held fixed, the 8-channel CMSR-3D configuration gave the highest mean Dice among the evaluated inputs (0.8699 vs. 0.8534 for the 4-channel baseline) and the lowest mean HD95 (5.9859 vs. 8.2308), whereas either two-map subset alone changed mean Dice by at most 0.0037. Conclusions. Architecture design and input-representation design are separable levers for brain tumor segmentation. The controlled representation ablation indicates that the complete set of subtraction maps was more informative than either subset under a fixed 3D U-Net. Both studies were evaluated internally on their respective datasets, and their numerical results are not directly compared because the datasets, dimensionality and evaluation protocols differ.

Pediatric posterior fossa group A (PFA) ependymoma is an aggressive, chemo-resistant brain tumor with a poor 10-year overall survival and no therapeutic options at relapse. Although conventionally classified as immune-cold, the spatial organization and therapeutic relevance of its rare immune infiltrates remain poorly characterized. Here, we present a spatially resolved immune analysis of 14 PFA ependymoma sections using published Visium spatial transcriptomics data analyzed through a multi-stage immune-focused computational framework combining reference-guided deconvolution, functional lymphocyte state scoring, ligand-receptor inference, and {beta}/{gamma}{delta} T cell immunotherapy opportunity scoring. Lymphocyte-associated hotspots were identified in 6 of 14 sections and, among confidently classified hotspots, were dominated by inflammatory-associated and retention-associated transcriptional states rather than cytotoxic or exhausted programs. These hotspots were preferentially confined to myeloid- and mesenchymal-rich tumor zones with near-complete exclusion from epithelial regions; ligand-receptor analysis identified four candidate restriction axes (SPP1-CD44, FN1-integrin, collagen VI-integrin, and APP-CD74). Immunotherapy opportunity scoring revealed heterogeneous and spatially compartmentalized {beta} and {gamma}{delta} T cell recognition landscapes across sections: {beta}T ligand availability and immunosuppressive tone both rose in the mesenchymal compartment, while the two components of {gamma}{delta} phosphoantigen-mediated recognition were spatially and transcriptionally dissociated from one another. Together, these findings reframe PFA ependymoma not as a monolithic immune desert but as a tumor type with spatially compartmentalized, mechanistically tractable immune niches, and provide a generalizable computational strategy for mapping immune architecture and T cell therapy susceptibility in low-infiltrated pediatric CNS tumors.

Objectives: To determine how strongly clinical referral text, rather than image content, drives the decisions of multimodal large language models (LLMs) differentiating glioma from brain abscess on MRI. Materials and methods: This retrospective single-center study included 60 contrast-enhanced T1-weighted brain MRI examinations (30 gliomas, 30 abscesses; reference-standard diagnosis). One axial slice per case was paired with five referral texts (explicitly inflammatory to explicitly tumor-suggestive) under three prompt instructions and submitted 20 times each to GPT-4o, Claude Sonnet 5, Gemini 3.5 Flash, and Qwen 3.6 (72,000 answers). The primary outcome was the text-driven span (difference in tumor-call frequency between explicit inflammatory and explicit tumor text). Two blinded radiologists classified the images without text; sensitivity, specificity, and accuracy were compared descriptively. Results: Patients (29 women) had a mean age of 55.8 +/- 16.4 years. With neutral text, models answered tumor in 45-67% of queries (specificity, 0.38-0.78), versus 52% and 60% for radiologists (specificity, 0.77 and 0.63). The text-driven span was 0.79-1.00 (p < 0.001 for all models), whereas confirmed gliomas and abscesses differed by only 0.01-0.10 in three models and 0.25 in Gemini 3.5 Flash. Subtle wording produced at least 83% of the span in three models. An instruction to ignore the text reduced the span to 0.48-0.70 in three models and to 0.04 in Gemini 3.5 Flash, partly through reversion to a tumor default. Model accuracy was 0.52-0.73 versus 0.78 and 0.73 for radiologists. Conclusion: Multimodal LLMs deferred to referral text over imaging evidence in differentiating glioma from brain abscess, and prompt instructions did not reliably correct this.

Background Gliomas are primary brain tumors that integrate into the surrounding brain via neuron-glioma synapses and disrupt normal neuronal functioning. Recent work links tumor-brain connectivity to clinical measures such as patients' functional status. However, few experimental systems allow the visualization of tumor and resident brain cell architecture together in human tissue at the scale needed to connect cellular organization to clinical outcomes. To address this gap, we developed an experimental framework for investigating the neuron-glioma network in organotypic human cortex from glioma patients, designed to support future correlation of cellular architecture to clinical outcomes such as functional status and survival. Methods Brain tissue samples containing cortex from seven glioma patients were collected during tumor resection and cultured for seven days as organotypic slices. We established several multiplexed immunohistochemistry panels to stain for glioma cells, various types of resident brain cells including neurons and cells from the oligodendrocyte lineage, as well as axonal networks and myelination patterns. Results We demonstrated the presence of tumor cells in all samples using SOX2, a tumor cell marker. NeuN+ neuronal cells were also successfully identified, as were cells from the oligodendrocyte lineage using SOX10 (pan-lineage marker), BCAS1 (pre-myelinating oligodendrocyte marker), and ASPA (mature oligodendrocyte marker). The neuronal network and myelin were successfully visualized using MAP2 (neurons and dendrites), SMI312 (axons), and PLP1 (myelin). Conclusions High-quality visualization of tumor cells, resident brain cells and the (myelinated) neuronal network in organotypic human cortex from glioma patients is possible after seven days of culturing. Future studies could further optimize culture conditions and should study stability of all cellular components in longer term slice cultures. Preliminary analyses indicate that cellular measures derived from human organotypic slices can be linked to patients' functional status, demonstrating the capacity to generate data suitable for large-scale investigation of the effects of glioma-brain network architecture on clinical outcomes.

Stereotactic needle-based delivery remains the standard for local administration of Advanced Therapy Medicinal Products (ATMPs) to the human brain. ATMP administration typically involves multiple trajectories, presenting cumulative risks and prolonging surgery. Reflux-prone, patchy therapy coverage compromises clinical results. We demonstrate a novel approach, deploying a helical delivery catheter via a single access trajectory per target, referred to as SpiraMed. Helix retraction is synchronised with therapy delivery, enabling comprehensive target coverage in seconds. Helix pitch and diameter can be precisely tailored to patient-specific target volume and vascular anatomy, as part of the preoperative stereotactic surgical planning process. Testing in agarose phantoms, live sheep and cadaveric human brain confirms enhanced therapy delivery volume, delivery speed and target coverage, with reductions in reflux and predicted risk of bleeding complication. SpiraMed represents a new paradigm, promising to help deliver on the transformative potential of cell and gene therapies across the spectrum of human CNS disease.

Mismatch repair (MMR) deficiency contributes to temozolomide (TMZ) resistance in a subset of isocitrate dehydrogenase 1/2 mutant (IDHmut) gliomas, creating a need for therapies that retain activity despite MMR loss. We evaluated the novel interstrand crosslinking agent KL-50, alone and in combination with the histone deacetylase inhibitor belinostat, in patient-derived IDHmut glioma models. MSH6 knockout or constitutive expression established four matched MMR-proficient and MMR-deficient culture models. Drug responses were assessed using live cell count and cytotoxicity assays, and KL-50 monotherapy was tested in intracranial BT142 orthotopic xenografts. LOEWE synergy analysis, RNA sequencing, and a genome-wide CRISPR knockout screen assessed combination activity and potential mechanisms. MMR deficiency increased TMZ GI values 2.2- to 30.4-fold, whereas KL-50 retained antiproliferative activity and showed enhanced cytotoxicity in selected MMR-deficient models. In TMZ-naive, MMR-proficient BT142 xenografts, KL-50 increased median survival from 107.5 to 194 days. Two of eight treated mice had no histologically detectable residual tumor after 220 days post-engraftment. KL-50 and belinostat exhibited synergistic cytotoxicity in BT142, 905, and TS603 IDHmut glioma cultures. Transcriptomic gene ontology analyses identified downregulation of DNA repair pathways following histone deacetylase inhibition, including terms for homologous recombination and double-strand break repair. The CRISPR screen identified depletion of PKMYT1-targeting gRNAs during KL-50 treatment, implicating this mitotic checkpoint kinase as a candidate determinant of drug sensitivity. PKMYT1 expression was also reduced by histone deacetylase inhibition. These findings support further preclinical development of KL-50, alone and in combination with belinostat, for IDHmut gliomas including tumors with MMR-associated TMZ resistance.

Neuronal-cancer cell interactions are a key component of brain tumor pathophysiology, yet many fundamental questions remain unanswered, with even more remaining unasked. Here, we present a comprehensive brain tumor reference map generated from bulk RNA-seq data of ~4,300 adult and pediatric brain tumors, including various glioma subtypes, medulloblastomas, ependymomas, and meningiomas, alongside ~1,400 healthy brain samples. By analyzing synaptic processes and synaptic gene expression across tumor types, we reveal the complexity of neuron-tumor crosstalk and its potential impact on patient survival. Our findings identify key synaptic signaling pathways and dysregulated patterns in brain tumors, including HNRNPH2 upregulation, a key factor in RNA processing and metabolism, in gliomas and medulloblastomas. Additionally, we highlight the role of cholinergic signaling, particularly CHRNA9, as a driver of glioma progression, which is also upregulated in WNT and Group 4 medulloblastomas, ependymomas, and meningiomas. Furthermore, P2 purinergic signaling emerges as a key player in glioma progression. These insights lay the groundwork for future studies exploring whether targeting these pathways could reprogram the tumor microenvironment toward an anti-tumor state, ultimately leading to novel therapeutic strategies and improved patient outcomes.

Background: Immune checkpoint inhibitors (ICI) are efficacious in many solid tumors, but response in glioma is restricted to a small subgroup. The determinants of response and resistance to ICI remain poorly understood. Methods: Here we exploit a syngeneic hypermutated high-grade glioma model with dichotomous response to combined PD-1 and CTLA-4 inhibition to unravel determinants of tumor-infiltrating T-cells driving response. Tumor-infiltrating T-cells from ICI-responsive and non-responsive tumors were analyzed by single-cell RNA and T-cell receptor sequencing and tumor-reactive T-cell receptor clonotypes were functionally validated to characterize their transcriptional phenotypes. We verify our findings in IDH1 wildtype glioblastoma patients treated with neoadjuvant pembrolizumab. Results: ICI response was associated with intratumoral clonal expansion of tumor-reactive cytotoxic T-cells and increased infiltration of CXCR6+ CD4+ tissue resident memory T-cells (Trm). CD4 stem-like memory T-cells in responding tumors demonstrated elevated interferon responses, following trajectories toward clonally expanded Trm, versus trajectories toward exhaustion in non-responsive tumors. In responsive tumors, CD4+ Trm interacted with infiltrating CXCR3+ tumor-reactive and clonally expanded, yet transcriptionally versatile cytotoxic T-cells. Probing the post neoadjuvant ICI high-grade glioma patient tissue dataset, we confirmed increased CXCR6 expression in CD4+ T cells and the association of CD4+ Trm with prolonged overall survival. Conclusion: These findings identify CD4 tissue-resident memory T-cells as determinants of ICI response in IDH1 wildtype high-grade glioma and warrant their further investigation to improve immunotherapy outcomes.

Despite intensive treatment, high-risk neuroblastoma (HRNB) remains a leading cause of cancer-related mortality in children. Current treatment paradigms include multimodal systemic treatments and multi-agent chemotherapy, which is limited by substantial acute and long-term toxicities. Platinum-based chemotherapy is a cornerstone of this treatment but is fraught with side effects and stands to benefit from dose reduction strategies. MicroRNA (miR)-based therapeutics represent an attractive strategy to simultaneously moderate multiple oncogenic pathways, providing a potential avenue to enhance the efficacy of current treatment regimens. However, the development of miR therapeutics has largely relied on chemically synthesized ones, which are limited by issues of inconsistency and poor in vivo stability. Biologically produced, tRNA/pre-miR containing bioengineered miRs (bioRNAs) address these limitations. We investigated the therapeutic potential of bioRNA encoding miR-124 and miR-34a across molecularly distinct HRNB models and evaluated their ability to enhance cisplatin efficacy. Both bioRNAs significantly suppressed neuroblastoma cell viability in vitro, with proteomic analyses demonstrating preferential induction of neuronal differentiation by miR-124 and apoptotic signaling by miR-34a. Combining bioRNA with cisplatin produced robust synergy across multiple HRNB lines, enhancing apoptosis while simultaneously promoting differentiation-associated phenotypes. In vivo, both bioRNAs suppressed tumor growth as monotherapies, while combination with low-dose cisplatin produced the strongest responses across multiple xenograft models with different HRNB subtypes. Notably, low-dose cisplatin combined with bioRNA therapy frequently achieved tumor control comparable to, or greater than, that observed with high-dose cisplatin monotherapy while maintaining favorable tolerability. These findings establish bioRNAs as potent cisplatin sensitizers and support bioRNA-based combination therapy as a strategy for improving HRNB treatment while reducing chemotherapy-associated toxicity in children.

Glioma is a fatal tumor of the central nervous system (CNS) with limited therapeutic options. While immune checkpoint inhibitors (ICI) are gaining traction as a novel alternative treatment for human gliomas (HG), clinical trials have yielded mixed results. A proposed major barrier to ICI therapy in cancer is epithelial-mesenchymal plasticity (EMP)-driven intratumoral immunosuppression. However, studying this mechanism is difficult in ex vivo and murine models, which fail to adequately replicate cancer cell-immune cell interactions. Formalin-fixed, paraffin-embedded (FFPE) patient-derived canine glioma (CG) samples represent an attractive alternative approach. Although mechanistic perturbation is unachievable in archival FFPE tissues, CG is notoriously 'cold' immunologically and is actively being investigated as a comparative model of HG. Moreover, the immune microenvironment in CG advantageously develops under exposure to environmental conditions directly shared with humans. Yet, it remains unknown whether CGs harbor heterogeneous niches combining varied plastic phenotypes and immunosuppressive populations. Defining the immune landscape of CG in relation to EMP is therefore critical to determining its potential as a comparative model for immunotherapy response in HG. By combining standard histology, immunohistochemistry, and tissue microarray-based spatial transcriptomics, we analyzed 30 low-grade (LGr) and high-grade (HGr) FFPE CG cases (n=10 cases/subtype): astrocytomas (4xLGr, 6xHGr), oligodendrogliomas (1xLGr, 9xHGr), and undefined gliomas (3LxGr, 7xHGr). All CG subtypes harbored heterogeneous immunosuppressive niches associated with varied EMP phenotypes. Astrocytomas exhibited a more-mesenchymal identity correlated with recruitment of tumor-associated macrophages (TAMs). Oligodendrogliomas displayed a strong stem-like signature and uniquely upregulated a FOXP3/LAG3/SNAI1 triad, positioned directly at the interface of immunosuppression and EMP. Across all CG subtypes, a more-mesenchymal phenotype co-occurred with TAMs, and intratumoral T-cell dysfunction and exhaustion. We conclude that CG replicates the EMP-immunosuppression heterogeneity seen in humans. Importantly, our results emphasize the existence of subtype-specific mechanisms of EMP and immune evasion, underscoring the major relevance of subtyping for translational applications.

Tissue immune measurements can guide immunotherapy only if one biopsy represents the rest of the tumor. We quantified this in a secondary analysis of public data from 75 magnetic resonance imaging (MRI)-localized glioblastoma (GBM) biopsies from 19 patients. Fourteen transcriptomic modules scored supportive, inhibitory, and checkpoint programs. The intraclass correlation coefficient (ICC) gave the share of variance between patients rather than regions, before and after removing the component explained by a 12-gene leukocyte composite. An ICC of 1 indicates no variation in module scores among biopsies within each patient, whereas an ICC of 0 indicates that biopsies from the same patient are no more similar, on average, than biopsies from different patients. Two hepatocellular carcinoma (HCC) cohorts and a microdissected GBM atlas served as comparisons. CD8 had the lowest unadjusted ICC among abundance scores (0.42; 95% patient-bootstrap interval, 0.10 to 0.68; leukocytes, 0.65). Within patients, CD8 correlated with supportive and inhibitory modules alike (unadjusted mean r, 0.37 and 0.36) but not with major histocompatibility complex class I (MHC-I; r = 0.06). Leukocyte adjustment lowered the median module ICC from 0.56 to 0.34 but interferon (IFN) only from 0.74 to 0.70. IFN had the highest adjusted ICC and ranked first in 86% of patient-bootstrap resamples (post hoc). MHC-I was second (0.47) and not separable from IFN (difference 0.23; interval, -0.04 to 0.43); after purity residualization in 67 biopsies, IFN and MHC-I were similar (0.66 and 0.62). Median adjusted ICCs were 0.34 in bulk GBM, 0.62 and 0.74 in HCC, and 0.08 in microdissected GBM. In bulk GBM, only IFN, and MHC-I after purity residualization, had adjusted ICC point estimates above 0.5. The data support multiregion sampling with CD8, IFN, MHC-I, and checkpoint readouts from the same regions.

Background. Hematoporphyrin derivative (HpD, Hiporfin) is used for photodynamic therapy (PDT) of solid tumors but had never been evaluated for fluorescence guided resection (FGR) in glioma. We assessed Hiporfin fluorescence accuracy against histopathology in recurrent glioblastoma (rGBM) and the feasibility of adding cavity PDT to FGR. Methods. In this prospective single arm series, adults with rGBM received a single preoperative intravenous Hiporfin dose of 5 mg/kg before FGR under blue light excitation and 630 nm cavity PDT. Intraoperative fluorescence assessment was the index test and histopathology the reference standard. Specimen level diagnostic accuracy was pooled with bivariate random-effects modeling. Results. Of 63 specimens, 35 were true positive, 7 false positive, 8 false negative and 13 true negative. Pooled sensitivity was 0.751 (95% confidence interval 0.600 to 0.858) and specificity 0.606 (0.407 to 0.775); the crude positive predictive value was 0.833 (0.694 to 0.917) and the negative predictive value 0.619 (0.409 to 0.792). All seven false positive specimens were peritumoral tissue and the eight false negatives were non fluorescent tumor. FGR combined with cavity PDT was completed in all six patients without new neurological deficits. Conclusions. Hiporfin fluorescence identified rGBM with moderate accuracy: fluorescent regions were likely tumor, while non fluorescent tissue often still contained tumor. The main source of error was peritumoral tissue of the treated cavity, and not the drug or the optics. Hiporfin is a new fluorescence agent for glioma. One drug provides both fluorescence guidance during resection and immediate cavity PDT.

Glioblastoma (GBM) is characterized by near-universal recurrence and resistance to therapy. Although tumor-intrinsic mechanisms of radiation resistance have been extensively studied, how the extracellular matrix influences signaling in radiation-resistant GBM remains poorly understood. Here, we investigated discoidin domain receptor 1 (DDR1), a collagen-activated receptor tyrosine kinase, using matched radiation-sensitive parental and radiation-resistant patient-derived GBM models generated through serial in vivo irradiation. Within a three-dimensional collagen I matrix, radiation-resistant GBM cells exhibited distinct temporal patterns of Ki-67 positivity and ERK1/2 phosphorylation compared with parental cells. Despite increased DDR1 expression, radiation-resistant cells exhibited markedly reduced DDR1 phosphorylation and enhanced ectodomain shedding, characterized by accumulation of the membrane-associated C-terminal fragment and release of the N-terminal fragment. DDR1 depletion reduced ERK1/2 phosphorylation, supporting its contribution to ERK1/2 signaling under these conditions. ADAMTS1 was markedly upregulated in radiation-resistant cells, and its knockdown reduced DDR1 ectodomain shedding while increasing full-length DDR1 abundance, ERK1/2 and RB phosphorylation, cyclin D1 expression, and Ki-67 positivity. Together, these findings reveal a distinct DDR1 regulatory state in acquired radiation-resistant GBM, characterized by enhanced ADAMTS1-associated ectodomain shedding, reduced receptor phosphorylation, and attenuated proliferative signaling within a three-dimensional collagen I matrix.

Background: Brain-penetrant histone deacetylase inhibitors (HDACi) are promising radiosensitizing agents for glioblastoma (GBM). HDAC inhibitors can impair DNA damage response (DDR) pathways and promote persistent DNA damage. Here, we evaluated whether combined inhibition of HDAC and the DNA repair kinase, ataxia-telangiectasia mutated (ATM), could synergize with radiation (IR) and improve therapeutic efficacy in GBM. Methods: In vitro dose-response assays were performed in patient-derived xenograft (PDX)-derived glioma stem cells (GSCs) with both inhibitors of HDAC (quisinostat, QST) and ATM (AZD1390) with or without IR treatment to assess synergy. Pharmacodynamic responses were evaluated by immunoblotting for histone acetylation, DDR signaling, and DNA damage markers. Transcriptomic analyses were performed to evaluate treatment-associated changes in DNA repair pathways. The combination of QST, AZD1390, and IR was further evaluated in an orthotopic GBM survival study. Results: Combined treatment with QST and AZD1390 produced synergistic radiosensitization in multiple GSC models in vitro. Furthermore, QST combined with IR suppressed transcription of homologous recombination (HR) pathway genes in GSCs, impairing double-strand break repair capacity through an epigenetic mechanism that does not directly inhibit ATM kinase activity. Pharmacodynamic analyses confirmed that QST increased histone acetylation while AZD1390 suppressed ATM signaling, together impairing complementary mechanisms to increase radiosensitivity of GSCs. In an orthotopic GBM model, QST combined with IR significantly prolonged survival compared with IR alone. However, the addition of AZD1390 did not provide a significant survival benefit beyond QST+IR, and AZD1390 combined with IR did not significantly improve survival relative to IR alone. Conclusions: Combined HDAC and ATM inhibition with QST and AZD1390 enhances radiosensitivity in patient-derived GBM cells, mechanistically underpinned by QST-mediated increase in DNA damage and dual disruption of DDR through complementary, non-overlapping mechanisms. However, this in vitro synergy did not confer additional survival benefit beyond QST+IR in an orthotopic GBM model under the dosing conditions tested, suggesting pharmacological limitations with the tumor microenvironment or suboptimal dosing schedules may have constrained in vivo efficacy.

Background: The Central Brain Tumor Registry of the United States (CBTRUS) uses a histology grouping model based on the World Health Organization (WHO) to classify cancer registry records for clinically relevant statistical reporting. Methods: CBTRUS, together with its consulting neuropathologists, reviewed and aligned its histology groupings with the 2021 WHO Classification update. Obsolete histology nomenclature along with their International Classification of Diseases for Oncology 3rd edition (ICD-O-3) codes were identified, currently included histologies were reclassified as appropriate, and new codes found in 2021 WHO were incorporated. An evaluation was conducted of the frequency of histology codes affected in the reclassification process, as well as incidence and survival pre- and post- reclassification of CBTRUS Tumor Type Groupings. Results: After review of the CBTRUS grouping scheme, 205 codes were reclassified and 2 new codes were incorporated. Tumor type groups most affected were those classified as glioma. Reclassification resulted in 167,038 of 491,804 (34%) cases having a grouping reclassification or reporting change, indicating that the 2021 revision of the WHO Classification has significantly impacted the collection and reporting of primary b CNS tumors. Conclusion: This work demonstrates the need to be responsive to changes in classification and coding for statistics to reflect real-world clinical use. This will require collaboration from all parties to have the ability to reconcile clinical practices and surveillance requirements.

Background: Localized or segmental overgrowth is a rare condition that may co-occur with vascular malformations. These diseases generally are caused by somatic mutations in the PI3K/AKT/mTOR pathway. Most lesions are progressive and may cause symptoms including pain, functional impairment, and disfigurement. Treatment options are limited, especially for the overgrowth component. Objective: To evaluate the efficacy and safety of the mTOR inhibitor sirolimus in patients with overgrowth with or without a vascular malformation over a 6-months treatment period. Methods: We conducted a single-arm, open-label, phase II study including 18 patients (12 pediatric, six adult) with overgrowth, all of whom initiated oral sirolimus. 16/18 (88.9%) participants received oral sirolimus for 6 months, with dosing adjusted to achieve target blood trough levels of 3-8 ng/mL. Primary outcome was radiological response at six months assessed by the Response Evaluation Criteria in Solid Tumors (RECIST) 1.1. Secondary outcome parameters were evaluated at three, six and nine months and included size and visual appearance of the overgrowth, quality of life (QoL), pain intensity, performance status, and safety. Results: No patient achieved complete or partial radiological response. 17 of 18 patients (94.4%) maintained stable disease at month six; one was not evaluable. QoL measured with WHOQOL-BREF improved modestly in patients aged >= 18 years (n=5, mean difference to baseline +9.3 (95%-CI: -0.9 to 19.5) in physical and +9.2 (95%-CI: 0.7 to 17.7) in psychological domains at month 6). In pediatric participants, no relevant improvement in KINDL total scores was observed over the study period. No significant changes occurred in pain scores. Performance status measured by the Lansky/Karnofsky scales showed minor improvement (mean +3.5 points (95%-CI: 1.0 to 6.1)). All patients experienced at least one adverse event, but no serious adverse events or CTCAE v5.0 grade [&ge;]3 toxicities occurred. Sirolimus was well tolerated. Six patients decided to resume sirolimus after study completion. Conclusions: Sirolimus induced minor lesion shrinkage in a subset of patients, although this did not meet the predefined radiological RECIST endpoint. However, sirolimus can lead to functional improvement in some adults, which may indicate that the primary radiological outcome did not capture patient-perceived benefit.

CREB-regulated transcription coactivator 1 (CRTC1) regulates neuronal development, plasticity, and activity-dependent transcription, but its role in medulloblastoma (MB) remains poorly understood. We investigated expression of the CRTC1 gene during human cerebellar development and across pediatric brain tumors and examined its molecular and clinical associations in MB using public transcriptomic datasets. CRTC1 was broadly expressed in the developing cerebellum, with cell-state-specific variation within the granule-cell lineage. Among pediatric brain tumors, MB showed the highest median CRTC1 expression, which differed significantly among MB molecular groups and subtypes, with highest levels in Group 4 MB. High CRTC1 expression was associated with longer overall survival specifically in Group 3 {beta} MB and remained significant after correction across the 12 molecular subtypes. Within Group 3 {beta} tumors, CRTC1 expression was inversely associated with enrichment of mitochondrial and bioenergetic processes, including oxidative phosphorylation, mitochondrial organization, and mitochondrial translation, whereas CRTC1-high and CRTC1-low tumors displayed distinct transcriptional profiles. CRTC1 was also associated with selected cell-type-related transcriptional signatures related to the tumor microenvironment. These findings identify CRTC1 as a marker of biologically and clinically relevant transcriptional heterogeneity in Group 3 {beta} MB and support further investigation of its functional and prognostic significance.

Glioblastoma (GB) is a highly invasive brain cancer characterized by extensive peritumoral glial reactivity. Although GB infiltration and recurrence remain major therapeutic challenges, the contribution of GB-induced gliosis to tumor progression is poorly understood. To investigate glia-GB interactions, we developed human iPSC-derived cerebral forebrain assembloids containing innate microglia and macroglia and transplanted them with GB cells. The model recapitulates key tumor features observed in patients, including distinct tumor regions, reactive gliosis, and altered tissue stiffness. Single-cell RNA sequencing revealed an unexpected enrichment of extracellular vesicles (EVs) in peritumoral reactive glia, which we validated in patient samples. EV inhibition impaired formation of the peritumoral niche, whereas EVs from GB-containing assembloids induced glial reactivity in GB-free assembloids. Furthermore, the modularity of our system enables incorporation of additional niche components, such as monocytes, allowing investigation of the monocyte-glia-tumor axis and providing a powerful platform to dissect mechanisms regulating the GB microenvironment.