Neuro-Oncology

Brain cancers hijack biological systems involved in neural development and synaptic plasticity. Medulloblastoma (MB), the most common malignant brain tumor in children, is thought to arise from disruptions in neurodevelopmental programs. Glutamatergic transmission mediated by -amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors (AMPARs) has been implicated in synaptic communication between adult brain tumors and surrounding neurons; however, the possible role of AMPARs in MB remains largely unexplored. Here, we analyzed the expression of genes encoding AMPAR subunits, GRIA1-4, in datasets of MB tumors, revealing distinct expression patterns and subgroup-specific associations with overall survival (OS) across molecular subgroups and histological variants. Expression of GRIA1, GRIA3, and GRIA4 was significantly lower in MB in comparison with normal cerebellar tissue. Higher GRIA1, GRIA2, and GRIA4 transcription was associated with more favorable patient outcomes in specific MB subgroups. In contrast, high expression of GRIA3 in SHH, or of either GRIA3 or GRIA4 in Group 3 MB, was associated with worse prognosis. Particularly robust but opposing associations with patient survival were found for GRIA3 and GRIA4 in SHH MB. Analysis of GRIA mRNA levels in MB cell lines representing different molecular subgroups, using data from The Human Protein Atlas, showed partial concordance with expression patterns observed in tumors. Together, these findings suggest that GRIA genes and their corresponding AMPAR subunits may have subgroup-specific prognostic relevance in MB and merit further investigation.

BackgroundGlioblastoma (GBM) is an aggressive form of primary brain cancer. Recent efforts to characterize GBM using single-cell or spatially-resolved transcriptomics have revealed a tremendous intra-tumoral heterogeneity between malignant cells and between different tumor areas. However, most efforts have focused on malignant cells, and the spatial and cellular heterogeneity of the tumor microenvironment (TME) remains poorly understood. Moreover, it is unclear how TME compositions and organizations influence clinical outcomes for patients. ResultsIntegrating spatial transcriptomics, single-cell RNA-seq and histology on 25 tumors, cellular composition of the TME was estimated on over 46,000 55-m wide spots. Spatial associations were revealed between mesenchymal-like cancer cells and monocyte-derived macrophages. Spots were clustered into six unique classes of TME, exhibiting differential composition of malignant and immune cells, and distinct activation of biological pathways. Spatial transcriptomics-informed deconvolution of large-scale bulk RNA-seq datasets revealed that the niche composition of tumors associated significantly with patient survival and response to immunotherapy. Mesenchymal-like, monocyte-derived macrophages-rich and hypoxic niche N1 associated with lower overall survival while oligodendrogial progenitor-like and microglia-derived macrophages-enriched niche N5 is associated with longer patients survival. Analysis of data from patients treated with immunotherapy showed that niches N1 and mixed mesenchymal-like and astrocyte-like niche N3 associated with response to PD-1 inhibitors. ConclusionsOur results show that GBM exhibits a strong spatial heterogeneity of TMEs, with distinct categories of niche. The niche composition of tumors associated with survival and immunotherapy response. Our results suggest incorporation of TME niches as biomarkers for risk stratification and therapeutic decisions for patients.

BackgroundPATZ1 fusion-positive central nervous system (CNS) tumors frequently harbor MN1::PATZ1 fusions as driver mutations, provisionally classified as a rare DNA methylation class of low-grade neuroepithelial tumors. Radiographically, they resemble pilocytic astrocytomas with tumor and cystic components, but their supratentorial cortex location and higher recurrence rates are distinguishing features. An intermediate clinical course, despite focal high-grade histopathology, underscores the need for longitudinal molecular and immune analyses to refine classification and standard therapy. Case SummaryA female pediatric patient presented with neurological symptoms, including headache and right upper extremity weakness. MRI revealed a large cystic lesion in the left frontal lobe, leading to a differential diagnosis of low-grade glioma and ependymoma. Genomic analysis identified an MN1::PATZ1 fusion. The tumor recurred after gross total resection prompting a second resection. Transcriptomic and histopathologic assessments identified multiglial lineage, and high-grade features closely related to adult glioblastoma alongside pro-inflammatory activity in the primary tumor. The recurrent tumor showed reduced malignancy, and oligodendroglioma-like features. Increased MHC gene expression, immune checkpoint receptors (PDCD1, CTLA4, TIGIT,TIM3), T cell regulators (CXCR6), and elevated macrophage frequency, coupled with reduced PD-L1 in the recurrent tumor, suggest a complex anti-tumor immune response constrained by T cell dysregulation. This case, along with two other MN1::PATZ1 fusion-positive tumors, identifies a distinct transcriptomic subtype separate from circumscribed astrocytic glioma, highlighting upregulation of growth factor receptor pathways, like PI3K/AKT, and immune dysfunction linked to recurrence. ConclusionLongitudinal multi-omics analyses of recurrent MN1::PATZ1 fusion-positive CNS tumors revealed tumor maturation, immune dysfunction, and potential therapeutic targets. Introductory ParagraphPATZ1 fusion-positive central nervous system (CNS) tumors are rare, predominantly pediatric and frequently recurrent neoplasms provisionally classified as neuroepithelial tumors. Their pronounced histopathological and clinical heterogeneity, along with limited immunological characterization complicates their treatment standardization. We report a new case of an MN1::PATZ1 fusion-positive CNS tumor with recurrence, highlighting its radiographic similarities to low-to-intermediate grade pediatric glioma. Longitudinal multi-omics analyses of this case, along with additional MN1::PATZ1 fusion-positive CNS tumors, however, delineates a transcriptome subtype resembling adult high-grade glioma, with activated oncogenic and pro-inflammatory programs. The recurrent tumor exhibits features of decreased malignancy and enhanced glial differentiation, phenotypically shifting towards oligodendroglioma, suggesting tumor maturation. This was accompanied by increased antigen presentation programs, indicating immune engagement, while increased immune checkpoint expression and microglia/macrophage frequency indicate T cell exhaustion and immunomodulation, respectively. This longitudinal study highlights potential therapeutic strategies targeting both the tumor and its immune environment in MN1::PATZ1 fusion-positive CNS tumors.

Gliomas comprise a heterogeneous group of central nervous system tumors in which gene fusions (GFs) are significant oncogenic drivers and emerging diagnostic and therapeutic biomarkers. In cancer diagnosis, GF detection largely relies on targeted short-read sequencing fusion panels, such as the Childrens Hospital of Philadelphia (CHOP) Fusion Panel (FUSIP). While these panels are effective for detecting recurrent, well-characterized GFs, they are limited to predefined gene sets and cannot identify full-length transcripts. Here, we analyzed 49 high-and low-grade gliomas previously classified as fusion-negative by FUSIP using an untargeted whole-transcriptome RNA sequencing approach with Oxford Nanopore Technologies (ONT) long-read sequencing. This enabled transcriptome-wide fusion discovery of additional known and potentially novel oncogenic GFs beyond panel constraints. Long-read sequencing further allowed direct resolution of full-length fusion transcripts and their associated isoform structures. By integrating GF detection with isoform-level transcript analysis, we identified fusion-associated transcript isoforms with alternative splicing patterns that aligned near reported GF breakpoints, including ZNF254::GNAS and PTPRK::NOX3, which have not been reported in literature or existing fusion databases. To assess functional relevance, candidate GFs were evaluated using the Drosophila melanogaster model, with ventral nerve cord (VNC) morphology serving as a quantitative in vivo readout of fusion-induced disruption of glial regulation. VNC enlargement or elongation reflects abnormal glial growth or defects in brain tissue organization. Of the 15 candidate GFs subjected to experimental functional testing, 8 induced significant VNC abnormalities relative to wild-type controls, indicating fusion-specific disruption and oncogenic potential. Notably, CLDND1::WRN and DUSP22::APOE produced the most pronounced VNC phenotypes. Together, these findings demonstrate that untargeted transcriptome-wide GF discovery, coupled with long-read isoform-level analysis and in vivo functional validation, enables the identification and prioritization of potentially novel and clinically relevant GFs that are missed by standard targeted short-read fusion panels in glioma.

Background and ObjectivesIntramedullary spinal cord tumors (IMSCTs) are rare, and the extent of surgical resection may influence overall survival (OS). Gross total resection (GTR) may offer superior outcomes compared to subtotal resection (STR) or biopsy. Our study seeks to quantify the benefits of resection extent on OS in patients with spinal gliomas (SGs). MethodsA systematic review was conducted using the following databases: Scopus, Embase, and PubMed. Studies reporting OS in patients who underwent GTR, STR, or biopsy for low- or high-grade SG. We used a random-effects model to calculate pooled hazard ratios (HRs) and 95% confidence intervals (CIs); this was performed separately for low-grade (WHO grade I-II) and high-grade (III-IV) SGs. Subgroup analysis was performed for radiotherapy. I2 statistic and Cochrans Q tests evaluated study heterogeneity, Eggers and funnel plot asymmetry tests assessed publication bias, and Risk Of Bias In Non-randomized Studies of Exposure (ROBINS-E) evaluated individual study bias. ResultsIn a pooled analysis of 5 studies, GTR was not associated with improvement in OS compared to STR or biopsy in high grade SGs (HR=0.48, 95% CI: 0.19 -1.26). However, low-grade SGs revealed significant benefit in overall survival with GTR (HR=0.27, 95% CI: 0.15-0.46). Patients treated with radiotherapy were associated with worse outcomes following GTR in low-grade SGs (HR=1.48, 95% CI: 1.30-1.69) but no survival differences in high-grade SGs (HR=1.21, 95% CI: 0.52-2.83). ROBINS-E determined only 1 study with high risk of bias. ConclusionGTR for intramedullary spinal gliomas may not confer a significant benefit in overall survival for high-grade lesions but may provide benefit in lower grades. Radiotherapy confers a worse survival in lower-grade tumors, potentially due to their infiltrative nature. Future studies should stratify outcomes based on tumor biology, as well as follow functional outcomes overtime.

Importance: Glioblastoma (GBM) cells integrate into neuronal circuits, and preclinical work implicates multiple neurotransmitter (NT) networks as key drivers of invasion and treatment resistance. Whether the integration of GBM within NT-defined large-scale brain networks conveys prognostic information for overall survival (OS) is unknown. Objective: To determine whether NT-specific network involvement of GBM is associated with OS in patients with newly diagnosed Isocitrate dehydrogenase (IDH)-wildtype(wt) GBM. Design, Setting, and Participants: In this observational multicenter cohort study, we analyzed two independent cohorts of adults with histopathologically confirmed IDH-wt GBM. Cohort 1 included 153 patients treated at the University Medical Center Hamburg-Eppendorf, Germany (2012-2024), and cohort 2 comprised 264 patients from the University of Pennsylvania Health System, USA (2006-2018). Preoperative contrast-enhanced MRI was used to derive individual tumor masks, which were spatially mapped onto normative NT-informed structural connectomes spanning 19 receptor and transporter systems. Exposures: Preoperative contrast-enhancing GBM lesions, quantified as patient-specific involvement scores (0-1) within each NT-defined brain network. Statistics: We used partial least-squares regression for variable selection and multivariable Cox proportional-hazards models alongside regularized logistic regression with out-of-sample prediction, adjusted for age, methylguanine methyltransferase (MGMT) promoter methylation, and extent of resection, to test associations between NT-specific GBM network involvement and OS. Results: Across 417 patients in two cohorts, greater GBM involvement within cholinergic networks, defined by normative vesicular acetylcholine transporter (VAChT)-weighted as well as dopaminergic D2 receptor involvement, was consistently associated with reduced OS, independent of age, MGMT status, and resection extent. Further, cholinergic network involvement showed the strongest contribution to the prediction models. Other NT networks did not show reproducible prognostic effects across cohorts. Tumor-intrinsic hypomethylation of acetylcholine receptor-associated regions correlated with imaging-based cholinergic network involvement and mirrored its prognostic relevance. Conclusion and Relevance: Tumor integration into neurotransmitter-specific brain networks is an independent predictor of poorer survival in GBM. By combining routine clinical MRI with normative NT-informed connectome data, this approach delineates a novel systems-level marker of tumor aggressiveness and supports cholinergic inhibition as a putative therapeutic target in GBM.

BackgroundFLASH-RT defines a promising treatment modality against medulloblastoma, as it minimizes treatment-related complications. To support its clinical translation, we dissected the cellular and molecular determinants of the FLASH response in the tumor-microenvironment (TME) and healthy hippocampus using an orthotopic human medulloblastoma mouse model treated with a hypo-fractionated FLASH regimen. MethodsFive cohorts of 4 weeks-old UW228-MB-bearing female nude mice (n=57) were irradiated, or sham-irradiated using 3x10 Gy (BED=60), delivered 48h apart at 0.1 Gy/s (CONV) or 5.5x106 Gy/s (FLASH) using an electron beam (eRT6). Digital spatial profiling (DSP) was performed 24h after radiotherapy in one cohort, while the four other cohorts were followed for long-term tumor response, cognition, and neuroinflammation. ResultsBoth CONV and FLASH-RT induced a complete and long-lasting anti-tumor response in 100% of animals associated with cognitive decline. However, more mice maintained a very good discrimination score after FLASH exposure (38%) than CONV (7%). DSP revealed a sustained microglial activation in the cerebellar tumor micro-environment, where FLASH enhanced expression of genes with phagocytic and proteolytic activity. In the tumor free hippocampus, FLASH exposure induced a preferential neuron/astrocyte transcriptional crosstalk, which manifested over protracted times to minimize neuroinflammation and cognitive complications. ConclusionThe study shows the tumor-ablative efficacy of hypo-fractionated FLASH-RT in a human medulloblastoma mouse model. It is associated with qualitatively distinct transcriptional signatures prone to tumor and debris clearance mediated by microglial cells of the TME. Moreover, in the hippocampus, FLASH mitigates radiation-induced neurotoxicity by enhancing genes involved in synaptic plasticity, attenuating neuroinflammation, and preserving metabolic function. Key PointsO_LIComplete response of medulloblastoma and reduction of neurotoxicity with hypo-fractionated FLASH regimen. C_LIO_LIClearance-prone phagocytic and proteolytic activity in the microglia of the TME. C_LIO_LINeuron/astrocyte transcriptional crosstalk in the hippocampus. C_LI Importance of the studyThis study constitutes a milestone for the future implementation of FLASH-RT in the treatment of children with brain cancer. It shows that FLASH does not protect medulloblastoma and on the contrary can be ablative when delivered in 3 fractions of 10 Gy. FLASH promotes a metabolically active, phagocytosis-prone phenotype in microglial cells consistent with immune activation and tumor surveillance, in contrast to the proliferative and immunosuppressive signaling programs induced by CONV. It also shows how FLASH may differentially shape long-term brain function in patients with brain tumors by modifying the transcriptional program of hippocampal subregions known to be critical for memory encoding, pattern separation, and consolidation. In summary, this study supports the idea that FLASH has the potential to shift treatment paradigms and change the dismal therapeutic outcome in patients with brain cancer.

BackgroundGlioblastoma (GB) is a highly aggressive brain tumor with a median survival of approximately 14 months, primarily due to its ability to infiltrate healthy brain tissue both as single cells and in collectives. A deeper understanding of GB cell motility, both individual and collective, is crucial for developing patient-specific therapies. We aimed to characterize migration in patient-derived GB cells using advanced modeling to identify stratification markers and therapeutic vulnerabilities. MethodsWe developed Single-Cell Behavior Live Imaging (ScBLI), an approach integrating live imaging with computational analysis, applied to 30 GB primary cell cultures. Trajectories and morphological features were tracked and analyzed. Diffusion Entropy Analysis (DEA) was applied to classify trajectories based on the Delta Scaling parameter ({delta} scaling). We evaluated functional responses correlating all findings with clinical outcomes and transcriptomic profiles. ResultsWe analyzed 4,279 cell trajectories. Based on {delta} scaling (range 0.28-0.837), we defined three distinct motility groups: Low (L, {delta} scaling [&le;]0.5), Medium (M, 0.5 < {delta} scaling [&le;] 0.7), and High (H, {delta} scaling >0.7). Functional assays demonstrated that Group H cells are more performant in both positive and negative chemotaxis. Clinically, the three groups showed a clear linear progression with patient survival: High {delta} scaling correlated with the shortest survival (poorer prognosis), while Low {delta} correlated with the longest survival, suggesting that structured motility drives invasiveness. Integrative multi-omic analysis, encompassing both exome and transcriptome profiling, demonstrated that these groups are defined by distinct molecular landscapes rather than poor behavioral traits. Moreover, exome data revealed that Group H is significantly enriched in PTEN alterations (75% vs. 8% in Group L), with PTEN gain-of-function (GoF) mutations exclusively restricted to this group (100% vs 0% in Group L). Notably, within our extended cohort (n=51) currently characterized by whole-exome sequencing, we observed that specific PTEN GoF mutations were associated with a significantly shorter survival compared to PTEN wild-type cases (median OS 6.4 vs 16.6 months; p=0.02), which typically harbor the canonical loss of chromosome 10q. A similar clinical trend was observed when comparing directly GoF carriers to patients with truncating (Ter) alterations (median OS 6.4 vs 14.3 months; p=0.09). Conversely, no survival difference was found between truncating (Ter) mutations and wild-type cases. ConclusionOur findings demonstrate for the first time that migratory efficiency, quantified through DEA, represents a powerful predictor of glioblastoma aggressiveness. Tumor cells adopting highly efficient exploration strategies are strongly associated with poor clinical outcomes and are characterized by distinct molecular signatures, notably PTEN gain-of-function alterations. Statement of significanceOur multi-scale computational framework elucidates emergent behavioral phenotypes as pivotal drivers of glioblastoma progression. By demonstrating a correlation between enhanced migratory efficiency, PTEN gain-of-function, and significantly reduced overall survival, we establish a foundational paradigm for deciphering the emergent complexity governing tumor invasiveness.

High-grade gliomas (HGGs) are aggressive tumors with poor outcomes and limited treatment options. Here, we combined genomic and transcriptomic tumor profiling with drug testing in a patient-derived 3-dimensional culture model to identify individualized treatments and predictive biomarkers. Activity of single agents targeting frequently dysregulated glioma pathways was relatively poor ex vivo and generally reflected historical patient data. However, compounds targeting PI3K, epigenetic, and survival/senescence signaling were effective in some cases. Drug sensitivity correlated with transcriptional rather than genomic features and suggested heterogeneity as a resistance mechanism. Bromodomain and extraterminal domain inhibition was particularly effective in tumors enriched in the mesenchymal transcriptional subtype, promoted proneural transition, and was overcome by upregulated PI3K signaling. Notably, combinations were largely effective, with 6 strategies exhibiting stronger efficacy than corresponding single agents in most cases (58-77%). This study identifies HGG vulnerabilities and associated biomarkers, resistance mechanisms, and effective combination strategies that warrant further clinical validation. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=171 SRC="FIGDIR/small/701806v1_ufig1.gif" ALT="Figure 1"> View larger version (31K): org.highwire.dtl.DTLVardef@cdb75corg.highwire.dtl.DTLVardef@1c133e6org.highwire.dtl.DTLVardef@1365153org.highwire.dtl.DTLVardef@11543a4_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundYoung age is an independent risk factor for the development of breast cancer brain metastases (BM). Prior work showed that 17{beta}-estradiol (E2), the predominant premenopausal hormone, promotes BM of tumors intrinsically unresponsive to E2, in part through modulating estrogen receptor-alpha expressing (ER) glial cells. However, how E2 reshapes the brain tumor microenvironment (TME), particularly microglia-mediated immunity, and its impact to BM progression remains unclear. MethodsscRNA sequencing and multiparametric flow cytometry were used to define the impact of E2 and E2-suppression on brain immune-cell populations across different stages of BM progression using spontaneous and experimental models of BM. Depletion of microglia and T cell co-cultures were used to study microglias role in E2-induced BM. The effects of E2-suppression alone or in combination with whole brain radiotherapy were tested in preclinical models mimicking late-stage BM. ResultsE2 repressed immune surveillance and immune activation programs in microglia from early to late stages of brain metastatic progression, suppressing recruitment of effector immune cells to BM. Estrogen suppression, in turn reactivated anti-tumoral signaling in microglia and increased recruitment of effector immune cells to the brain. Microglia from E2-stimulated BM-bearing mice showed decreased ability to induce interferon cytotoxic function and expansion of activated T cells. Conversely, E2-suppression reactivated an effective anti-tumoral response and synergized with RT to significantly decrease BM progression. ConclusionThese findings reveal a previously unrecognized mechanism by which E2 accelerates BC-BM progression through microglial immunosuppression and support evaluation of endocrine therapies as adjunct treatments for ER- brain metastases. Importance of the StudyStandard of care for BM includes stereotactic radiosurgery (SRS) alone or in combination with surgery, systemic chemotherapy or targeted therapies. Our studies show that ovariectomy (which eliminates ovarian E2) and aromatase inhibitors (AIs, which eliminate peripheral E2 synthesis) reduce progression of BM when used in combination with WBRT and in immuno-competent models. We demonstrate E2 promotes an immunosuppressive brain microenvironment from early stages of metastatic progression, in part through modulation of myeloid cells and repression of recruitment of effector T cells to the brain. Thus, these studies suggest that FDA-approved E2-depletion therapies (aromatase inhibitors and selective-estrogen modulators) could be used in combination with brain irradiation to decrease BM progression.

Atypical teratoid rhabdoid tumor (ATRT) is a malignant brain tumor of children that has an overall survival of less than 40 percent even with aggressive therapy. We identified upregulation of the mitogen activated protein (MAP) kinase pathway in ATRT. The novel, brain-penetrant MEK inhibitor mirdametinib inhibited the growth of ATRT cell lines in culture at nanomolar concentrations. Mirdametinib suppressed proliferation as measured by BrdU incorporation and induced apoptosis as measured by cPARP and Annexin V staining. Monotherapy with mirdametinib extended the life of mice bearing orthotopic xenografts. Combination therapy with the brain-penetrant cyclin dependent kinase 4/6 inhibitor abemaciclib further suppressed growth and BrdU incorporation in ATRT cell lines representing all molecular subgroups. Mirdametinib and abemaciclib combined to extend survival of mice bearing orthotopic ATRT xenografts. In conclusion, mirdametinib has single agent activity against ATRT and combines with abemaciclib to decrease proliferation and extend survival in orthotopic xenograft models of ATRT.

PurposeEarly noninvasive assessments of treatment response are desperately needed to improve outcomes in glioblastoma (GBM). Molecular imaging techniques that measure glycolytic metabolism are being increasingly studied, but limitations such as variable substrate delivery present significant barriers to clinical interpretation. To develop more robust translational imaging biomarkers, we propose utilizing the interrogation of oxidative stress, a critical component of tumor metabolism for which no method of clinical measurement currently exists. This study investigates the simultaneous measure of oxidative stress and glycolytic flux using co-hyperpolarized [1-13C] dehydroascorbate and [1-13C] pyruvate (HP DHA/PA) as a predictor of treatment response in GBM. Experimental DesignTo establish a model that exhibits known metabolic responses to oxidative stress, we characterize radiation induced metabolic reprogramming in four human GBM lines (U87, U251, A172, T98) in vitro. We extend this in vivo and establish radiosensitive and radioresistant orthotopic xenograft models to investigate HP DHA/PA magnetic resonance imaging as a predictor of treatment response. ResultsIn vitro analyses revealed that radiation upregulates the pentose phosphate pathway and response is augmented by glutathione depletion. In vivo metabolomic profiling identified preferential nucleotide metabolism pathways in each tumor type. HP DHA/PA imaging revealed that DHA perfusion was not impacted by blood-brain-barrier integrity and detected reductions in DHA-to-vitamin C and pyruvate-to-lactate conversion in treatment-sensitive tumors, reflecting diminished reductive capacity following radiation. ConclusionsThese findings demonstrate successful prediction of radiosensitivity in GBM utilizing measurement of oxidative stress and establish HP DHA/PA imaging as an innovative method to address existing clinical limitations in treatment response assessment.

We studied the effect of stimulating innate immune function in tumor-associated myeloid cells (TAMs) in medulloblastoma (MB) and diffuse midline glioma (DMG), using a polyoxazoline nanoparticle formulation of the TLR7/8 agonist resiquimod (ResiPOx). Children with MB and DMG need novel therapeutic strategies to improve outcomes and reduce recurrence. We investigated the effect of systemically administered ResiPOx on TAMs in MB and DMG using endogenous MB and DMG models in immune-competent mice and identified multiple mechanisms of anti-tumor effect. We packaged resiquimod into polyoxazoline micelles to generate ResiPOx. We studied ResiPOx efficacy as a single agent or paired with radiation therapy (RT). We determined ResiPOx pharmacokinetics (PK) using tritium-labeled resiquimod and mass spectroscopy imaging (MSI). We determined ResiPOx pharmacodynamics (PD) using flow cytometry immunohistochemistry, bulk and single-cell RNA-seq and immunoblotting. We then studied ResiPOx safety and PD in a non-human primate model using rhesus macaques. ResiPOx formulation improved the blood-brain barrier penetration and anti-tumor efficacy of resiquimod. ResiPOx treatment extended progression-free survival (PFS) in mice with MB and DMG. In both tumor types, ResiPOx expanded TAM populations and reprogrammed TAMs toward anti-tumoral states, characterized by activation of IFN{beta} and extrinsic apoptosis pathway signaling, antigen presentation, and T cell activation signatures. In rhesus macaques, systemic ResiPOx administration was well tolerated and induced brain transcriptional responses that resembled ResiPOx responses in DMG and MB mouse models, indicating common effects across species from mice to non-human primates, and highlighting potential for similar effects in patients. ResiPOx is a brain-penetrant immunomodulatory therapeutic that reshapes the immune-privileged brain tumor microenvironment. Systemic administration activates myeloid-driven anti-tumoral immunity mediated by microglial and macrophage TAMs, and improves survival in preclinical models of DMG and MB.

Meningiomas are the most common primary central nervous system tumors in adults, posing a significant burden to society. Although a large percentage of lower-grade meningiomas are curable by surgery or radiation alone, high-grade and a subset of low-grade meningiomas demonstrate recurrences and complications from treatment. Systemic therapies for meningioma remain ineffective, and no targeted treatments are approved. Despite the central role of YAP1/TAZ-TEAD signaling in NF2-deficient/mutant tumors, no studies have systematically examined TEAD inhibition across molecularly defined meningioma subtypes or investigated mechanisms of resistance in this disease. We have recently shown that YAP1/TAZ signaling is an oncogenic driver of meningioma. Here, using established and patient-derived meningioma cell lines, we demonstrate that genetic ablation of YAP1/TAZ suppresses growth in both NF2 mutant and NF2 wild type cell lines, establishing YAP1/TAZ-TEAD signaling as a shared oncogenic dependency. Pharmacologic TEAD inhibition suppressed growth of benign NF2 mutant and a subset of higher-grade NF2 mutant meningiomas, whereas NF2 wild type meningiomas were generally more resistant. RNA-Seq and Western Blot analysis identified compensatory activation of MEK-ERK, mTOR-S6, and FAK signaling in resistant lines exhibit. Importantly, co-targeting these pathways was able to overcome resistance to TEADi and was superior to MEK/mTOR/FAK inhibition alone. These studies provide a compelling proof-of-concept that TEADi represents a novel therapeutic vulnerability in meningioma and reveal adaptive signaling responses that can be therapeutically exploited.

Pediatric high-grade gliomas (HGGs) are aggressive and lethal brain tumors that account for 15- 20% of all pediatric central nervous system (CNS) malignancies and remain largely incurable. These tumors, despite having mutational targets that activate MAPK signaling, are frequently resistant to targeted therapies in their malignant states, but often show responses when they are in lower grade form. These findings suggest a need to identify and intercept early tumorigenic events that arise in earlier tumor developmental stages. To investigate the molecular events in glioma progression, we developed and characterized a NestinCre/+;Trp53fl/fl mouse model combined with in utero exposure to the classic chemical mutagen N-ethyl-N-nitrosourea (ENU). This model mimics the context of genetic predisposition paired with an environmental genotoxic insult, and mice with loss of TRP53 in early neural precursors who are exposed to ENU at embryonic day 13.5 reproducibly develop HGGs postnatally that retain features of the human tumors. By sampling discrete lesions at premalignant, early, and late stages, we observed progressive increases in genetic complexity, stemness features, and immune signatures across tumor evolution. Notably, a recurrent Braf mutation emerged in a majority of early lesions and persisted in advanced tumors, consistent with the occurrence of BRAFV600E mutations in human gliomas that arise in children and undergo transition from lower grade to higher grade stages. Additional components of the RAS-RAF-MAPK signaling cascade, including Kras, Nras and Nf1 were found to be mutated at the late tumor stage, indicating convergent activation of this pathway in this model. Cell lines derived from early lesions responded to BRAF inhibitors, but cells from endpoint tumors were less responsive. Together, this model reveals aspects of the molecular and cellular evolution of glioma development in vivo, and identifies RAS-MAPK signaling as a critical molecular bottleneck selected for the ENU-induced mutations. This genetic-environmental model may be valuable to understanding key determinants of glioma initiation and progression, and for evaluating new therapies that limit MAPK signaling.

Malignant rhabdoid tumors (MRTs) are extremely rare and highly aggressive pediatric cancers classically defined by biallelic loss of the SMARCB1 gene, with rare involvement of SMARCA4. However, the molecular mechanisms leading to this loss are not yet fully understood. MRTs occur predominantly in infants, with the highest incidence in children under one year of age. Clinically, they are characterized by early metastatic dissemination and dismal outcomes, with 5-year event-free survival rates below 20%. There are currently no curative therapies for these patients. Here, we performed integrated genomic, transcriptomic, and epigenomic profiling of 16 patient-derived MRT models including intracranial, renal, and soft tissue origins. While SMARCB1 deficiency was ubiquitous, we observed substantial heterogeneity in the mechanisms driving its inactivation. Only two tumors harbored detectable coding single-nucleotide variants in SMARCB1; the predominant mechanisms involved large-scale deletions and broad loss-of-heterozygosity (LOH) on chromosome 22, with extensive LOH in tumors lacking point mutations or focal deletions, consistent with allelic loss as a frequent "second hit." In contrast, SMARCA4 remained intact across all models, reinforcing the mutual exclusivity of SMARCB1 and SMARCA4 alterations. Structural analyses revealed extensive variation, including more than 400 events per tumor on average and candidate gene fusions such as AHI1:MYB, whereas alterations in TP53 and BRCA1/2 genes were infrequent. Transcriptomic and epigenomic profiling showed heterogeneity driven by tissue of origin, disease progression, and therapeutic response, with subtype-specific programs and epigenetic modulation of DNA repair and immune-related genes (SLFN11, MGMT, LIF) linked to treatment sensitivity. Collectively, our findings refine the molecular definition of MRTs, showing that while SMARCB1 loss remains the foundational driver, tumor behavior is further shaped by structural variation, impaired DNA repair pathways, and dynamic epigenetic landscapes. These integrated changes contribute to tumor heterogeneity, progression, and differential therapeutic vulnerabilities. Beyond advancing mechanistic understanding and identifying candidate biomarkers for patient stratification, our multi-omics dataset represents a valuable resource for the research community, supporting future studies and efforts to improve clinical management of this highly aggressive pediatric malignancy.

Pediatric-type diffuse high-grade gliomas (pHGGs) are aggressive, heterogeneous brain tumors shaped by intricate cancer-microenvironment cell-cell interactions. Here, we present an integrative multimodal pHGGmap, encompassing over 800,000 cells from 136 patients profiled across transcriptomic, epigenomic, and spatial modalities. Its analysis delineated robust cancer-myeloid cell programs that structured the tumor ecosystem and identified ten distinct cancer cell states, including previously unrecognized developmental and context-responsive programs. Among these, radial glial-like (RG-like) cells exhibited dual stress-adapted and infiltrative phenotypes. Tumor-associated monocyte-derived macrophages and resident microglia engaged in four distinct immunomodulatory programs aligned with specific cancer states. Three conserved multicellular communities were maintained across treatment, including a stable, spatially and transcriptionally linked RG-like/complement-macrophage niche, indicative of cellular co-option and adaptation to support invasion. Longitudinal profiling of a metastatic diffuse midline glioma case showed that RG-like cells predominate during dissemination and remain associated with complement-enriched macrophages, whose reprogramming restores immune activation. pHGGmap establishes a landmark resource for translational discovery. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=183 SRC="FIGDIR/small/701142v1_ufig1.gif" ALT="Figure 1"> View larger version (54K): org.highwire.dtl.DTLVardef@7ae699org.highwire.dtl.DTLVardef@b95b92org.highwire.dtl.DTLVardef@12adcf9org.highwire.dtl.DTLVardef@1118703_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundGlioblastoma (GBM), Isocitrate dehydrogenase-wildtype (IDH-wt) is characterised by diffuse infiltration, with progression often arising from perilesional tissue and occult white-matter damage. We investigated whether radiomics from the T2/FLAIR-defined oedema and the structural disconnectome improve prediction of progression-free survival (PFS). MethodsWe retrospectively analysed 387 adults with newly diagnosed GBM, IDH-wt treated at a single tertiary centre (2005-2020). A deep-learning pipeline segmented enhancing tumour, non-enhancing tumour, and oedema on pre-operative MRI; lesion masks were propagated to normative tractography to derive disconnectome maps. 3-D shape radiomic features extracted for each segmented region underwent appropriate feature selection. Finally, 10 tumour and 9 oedema radiomics were combined with 6 clinical features to train 3 survival models (Random Survival Forest (RSF), XGBoost, Cox proportional hazards (CPH)) that were evaluated on a held-out 20% test set using Harrells C-index, Kaplan-Meier risk stratification and time-dependent ROC curves. ResultsThe best performance was achieved by RSF using all clinical and radiomic features (C-index 0.665 vs 0.595 for clinical features only, p=0.088). Models including oedema radiomics outperformed those using tumour radiomics alone, and disconnectome features, derived from both tumour and oedema regions, were repeatedly selected among the top predictors across algorithms. Combining radiomic and clinical features improved risk stratification and 12-month early-versus-late recurrence classification (AUC 0.704 vs 0.582 for clinical features alone). ConclusionsIntegrating perilesional oedema and white-matter disconnectome MR features with clinical and molecular data enhances prediction of PFS in GBM, IDH-wt. These network-aware, multimodal survival models may support personalised risk-adapted treatment strategies pending external validation. Key Points- GBM IDH-wt exhibits a high recurrence rate despite aggressive treatment. - Addition of high-dimensional oedema and disconnectome radiomic features to clinical features showed consistent improvement in the test performance of 3 ML models. - This can support informed clinical decision-making. Importance of the StudyPrediction of progression free survival (PFS) for a patient with highly recurrent glioblastoma IDH-wt traditionally relies on clinical history, demographics, and molecular markers of the tumour. Recent literature reveals the tumours disruptive nature through its invasion of white-matter tracts and identifies its microenvironment, particularly the perilesional oedema, as a harbour of treatment resistant tumour cells. This study is the first to combine high-dimensional radiomic features of the tumour, the oedema, and their disconnectome with clinical and treatment factors to predict PFS. Using 3 model architectures (XGBoost, RSF, and CoxPH), we demonstrate consistent directional improvements in performance, on addition of radiomic features to clinical baseline models. Furthermore, oedema and disconnectome radiomics are identified as top predictor features across algorithms. This proof-of-concept study provides a reproducible multimodal pipeline, reaffirms the usability of MR radiomics, and identifies features of the oedema and the structural connectome as promising biomarkers, demanding large-scale external validation.

Intratumor heterogeneity (ITH) is one of the main reasons for the lack of effective targeted therapies for glioblastoma (GBM). Imaging-guided surgical navigation allows for tumor-wide sampling to account for variation across distant regions of the tumor, but typical drug screening is performed on cell lines derived from a single biopsy and does not account for GBM heterogeneity. Here we profiled matching MRI-guided multi-region primary tumor biopsies from 6 GBM cases (n=40 biopsies) and corresponding neurosphere cultures (n=30) derived from these spatially distinct tumor samples. We found that in vitro cultures derived from distinct regions of the same tumor display divergent phenotypes, proliferative capacity and ability to accumulate 5-aminolevulinic acid, used to visualize cancer cells during surgery. The differential drug response of the multi-region neurospheres remains linked to the gene expression of the original tumor biopsies. Thus, studies with multiregion-derived neurospheres are essential to faithfully model GBM ITH for therapeutic testing. KEY POINTSO_LIMulti-region biopsy-derived neurospheres represent distinct spatial locations in the GBM tumor. C_LIO_LICultures derived from different regions of the tumor retain phenotypic diversity. C_LIO_LIParental biopsy phenotype predicts drug response better than to in vitro phenotype. C_LI IMPORTANCE OF THE STUDYCell lines developed from spatially distinct regions of glioblastoma capture its intratumor heterogeneity. We show that while the transcriptional output of these cell lines is not connected to their spatial origin, their drug response can be linked to it. Thus, spatial heterogeneity reflected in our neurosphere collection provides a new paradigm for drug screening in these highly heterogenous and difficult to treat tumors.

PURPOSE: Newly-diagnosed glioblastoma (nGBM) is a devastating tumor with median survival of only 14-18 months despite aggressive standard of care (SOC). Dendritic cell (DC) homologous antigenic double-loading provides a powerful pattern-based signal that initiates cDC1-like skewing of monocytic precursors, inducing downstream development of CD8+ memory effectors. Here we report phase I results for DOC1021 (dubodencel), a novel DC vaccine regimen integrated with SOC. METHODS: In this dose-escalating study, DC prepared from mobilized peripheral blood were doubly loaded with autologous tumor lysate and amplified tumor mRNA and administered bilaterally near the deep cervical node chains in three biweekly courses given with weekly peg-IFN after conclusion of chemoradiation. Four dose levels from 3.5x106 to 3.6x107 total cells were tested. Patients with subtotal resection or tumor progression prior to vaccination were not excluded. RESULTS: Eighteen patients (median age 61 years (range 47-73), 94% MGMT unmethylated, 25% subtotal/partial resected) completed vaccination (16 nGBM, 2 recurrent) with no dose-limiting toxicities. Attributable AE were mostly mild and flu-like or injection-site reactions. Twelve-month OS among the newly-diagnosed cohort was 88% compared to an expected ~60% for SOC alone. Patients who received observation rather than reoperation in response to worsening MRI contrast-enhancement demonstrated gradual lesional resolution and improved OS. Immunophenotyping revealed post-vaccination elevations in CD4 and CD8 memory T-cells in peripheral blood, and spatial transcriptomic analysis revealed foci of activated inflammatory complexes at the primary tumor site. CONCLUSIONS: DOC1021 was safe, feasibly integrated within SOC, and associated with more favorable outcomes in this challenging patient population. Patients who received observation rather than reoperation for worsening MRI contrast-enhancement exhibited superior survival, suggesting an immune-reactive tumor microenvironment manifesting as pseudo-progression. These data supported initiation of a randomized Phase II trial (NCT06805305) for nGBM.