Neuro-Oncology

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.

BackgroundDiffuse midline glioma (DMG) is a lethal pediatric brain tumor driven by the H3K27M oncohistone, which disrupts epigenetic regulation and promotes tumor proliferation. While prior studies show that H3K27M is essential for tumor initiation, its role in established tumors, tumor microenvironment (TME) regulation, and therapeutic response remain unclear. MethodsHere, we developed inducible and reversible H3.3K27M and H3.1K27M cell and mouse models to study oncohistone-dependent effects on tumor growth, recurrence, and the immune/stromal microenvironment. We generated a tetracycline-inducible PiggyBac-based oncohistone expression cassette in patient- and murine-derived models and validated inducible and reversible H3K27M expression. ResultsRe-expression of H3K27M in knockout cells induced morphological changes and suppressed astrocytic markers. Chromatin accessibility profiling revealed distinct states between ON, OFF, and OFF-ON groups, including PD1-mediated immunosuppressive mechanisms associated with H3K27M expression. Single-cell RNA sequencing demonstrated that the oncohistone reshapes the TME. H3K27M expression promotes tumor-neuron interactions, enhances neuronal excitability, excitatory/inhibitory imbalance, and synaptic connectivity that supports tumor proliferation. These effects are associated with increased glutamatergic signaling and enhanced tumor-neuron coupling through glutamate transport and receptor pathways, including EAAT1 (SLC1A3) and AMPARs (GRIA3). Conversely, H3K27M inhibition reduces neuronal excitation, disrupts tumor-associated signaling, and partially restores neuron-neuron and neuron-immune communications. These findings identify H3K27M as a key driver of excitatory neuron-to-tumor coupling and immunosuppression in DMG. ConclusionsOverall, our findings demonstrate that H3K27M extensively reshapes TME in DMG and support direct oncohistone targeting as a potential therapeutic strategy, including potential CRISPR-based or small-molecule approaches for patients with H3K27M-mutant DMG. Key PointsO_LIWe developed inducible and reversible H3K27M DMG models to investigate the role of H3K27M in the tumor microenvironment. C_LIO_LIH3K27M promotes tumor-neuron communication, while its inhibition disrupts these interactions, supporting H3K27M-targeted therapies for DMG. C_LI Importance of StudyDiffuse midline glioma (DMG) remains one of the deadliest pediatric brain tumors, with limited effective treatment options and poor patient survival. Although the H3K27M oncohistone is recognized as a key driver of tumor initiation, its role in maintaining tumor progression and shaping the tumor microenvironment is unclear. In this study, we developed inducible and reversible H3.3K27M and H3.1K27M murine and patient-derived DMG cell- and mouse-models that enabled precise control of the oncohistone expression. Using these models, we demonstrate that H3K27M actively promotes tumor-neuron interactions, neuronal excitability, and glutamatergic signaling pathways that support tumor growth. Importantly, inhibition of H3K27M disrupted these tumor-associated signaling networks and partially restored neuron-immune communication within the tumor microenvironment. Together, these findings demonstrate that H3K27M extensively reshapes the tumor microenvironment in these Diffuse Midline Gliomas and provides strong rationale for directly targeting the oncohistone as a therapeutic strategy for patients with H3K27M-mutant DMG. Lay SummaryDiffuse Midline Glioma (DMG) is a devastating childhood brain cancer. Despite decades of research, radiation remains the primary treatment and provides only temporary benefit. Most DMGs carry a mutation called H3K27M, which is an attractive target for new treatments such as directly inhibiting or removing this mutation using gene-editing. However, it remains unclear whether inhibiting H3K27M alone will be sufficient to stop the growth of established tumors. In this study, we developed human and mouse models that allow H3K27M to be turned on and off. We found that H3K27M helps tumors communicate with surrounding cells, particularly neurons. Inhibiting H3K27M disrupted tumor-promoting interactions and partially restored normal communication, supporting direct H3K27M-targeted therapies as a promising strategy for children with DMG.

Diffuse intrinsic pontine glioma (DIPG) is a devastating pediatric brain tumor with limited treatment options. Emerging evidence indicates infiltration of tumor-associated macrophages (TAMs) within tumor sites, accompanied by an immunosuppressive tumor microenvironment (TME). However, the mechanisms underlying macrophage recruitment and communication between TAMs and other cellular compartments within brain tumors remain poorly understood. Bulk RNA sequencing of 26 DIPG autopsy specimens with matched normal brain tissue, single-cell RNA sequencing data from eight DIPG patients integrated with public pediatric high-grade glioma (pHGG) datasets, and in vitro transwell and flow cytometry assays collectively indicated that DIPG tumors actively recruit monocytes through chemokine-mediated mechanisms. The chemokine expression of tumor cells is driven by a mesenchymal-like (MES-like) lineage state rather than histone mutations, as evidenced by significant correlation between MES-like lineage scores and chemokine expression scores across 46 pHGG cell lines. CellChat analysis identified APP-CD74 signaling as a prominent tumor cell-TAM interaction pathway, supported by immunofluorescence validation. Notably, APP expression was significantly reduced in DIPG tumor tissues compared with normal brain tissue at both the RNA and protein levels. Recombinant APP stimulation of THP-1-derived macrophages induced a robust proinflammatory response, including upregulation of M1-like markers, enrichment of interferon-related pathways, and elevated secretion of inflammatory cytokines. Collectively, these findings indicate that APP suppression in tumors attenuates the antitumor activity of TAMs and promotes an immunosuppressive microenvironment. Furthermore, protein modeling and docking analyses identified the APP-CD74 binding interface, providing a structural basis for therapeutic targeting.

BackgroundTelomerase reactivation, a hallmark of many cancers, is associated with expression of its catalytic subunit, hTERT. However, the prognostic significance of telomere maintenance mechanisms in pediatric medulloblastoma remains poorly defined. MethodsIn this multi-institutional retrospective study of telomerase expression and hTERT regulation in newly diagnosed children with medulloblastoma, hTERT and MYC expression were assessed by qRT-PCR, normalized to non-neoplastic brain control samples. hTERT promoter methylation was analyzed using quantitative pyrosequencing and Illumina 450k methylation array. Cox proportional-hazard regression analyses evaluated the association of hTERT expression with progression-free survival (PFS) or overall survival (OS). Spearman correlation and Kruskal-Wallis tests correlated hTERT promoter methylation and expression and assessed variations among medulloblastoma subgroups, respectively. ResultsAmong 74 patients with available hTERT expression and outcome data, higher expression was associated with worse OS (HR=1.22, 95% CI: 1.01-1.47, p=0.036) and PFS (HR=1.17, 95% CI: 1.00-1.37, p=0.051) after adjusting for subgroup. Similar results were obtained when adjusting for metastatic status. Group 3 patients had the highest hTERT expression (p=0.001). Pyrosequencing data were available for 61 patients and 450k methylation array data for 292 patients. hTERT promoter was differentially methylated across subgroups with WNT followed by group 3 demonstrating the highest methylation on 450k (p<0.0001), findings that were confirmed by pyrosequencing. hTERT promoter methylation positively correlated with hTERT expression (Spearman correlation=0.42, p=0.02 by 450k and 0.34, p=0.007 by pyrosequencing). No significant correlation was observed between hTERT and MYC expression. ConclusionElevated hTERT expression is associated with worse PFS and OS in medulloblastoma across subgroups, supporting telomerase inhibition as a potential therapeutic strategy.

AbstractO_ST_ABSBackgroundC_ST_ABSGlioblastoma (GB) is the most aggressive primary brain tumor, characterized by therapy resistance, attributed to a multitude of epi-genetic changes resulting in phenotypic plasticity with altered cell states. To uncover druggable epigenetic vulnerabilities, we disturbed GB-derived spheres and observed coordinated repression of the aberrantly activated hemopoietic stem-like cell signature, dominated by HOXA genes. This signature has been associated with poor prognosis and resistance to therapy in GB. Here we investigate biological vulnerabilities associated with the deregulated epigenetic landscape in high-HOX GB. MethodsGB-derived spheres (GS) were treated with an inhibitor of Bromodomain and extra-terminal motif proteins (BETi) (JQ1) or transduced with inducible constructs to genetically modulate HOXA10 expression (shRNA for knockdown, ectopic HOXA10). Functional effects were evaluated through proliferation, neurosphere formation, and senescence assays. Epigenomic profiling incorporated RNA-seq, ChIP-seq, ATAC-seq, promoter capture MicroC, and DNA methylation. ResultsBETi-mediated rapid, coordinated downregulation of the HOX-signature, suggested direct transcriptional regulation. Knockdown of HOXA10 alone yielded similar effects, decreasing expression of HOXA genes, reducing proliferation, self-renewal capacity, and triggering senescence. Conversely, ectopic HOXA10 expression was ineffective in reactivating the HOXA cluster, or reverse BETi-mediated biological effects. Integrative epigenomic analysis of high-HOX-GS revealed concerted activation of the HOXA region, with broad domains of H3K27ac/H3K4me3 associated with super-enhancer activity, open chromatin (ATAC) and focal DNA hypomethylation. Architectural changes included altered CTCF interactions and increased promoter-anchored looping. ConclusionThese results position the HOX-signature as a potential therapeutic target and offer a mechanistic rationale for disrupting BET-dependent transcriptional regulation in high-HOX GB. Key pointsO_LIEpigenetic activation of stem cell-related high-HOX signature in GB is associated with a super-enhancer encompassing the HOXA locus. C_LIO_LITargeting this vulnerability by BETi or HOXA10 knockdown results in concerted repression and loss of stemness features. C_LI Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=74 SRC="FIGDIR/small/727851v1_ufig1.gif" ALT="Figure 1"> View larger version (21K): org.highwire.dtl.DTLVardef@5bf4b9org.highwire.dtl.DTLVardef@11fa405org.highwire.dtl.DTLVardef@497a2eorg.highwire.dtl.DTLVardef@1f47084_HPS_FORMAT_FIGEXP M_FIG C_FIG Created in BioRender. Chiesi, D. (2026) https://BioRender.com/eknk0ez Importance of studyGlioblastoma (GB) are the most aggressive brain tumors in adults that are difficult to treat, due to their high plasticity resulting invariably to resistance to therapies. Here we report on the identification of epigenetic vulnerabilities that may be leveraged in combination therapies. Disturbing GB-derived stem-like cells with epigenetic drugs, we uncovered that a HOXA gene dominated hematopoietic stem cell-related signature, previously associated with aggressiveness and treatment resistance, can be repressed in a coordinated manner, resulting in loss of stem cell features. Analysis of the underlying epigenetic landscape revealed that the HOXA region was activated in high-HOX glioblastoma through the formation of a super-enhancer. This feature presents a particular vulnerability that may be leveraged by BETi as strategy of a combination therapy.

Metastatic neuroblastoma (NB), the most common pediatric extra-cranial solid tumor, has a cure rate of <50%. DNA-sequencing studies have demonstrated rare recurrent driver mutations at diagnosis, with the most common alterations detected in ALK-RAS-MAPK pathway. Activating ALK and RAS-MAPK mutations are associated with inferior outcome and are increased at relapse, and thus, represent therapeutic vulnerabilities in NB. Previously, we identified combinations of RAS/MAPK inhibitors, including SHP2 and MEK, with efficacy in resistant MAPK-altered tumor cells, including those with the most common NB-associated RAS mutation NRAS-Q61K. However, toxicities of SHP2 inhibitors and promising results using compounds that directly target RAS suggest there may be superior strategies to target RAS/MAPK pathway in NB. Here, we have assessed the efficacy of RAS/MAPK inhibitors, including tovorafenib (pan-RAF), RMC-6236/daraxonrasib (pan-active-RAS) and avutometinib (RAF/MEK) in NB in vitro and in vivo using NB models harboring differing genomic status of RAS/MAPK pathway effectors. We demonstrate selective efficacy of RMC-6236 and avutometinib via RAS-MAPK pathway inhibition in NB cells and xenografts harboring RAS, NF1 or ALK alterations. Importantly, we demonstrate that presence of the NRAS-Q61K mutation confers drug sensitivity. Using newly generated and previously established NB cell models of acquired resistance to RMC-6236 or the ALK inhibitor lorlatinib, we identified targeted combinations, including RMC-6236 plus avutometinib, that demonstrate re-sensitization in resistant NB cell and xenograft models. Finally, transcriptomic studies of RMC-6236-resistant cells detected upregulation of RAS/MAPK signatures, as well as TNF/NF{kappa}B and IL-6/JAK/STAT3 pathway enrichment, thus informing future combinations to enhance sensitivity to RAS inhibitors. STATEMENT OF SIGNIFICANCEOur work demonstrates that newly available RAS pathway inhibitors RMC-6236/daraxonrasib and avutometinib have efficacy in neuroblastoma tumors, which have frequent alterations in the RAS/MAPK pathway. These drugs with early efficacy results in adult RAS-driven tumors provide an important option for patients with relapsed neuroblastoma alone or in combination.

Cerebellum tissue invasion and dissemination are major drivers of recurrence and metastatic spread in medulloblastoma (MB), yet no invasion-inhibitory therapy is currently available. The serine/threonine kinase MAP4K4 is highly expressed in MB and promotes invasive behavior downstream of growth factor signaling, while its physiological postnatal downregulation suggests that disrupted developmental control may contribute to tumor pathogenesis. Here, we investigate pharmacological targeting of MAP4K4 using famlasertib, a CNS-penetrant and neuroprotective MAP4K inhibitor, as a strategy to suppress invasion in MB. Using 3D invasion assays, quantitative live-cell microscopy, and phospho-proteomics, we demonstrate that famlasertib markedly reduces invasive behavior and single-cell motility of MB cells. Zebrafish larval and tissue models further confirm anti-invasive efficacy without detectable developmental toxicity at effective concentrations. Mechanistically, MAP4K inhibition alters kinase signaling linked to cytoskeletal remodeling, leading to suppressed F-actin dynamics, increased cell clustering, and enhanced cortical accumulation of tight junction protein 1 (TJP1). Collectively, our findings confirm MAP4Ks as a therapeutic targetable regulators of MB invasion and establish famlasertib as a candidate migrastatic agent that restrains tumor cell dissemination while preserving developmental integrity.

Background: Medulloblastoma (MB) is the most common malignant brain tumour in children, and aggressive subgroups are frequently driven by the oncoproteins MYC or MYCN. Direct therapeutic targeting of MYC/MYCN has been challenging because of their intrinsically disordered protein structures. The aim of this study was to determine whether novel SE486-11 analogues (UNSW-SCs) can therapeutically target MYC/MYCN-driven MB. Methods: The anticancer activity of UNSW-SCs was assessed in MB cell lines with differential MYC/MYCN expression. Target engagement was evaluated using surface plasmon resonance and drug affinity responsive target stability assays. Blood-brain barrier penetration, MYC/MYCN protein degradation, cell cycle effects, apoptosis, DNA damage, and synergy with histone deacetylase (HDAC) inhibitors were examined. Therapeutic efficacy was evaluated in murine models of MYC- and MYCN-driven human MB. Results: UNSW-SCs showed potent anticancer activity, with preferential selectivity toward MB cells expressing high MYC/MYCN levels and IC50 values ranging from 0.22 to 1.18 M. The lead molecule, UNSW-SC-22, directly bound MYC, crossed the blood-brain barrier, and achieved a brain-to-plasma ratio of 1.44 at peak concentrations. UNSW-SC-22 induced MYC/MYCN-dependent cytotoxicity associated with enhanced proteasomal degradation, cell cycle arrest, apoptosis, and DNA damage. Combined treatment with HDAC inhibitors further reduced MYC/MYCN protein levels, increased DNA damage, and enhanced apoptosis. In vivo, UNSW-SC-22, either alone or with entinostat, significantly suppressed intracranial tumour growth and prolonged survival. Conclusions: UNSW-SC-22 is a brain-penetrant MYC/MYCN-targeting molecule with potent preclinical activity in MYC/MYCN-driven MB, supporting its development as a monotherapy or combination strategy with HDAC inhibition.

Oligodendroglioma is a primary central nervous system tumor classified by the presence of isocitrate dehydrogenase (IDH) mutations and codeletion of 1p/19q. Here we describe the generation of an IDH-mutant 1p/19q-codeleted oligodendroglioma mouse model using in utero electroporation. We identified IDH1R132H, PIK3CAE545K, CicKO, Fubp1KO and Cdkn2aKO as the optimal combination (termed OligoCdkn2a) to drive fully penetrant tumors that histologically resemble human grade II/III IDH-mutant, 1p/19q-codeleted oligodendroglioma. Replacing Cdkn2a with Trp53 loss in this mouse model shifted tumor histology towards high grade astrocytoma. OligoCdkn2a tumors displayed metabolic and transcriptional changes associated with IDH and CIC mutations, and single cell sequencing identified a bias towards oligodendrocyte differentiation compared to an IDH wild-type glioblastoma mouse model. OligoCdkn2a tumors represent the first mouse model system to recapitulate the genetic, histological and transcriptional features of human IDH-mutant 1p/19q-codeleted oligodendrogliomas, offering a platform to further dissect tumor biology and test new therapeutic strategies.

BackgroundThe Netrin-1 dependence receptor pathway plays critical roles in neural development, but its expression landscape and prognostic significance in glioblastoma (GBM) remain poorly characterized. MethodsSingle-cell RNA-seq data from 148,019 cells across 34 tumors (Neftel et al., 2019) were analyzed to map Netrin-1 pathway gene expression across GBM cellular states. Differential gene expression and pathway enrichment analyses were performed on NEO1-defined subpopulations. Bulk RNA-seq survival analysis was conducted across three independent GBM cohorts TCGA (n=106), CGGA mRNAseq_325 (n=137), and CGGA mRNAseq_693 (n=237), totaling 480 patients. Primary analysis used continuous Cox regression (per-SD hazard ratios); meta-analysis employed fixed-effects inverse-variance weighting. ResultsIn GBM single-cell data, Netrin-1 pathway genes showed state-specific enrichment --NEO1, DCC, NTN1, and RGMB were predominantly expressed in oligodendrocyte-precursor (OPC) and neural-progenitor (NPC) states. Cells positive for NEO1 were enriched for neural differentiation programs (nervous system development, p=9.6x10-; Axon Guidance, p=2.8x10-), whereas NEO1-negative cells were dominated by ribosomal/translational and immune activation programs. In the 3-cohort survival meta-analysis, NTN1 (Netrin-1 ligand) emerged as the sole gene reaching meta-analytic significance as a risk factor (Meta HR=1.163 per SD, 95% CI 1.056-1.281, p=0.0021, I{superscript 2}=0%, 3/3 cohorts concordant), while DCC and RGMB showed directionally consistent protective trends (DCC: Meta HR=0.938, 95% CI 0.858-1.025, p=0.156; RGMB: Meta HR=0.979, 95% CI 0.881-1.087, p=0.686; both 3/3 cohorts concordant). NEO1 itself did not independently predict survival (Meta HR=1.008, 95% CI 0.885-1.147, p=0.910). After Bonferroni correction for 10 genes tested (threshold p<0.005), only NTN1 met strict significance. In exploratory sex-stratified analysis of a single cohort (CGGA 693, n=237), NEO1 and NTN1 exhibited female-specific risk enhancement (NEO1: HR=1.417, p=0.014; NTN1: HR=1.249, p=0.019), with minimal effects in males. UNC5B showed context-dependent risk in MGMT-unmethylated tumors (HR=1.331, p=0.037). These sex-dimorphic findings require independent validation. ConclusionsThe Netrin-1 pathway exhibits divergent prognostic trends in GBM, with NTN1 as a risk factor and DCC trending toward protection--consistent with the dependence receptor model. These findings, which should be interpreted as hypothesis-generating, nominate NTN1 as a candidate therapeutic target and highlight the potential importance of sex-stratified evaluation in future Netrin-1-directed trials. Independent replication in larger cohorts is warranted.

BackgroundRadiation therapy is integral to the curative treatment of childhood brain tumors but contributes to late neurocognitive impairment in survivors. FLASH (ultra-high dose rate, >40Gy/s) reduces normal-tissue toxicity in preclinical models, and proton-FLASH is currently the only modality capable of delivering ultra-high dose rates to the deep targets, such as pediatric brain tumors. However, two questions remain unresolved before clinical translation: (1) whether the FLASH effect can be achieved on synchrotron-based proton systems, which deliver protons in discrete spills that may be insufficient to cover a clinical target within a single delivery, and (2) which dose-rate metric, among the multiple definitions currently used in the field, best predicts the biological FLASH effect. MethodsC57BL/6 mice (7-8 weeks) received 10 Gy whole-brain RT via a clinical Hitachi ProBEAT synchrotron with CBCT-guided delivery, using three transmission-beam techniques: single-spill pencil beam scanning (SS PBS), multi-spill PBS with [~]2-second inter-spot delay (MS PBS), and passive scatter (PS), compared to conventional (CONV) delivery and unirradiated controls (n=24-28/group, equal sex distribution). Dose rate was quantified using three frameworks: field dose rate (FDR), PBS dose rate (PBSDR), and dose-averaged dose rate (DADR). Recognition memory was assessed by novel object recognition (NOR) at 6 weeks post-RT, and cognitive flexibility was assessed via touchscreen visual discrimination and reversal learning at 14 weeks. Hippocampal neuroinflammation was evaluated by immunofluorescence and immunohistochemistry for Iba1, NeuN, and GFAP. ResultsFLASH conditions were met by SS PBS and PS under all three dose-rate definitions, but MS PBS qualified as FLASH only by DADR. Despite this, neuroprotection was preserved across all three FLASH techniques: discrimination index was significantly higher for SS PBS (P=0.021), MS PBS (P=0.008), and PS (P<0.001) versus CONV, with no significant difference between FLASH techniques. On touchscreen testing, FLASH-treated females demonstrated preserved cognitive flexibility (P=0.047 vs. CONV on reversal learning correct trials). Iba1+ microglia were reduced in FLASH compared to CONV mice, with morphology suggestive of preserved homeostatic state. ConclusionsSynchrotron-based proton FLASH preserves neurocognitive function across all delivery techniques, including under multi-spill delivery essential for treating clinical-scale pediatric brain tumors. Critically, this neuroprotection was observed even for deliveries that qualified as FLASH only by DADR, identifying DADR as the dose-rate metric most relevant to the biological FLASH effect with direct implications for clinical trial design and dose-rate reporting standards.

Glioblastoma (GBM) is the most aggressive primary brain tumor in adults. Cognitive impairment is a common sequela in glioblastoma survivors, yet the underlying mechanisms remain poorly understood. Extracellular vesicles (EVs) derived from glioblastoma are established mediators of intercellular signaling within the tumor microenvironment. Here, we investigated whether GBM-derived EVs released after radiation treatment (RT-EVs) regulate cognitive function. Treatment with RT-EVs was associated with cognitive deficits and neuroinflammatory responses in vivo. In vitro, RT-EVs activated the NF{kappa}B pathway and induced the release of neurotoxic H2O2. Importantly, NF{kappa}B p50 knockdown abolished the H2O2 release previously triggered by RT-EVs, demonstrating mechanistic dependence on NF{kappa}B signaling. Collectively, these findings identify GBM-derived RT-EVs as critical mediators of cognitive impairment through NF{kappa}B-dependent redox imbalance. EV-driven redox dysregulation may therefore represent a therapeutic target to mitigate GBM-associated cognitive dysfunction. Highlights- Radiation induces the release of glioblastoma-derived EVs that are biologically different from those released under non-irradiated conditions. - EVs released from glioblastoma after radiation are sufficient to impair cognition - EVs from irradiated glioblastoma can activate microglia via NF{kappa}B and induce production of neurotoxic H2O2 Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=52 SRC="FIGDIR/small/730969v1_ufig1.gif" ALT="Figure 1"> View larger version (11K): org.highwire.dtl.DTLVardef@8dc45borg.highwire.dtl.DTLVardef@156547forg.highwire.dtl.DTLVardef@c593e0org.highwire.dtl.DTLVardef@16f68f5_HPS_FORMAT_FIGEXP M_FIG C_FIG

CD47 delivers a dominant "Dont Eat Me" signal that inhibits macrophage-mediated clearance of tumour cells. Using immune competent, chemoresistant neuroblastoma (NB) models, we tested a Fc-silent CD47 blocker (ALX301) with anti-GD2 antibody alone and in combination with a clinically aligned temozolomide/irinotecan chemoimmunotherapy backbone. Tumours expressed GD2 and CD47, and bound ALX301. In macrophage coculture assays, anti-GD2 antibody induced dose-dependent phagocytosis, whereas ALX301 or an anti-CD47 antibody alone did not. CD47 blockade in combination with a suboptimal concentration of anti-GD2 antibody showed an additive effect on phagocytosis in vitro. In vivo, however, ALX301 failed to improve tumour control or survival when added to anti-GD2 or to chemoimmunotherapy in two models. Toxicity was acceptable, showing only mild, expected red-cell changes without organ injury. This form of CD47 inhibition is therefore mechanistically active in vitro but insufficient to enhance anti-GD2 antibody-based therapy in immune competent mice bearing a chemoresistant NB, highlighting the potential need for myeloid-reprogramming partners.

Abstract and KeywordsO_ST_ABSBackground and ObjectivesC_ST_ABSPreoperative prediction of functional outcomes in contrast-enhancing glioma could support surgical decision-making and patient counseling, yet most existing models incorporate histopathological or postoperative variables unavailable before surgery. Our objectives were to develop a preoperative-only prediction model for one-year functional status and evaluate the added value of MRI-based tumor characteristics beyond clinical predictors. MethodsWe conducted a retrospective cohort study of consecutive adults ([&ge;] 18 years old) undergoing first resection of supratentorial contrast-enhancing glioma (WHO grade [&ge;] 2, histopathologically confirmed postoperatively) at a single center, with one-year follow-up. The primary outcome was functional status classified as mortality (Karnofsky Performance Score (KPS) = 0), functional dependence (KPS 10-60), or functional independence (KPS [&ge;] 70). In addition to clinical variables (age, sex, preoperative KPS, preoperative seizures), a deep learning tool was used to extract structural MRI-based tumor characteristics as predictors. A machine-learning model was developed and conformal prediction was applied to stratify patients by prediction confidence level. Results552 patients were included (median age: 60 years, range: 18-84; median contrast-enhancing volume: 24 mL, IQR: 10-43; median preoperative KPS: 80, range: 30-100; retrospectively confirmed 88% glioblastoma). Most MRI-based predictors did not improve performance as the best-performing model included three predictors: age at diagnosis, contrast-enhancing volume, preoperative KPS. Bootstrapped areas under the curves were 0.77 (95% confidence interval 0.70-0.84) for mortality, 0.64 (0.52-0.77) for functional dependence, and 0.71 (0.63-0.79) for functional independence. F1 scores per class were 0.65, 0.24, 0.65, respectively. Conformal prediction provided reliable predictions for 18% patients, moderate uncertainty for 57%, and identified 25% with genuinely unpredictable outcomes. DiscussionOur preoperative machine-learning model predicted one-year functional status in contrast-enhancing glioma with functional independence being the most reliably classified outcome (ROC-AUC = 0.77, F1 score = 0.65) and functional dependence the most challenging to predict (ROC-AUC = 0.64, F1 score = 0.24). A small set of three preoperative predictors drove model performance, supporting generalizability to broader patient populations. Our open-source model enables individualized risk stratification and may help clinicians identify patients with uncertain prognoses warranting more intensive preoperative counseling or follow-up planning.

Glioblastoma (GBM) is a highly lethal brain cancer with limited therapeutic durability, where the majority of patients develop recurrent or persistent disease after standard chemoradiotherapy. Meanwhile, tRNA-derived fragments (tRFs) have become increasingly relevant to cancer biology; however, their clinical relevance in GBM remains undefined. Here, we report that a specific family of tRFs, 5-tRNA halves (tiR5s) dominates the small RNA landscape of GBM patient tumors and associates with worse overall survival, post-therapeutic disease persistence, and pro-invasive proteogenomic pathways across two independent GBM patient cohorts. This association between elevated tiR5 levels and therapeutic resistance re-emerges in radiation-resistant GBM xenograft models. Our findings reveal that tiR5s are an underappreciated molecular feature of highly aggressive GBM tumors, supporting further investigation into their biological roles and prognostic utility in GBM. HighlightsO_LItiR5s are the predominant tRF family in primary GBM patient tumors C_LIO_LIElevated tiR5 expression distinguishes primary GBM tumors that develop persistent disease after first-line therapy C_LIO_LIRadiation-resistant GBM PDX models show elevated tiR5 expression C_LIO_LIElevated tiR5 expression associates with poor overall patient survival and pro-invasive molecular programs in GBM patient tumors C_LI Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=200 SRC="FIGDIR/small/738483v1_ufig1.gif" ALT="Figure 1"> View larger version (54K): org.highwire.dtl.DTLVardef@184ddc1org.highwire.dtl.DTLVardef@1faadc2org.highwire.dtl.DTLVardef@a5ae02org.highwire.dtl.DTLVardef@1431506_HPS_FORMAT_FIGEXP M_FIG C_FIG

In pediatric brain tumors medulloblastoma (MB) and diffuse midline glioma (DMG), tumor-associated myeloid cells (TAMs) support malignant progression by secreting paracrine growth factors and suppressing local immune function. We studied the potential for reversing this cancer-supportive phenotype by stimulating TAM pathogen receptors using ResiPOx, a brain-permeant, polyoxazoline nanoparticle formulation of the TLR7/8 agonist resiquimod. ResiPOx showed blood-brain barrier penetration and anti-tumor efficacy, extending progression-free survival (PFS) in mice with MB and DMG. Integrated cellular and molecular analysis including scRNA-seq showed that ResiPOx expanded TAM populations and reprogrammed TAMs toward anti-tumoral states, blocking paracrine IGF1 signaling and inducing local cytokine signaling and phagocytosis of tumor cells. In rhesus macaques, systemic ResiPOx was well tolerated and induced brain transcriptional patterns that resembled ResiPOx responses in DMG and MB mouse models, indicating effects in non-human primates that highlight translational potential. Our data show that ResiPOx reshapes the brain tumor microenvironment to inhibit tumor growth. As a systemically administered, brain penetrant immunomodulator, ResiPOx is able to reach multifocal and unresectable brain tumors, including MB and DMG.

Background Platinum refractory paediatric germ cell tumours (GCTs) carry a poor prognosis, with five year survival below 30% and no validated molecular stratification tool. The biological mechanisms underlying platinum resistance in this population remain poorly defined, limiting the development of targeted therapeutic strategies and early warning biomarkers. Methods We performed integrated plasma multi-omics profiling in 105 pediatric GCT patients (54 refractory and 51 treatment naive) using data-independent acquisition proteomics, untargeted metabolomics, and exploratory lipidomics. Candidate biomarkers were validated using ELISA and spatial multiplex immunofluorescence. Predictive models were constructed using logistic regression and evaluated by ROC analysis, calibration, and decision-curve analysis. Results Multiomics integration has revealed the coordinated dysregulation of sphingolipid metabolism, extracellular matrix remodeling, and immune checkpoint signaling in refractory diseases. Lipidomic analysis demonstrated a significant depletion of sphingolipid associated species, including lysophosphatidylserine, lysophosphatidylethanolamine, and phosphatidylserine. Proteomic profiling identified the upregulation of LAG3 and HTRA1, which was validated by ELISA. Multiplex immunofluorescence demonstrated the spatial enrichment of exhausted CD8 + LAG3 T cells adjacent to CK-PAN tumor cells in refractory tumors. A plasma biomarker panel integrating LAG3, HTRA1, and AFP showed improved discrimination of refractory disease (AUC = 0.821) compared with AFP alone. Conclusions Our study identified a sphingolipid HTRA1 LAG3 immune evasion axis as a defining molecular feature of refractory pediatric germ cell tumors and proposed a clinically applicable plasma biomarker panel for early risk stratification.

Diffuse midline glioma (DMG) is a lethal pediatric brain tumor with no curative therapies. Immune checkpoint blockade (ICB) has shown limited efficacy in DMG, largely due to poor T cell infiltration, low immune checkpoint (IC) expression, and a low tumor mutational burden. Here, we identify adenosine deaminase acting on RNA (ADAR), an RNA-editing enzyme that suppresses endogenous dsRNA sensing, as a key mediator of immune evasion in H3K27M-mutant DMG. ADAR is significantly overexpressed in H3K27M tumors relative to wild-type high-grade gliomas, and its depletion selectively suppresses proliferation in patient-derived DMG cells. The H3K27M mutation was found to synergize with ADAR loss to increase retroelement expression, activate type I interferon signaling, and induce immune checkpoint expression. We further identify all-trans retinoic acid (ATRA) as a pharmacologic inducer of ADAR degradation. At clinically relevant doses, ATRA phenocopies ADAR depletion, enhancing antiviral and interferon responses while increasing tumor immunogenicity. In orthotopic immunocompetent DMG models, ATRA enhances CD8+ T cell infiltration and synergizes with ICB and irradiation to improve survival.

Gliomas are primary brain tumours that develop from neural stem or progenitor cells containing oncogenic alterations. Gliomas undergo remission with partial or complete disappearance of the disease, and in rare instances, spontaneous remission. Spontaneous remission happens without treatment or with inadequate medical intervention. This is a rare but well-documented phenomenon and has been observed across various tumour types, including gliomas, with varying frequency. While historically viewed as clinical anomalies, we hypothesize that SR may be driven by a measurable, latent neuro-immune axis specifically, autonomic vagal nerve modulation of the tumour microenvironment (TME) via the cholinergic anti-inflammatory pathway. Using a Gamma frailty Cox proportional hazards model on a SEER cohort of 6,939 glioma patients, we identified a latent biological variable (Z) that explains 27.1% of survival variance independent of age, grade, treatment, and tumour location. To determine the molecular basis of this latent survival advantage, we applied parallel frailty and Cox models to the TCGA Lower Grade Glioma and Glioblastoma (LGG+GBM) cohorts. Clinical validation confirmed expected hazards for age and grade, with the frailty model achieving high predictive accuracy (5-year AUC = 0.840; 10-year AUC = 0.841). Transcriptomic integration revealed that the alpha7 nicotinic acetylcholine receptor (CHRNA7) is highly protective, inversely correlating with biological frailty (r = -0.285, p < 0.0001). Conversely, pro-inflammatory cytokines (IL6) and M2 macrophage markers (CD163) positively correlated with frailty. Grade-stratified Cox regression and Kaplan-Meier analyses confirmed that CHRNA7 confers a significant survival advantage entirely independent of tumour grade. Single-cell RNA-sequencing data (Core GBmap) confirmed that CHRNA7 and TLR4 are expressed heavily on tumour-associated macrophages and microglia, rather than malignant cells. Our in-silico integration suggests that high vagal tone releases acetylcholine, binding to alpha7nAChR on TME macrophages. This triggers a signalling cascade that dampens the IL-6 production required for glioma proliferation, effectively halting tumour growth. Ongoing in vitro wet-lab experiments utilizing specific alpha7nAChR agonists (GTS-21) and physiological stress models aim to clinically validate this vagal-immune mechanism.

BackgroundConvection-enhanced delivery of topotecan enables sustained local chemotherapy for recurrent glioblastoma and was associated with reduced tumor proliferation in our previous phase 1B clinical trial. That trial incorporated a paired pre- and post-treatment biopsy design - rare in glioblastoma clinical research - enabling tissue-anchored assessment of drug effect without reliance on radiographic or survival endpoints, which are notoriously difficult to interpret in this disease. However, the cellular and molecular consequences of local chemotherapy within the treated tumor microenvironment remain incompletely defined. MethodsWe integrated paired, MRI-localized pre- and post-treatment biopsies from a first-in-human CED-topotecan trial (n=5), leveraging the paired biopsy architecture, in which each patient serves as their own control and post-treatment specimens are spatially annotated relative to the MRI-defined infusion zone, to generate tissue-based evidence of drug effect without requiring large patient numbers. These biopsies were integrated with complementary experimental models, including a time-resolved syngeneic murine glioma CED model, acute patient-derived glioblastoma slice cultures, and in vitro human microglial and glioma systems. Clinical biopsies were analyzed by bulk RNA-seq, cell-type deconvolution, and multiplex immunofluorescence. Murine tumors were analyzed by survival, immunofluorescence, and single-cell RNA-seq; patient-derived slice cultures were profiled by single-cell RNA-seq. ResultsIn paired human biopsies, CED-topotecan induced spatially restricted transcriptional remodeling within the infusion zone, characterized by suppression of proliferative tumor programs and enrichment of inflammatory, interferon, hypoxia, and mesenchymal signatures. Cell-type deconvolution and immunofluorescence linked this response to myeloid remodeling, including enrichment of monocyte-derived tumor-associated macrophage states, increased MARCO-positive myeloid populations, and pH2AX-positive genotoxic stress within Iba1-positive myeloid cells. In the murine CED model, topotecan prolonged survival and reduced tumor cellularity, while also inducing inflammatory and DNA-damage programs in tumor-associated macrophages that evolved by 7-days toward hypoxia, angiogenesis, TGF-{beta} signaling, and mesenchymal/tissue-remodeling programs. Human slice culture and in vitro microglial systems confirmed stress-coupled inflammatory and DNA-damage responses in human myeloid cells. ConclusionsLocal topotecan delivery produces spatially structured tumor cytotoxicity together with a genotoxic, stress-coupled inflammatory myeloid response that evolves toward mesenchymal macrophage remodeling. By integrating paired clinical biopsies with time-resolved and mechanistic experimental models, this study provides a framework for understanding how local chemotherapy reshapes the glioblastoma microenvironment and for future studies evaluating dose, schedule, treatment duration, and combination strategies. These findings demonstrate that paired, spatially annotated tissue sampling from small, precisely characterized clinical cohorts can yield mechanistic insight that conventional radiographic and survival endpoints cannot provide, and support tissue-based response assessment as the appropriate paradigm for evaluating novel locoregional therapies in glioblastoma.