Ex vivo stem-like cell families model evolution of glioblastoma therapeutic resistance

Glioblastoma (GBM) arises from stem-like cells (GSCs) that exhibit intrinsic therapeutic resistance and can be positively selected by treatment, rendering recurrent GBM intractable. Mechanistic dissection of therapeutic resistance evolution has been limited by scarce matched primary/recurrent tractable models. To address this gap, we developed "resistant GSC families", a within-patient matched platform that models therapy-driven selection by ex vivo deriving, from the same primary whole GBM, temozolomide (TMZ)- and ionizing radiation (IR)-selected GSCs, alongside a treatment-naive control (CTRL-GSC). This design enables pressure-specific dissection of resistance evolution, separating chemotherapy- and radiotherapy-associated genetic alterations and adaptations that are often confounded in primary-versus-recurrent comparisons. Using this framework, we link TMZ-driven relapse-like states to either mismatch repair (MMR)-dependent stable resistance or O6-methylguanine-DNA methyltransferase (MGMT)-independent drug tolerance, and identify adaptive DNA damage response and cell-cycle changes as a route to increased radioresistance. Across pressures, treatment-emergent GSCs accumulate chromosomal alterations and exhibit adaptive phenotypic remodeling, including increased receptor tyrosine kinase activity. Resistant GSC families represent a model enabling mechanistic studies and hypothesis-driven testing of strategies aimed at preventing or treating GBM recurrence.