Diffuse midline glioma treated with epigenetic agent-based immunotherapy

Clinical Prognostic Factors and Molecular Characteristics of Spinal Cord Diffuse Midline Gliomas

BACKGROUND AND OBJECTIVE

Spinal cord diffuse midline glioma (DMG) is an extremely rare and aggressive tumor, characterized by a poor prognosis. While sharing similarities with brain DMGs, spinal cord DMGs may exhibit distinct clinical and prognostic features. Recognizing these differences is crucial for developing effective treatment strategies tailored to spinal cord DMGs. The objective of this analysis was to evaluate the survival prognosis and the influencing factors associated with spinal cord DMGs.

METHODS

This study describes the clinical and molecular features of 46 patients with spinal cord DMG. The prognostic value of these clinical and molecular characteristics was investigated using Cox regression analysis and Kaplan-Meier curves.

RESULTS

The average age at diagnosis was 30 ± 14 years, with male-to-female ratio close to 2.1:1. The median survival time of patients was 16.5 months. Tumors predominantly occur in the thoracic spine, and they exhibited a notably superior prognosis than those in other locations (P = .009). The survival rate of patients undergoing radical resection tended to increase (P = .003). In addition, patients undergoing a second surgery demonstrated a significant increase in survival rates (P = .022). Median survival varied among histological grades: 43 months for grade II, 16 months for grade III, and 12 months for grade IV. Patients with histological grade IV had significantly worse prognosis than those with grades II and III (P < .001). Thoracic (P = .001) and thoracolumbar (P = .017) segments and gross total resection (P = .018) exhibited significantly higher survival rates for patients with histological grades II and III tumor, whereas none were observed for patients with histological grade IV tumor.

CONCLUSION

We conducted an analysis of the clinical and molecular features of 46 patients with spinal cord DMG, exploring their prognostic value. This study aims to provide evidence for evidence-based treatment strategies for spinal cord DMG.

Epigenetic reprogramming and antitumor immune responses in gliomas: a systematic review

Gliomas, particularly glioblastoma, are among the most aggressive and treatment-resistant brain tumors. Their immunosuppressive tumor microenvironment (TME) and intrinsic molecular heterogeneity hinder effective therapeutic responses. Epigenetic dysregulation in gliomas significantly impacts tumor progression and immune evasion, presenting an opportunity for therapeutic intervention. This systematic review evaluates the role of epigenetic reprogramming in modulating antitumor immune responses in gliomas and explores its potential to enhance treatment outcomes. A comprehensive literature search across major databases, adhering to PRISMA guidelines, identified preclinical and clinical studies examining the effects of epigenetic therapies on glioma-associated immune modulation. Inclusion criteria focused on studies involving DNA methylation inhibitors, histone deacetylase inhibitors, chromatin remodelers, and non-coding RNA-based therapies. Key outcomes included immune activation, tumor progression, survival, and TME modulation. Among 22 included studies, epigenetic therapies demonstrated substantial efficacy in reprogramming the glioma immune landscape. DNA methylation inhibitors such as decitabine enhanced antigen presentation and immune recognition, while histone deacetylase inhibitors improved T-cell-mediated cytotoxicity. Non-coding RNA-targeted interventions disrupted immune suppression and facilitated immune cell infiltration. These strategies showed synergistic potential with immune checkpoint inhibitors, leading to tumor growth inhibition and improved survival in preclinical models. Epigenetic therapies hold promise in overcoming glioma-induced immune resistance by modulating immune escape mechanisms and reprogramming the TME. Their integration with existing treatment modalities, including immunotherapy, represents a transformative avenue for glioma management. Further clinical validation is warranted to optimize their therapeutic potential and safety.

Aneurysmal formation of periventricular anastomosis is associated with collateral development of Moyamoya disease and its rupture portends poor prognosis: detailed analysis by multivariate statistical and machine learning approaches

Periventricular anastomosis (PA) is the characteristic collateral network in Moyamoya disease (MMD). However, PA aneurysms are rare, resulting in limited knowledge of their clinical significance. We aimed to elucidate the associated factors and clinical outcomes of PA aneurysms. We reviewed MMD patients who underwent digital subtraction angiography in our institution between December 2001 and March 2023. Genetic analysis was conducted in several cases, and PA aneurysm-positive patients were identified. PA score was defined as the grades of development of periventricular anastomosis. Multivariate analysis and machine learning approaches were used to investigate the significance of the disease and factors associated with PA aneurysm positivity. A total of 301 hemispheres (171 patients) were included. PA aneurysm occurred in 8 hemispheres of MMD (2.7%). PA aneurysm was associated with higher initial modified Rankin scale (mRS) scores (OR, 2.61; 95% CI, 1.45-4.70) and higher PA scores (OR, 1.60; 95% CI, 1.06-2.40). This predisposition was corroborated by gradient boosting and random forest algorithms. Further analysis revealed that PA aneurysm was a risk factor for future hemorrhagic stroke events (HR, 8.29; 95% CI, 1.44-47.7). Among patients in the hemorrhagic-onset group (33 cases), PA aneurysm was a risk factor for worse outcomes (P = 0.008). Principal component analysis also revealed distinct characteristics of hemorrhagic onset aneurysms compared to other MMD cases. Higher PA scores were associated with the presence of aneurysm. PA aneurysm suggests a higher risk of future hemorrhagic strokes, and its rupture portends a worse prognosis.

Characterizing the relationship between MRI radiomics and AHR expression and deriving a predictive model for prognostic assessment in glioblastoma

PURPOSE

Aryl hydrocarbon receptor (AHR), a crucial molecular marker associated with glioma, is a potential therapeutic target. We aimed to establish a non-invasive predictive model for AHR through radiomics.

METHODS

Contrast-enhanced T1-weighted (T1W) MRI and the corresponding and clinical variables of glioblastoma patients from The Cancer Genome Atlas (TCGA) and The Cancer Imaging Archive (TCIA) were obtained for analysis. KM curves and Cox regression analyses were used to assess the prognostic value of AHR expression. The radiomics features were screened by Max-Relevance and Min-Redundancy (mRMR) and recursive feature elimination (RFE), followed by the construction of two predictive models using logistic regression (LR) and a support vector machine (SVM).

RESULTS

The expression levels of AHR in tumour patients were significantly higher than those in the control group, and higher AHR expression was associated with worse prognosis (P<0.05). AHR remained a risk factor for poor prognosis in glioblastoma after multivariate adjustment (HR: 1.61, 95% CI: 1.085-2.39, P<0.05). The radiomics models constructed using LR and SVM based on three selected features achieved area under the curve (AUC) values of 0.887 and 0.872, respectively. Radiomics score emerged as a key factor influencing overall survival (OS) after multivariate adjustment in the Cox model (HR: 3.931, 95% CI: 1.272-12.148, P < 0.05).

CONCLUSION

The radiomics models could effectively distinguish the expression levels of AHR and predict prognosis in patients with glioblastoma, which may serve as a powerful tool to assist clinical assessment and precision treatment.

Usefulness of magnetic resonance imaging characteristics in discriminating H3 K27M-mutant gliomas from wildtype gliomas in spinal cord

AIM

The aim of this study was to determine the usefulness of magnetic resonance imaging (MRI) characteristics in discriminating H3 K27M-mutant gliomas from wildtype gliomas in the spinal cord.

MATERIALS AND METHODS

Fifty-eight patients with spinal cord gliomas were enrolled in this study. The H3 K27 gene status was identified by Sanger sequencing or immunohistochemistry test of resection tumor specimens. The MR imaging characteristics were evaluated and compared between H3 K27M-mutant and wildtype gliomas using the χ2 test and the Mann-Whitney U test.

RESULTS

Of 58 recruited patients, 23 (39.7%) were diagnosed with H3 K27M-mutant glioma. The H3 K27M-mutant gliomas were found to more likely occur in men compared with wildtype gliomas (87.0% vs. 42.9%, p = 0.001). On T2-weighted MR images, the signal-to-noise ratio (SNR) of H3 K27M-mutant gliomas was significantly lower than that of wildtype gliomas (103.9 ± 72.0 vs. 168.9 ± 86.8, p < 0.001). Of 35 wildtype tumors, 60% showed well-defined margin but this feature was not found in all mutant tumors (p < 0.001). The SNR of tumors on contrast-enhanced T1-weighted images of the H3 K27M-mutant gliomas was significantly lower than that of wildtype gliomas (187.7 ± 160.4 vs. 295.1 ± 207.8, p = 0.006). Receiver operating-characteristic analysis revealed that area under curve (AUC) of combination of 1/SNR on T2-weighted images, 1/SNR on contrast-enhanced T1-weighted images, ill-defined margin, and sex reached 0.937 (95% CI, 0.873-1.000) in discriminating H3 K27M-mutant gliomas.

CONCLUSIONS

The MR imaging characteristics are valuable in discriminating H3 K27M-mutant from wildtype gliomas in the spinal cord and the combination of these imaging features with sex had a high strength in this discrimination.

Identification of m6A/m5C-related lncRNA signature for prediction of prognosis and immunotherapy efficacy in esophageal squamous cell carcinoma

N6-methyladenosine (m6A) and 5-methylcytosine (m5C) RNA modifications have garnered significant attention in the field of epigenetic research due to their close association with human cancers. This study we focus on elucidating the expression patterns of m6A/m5C-related long non-coding RNAs (lncRNAs) in esophageal squamous cell carcinoma (ESCC) and assessing their prognostic significance and therapeutic potential. Transcriptomic profiles of ESCC were derived from public resources. m6A/m5C-related lncRNAs were obtained from TCGA using Spearman's correlations analysis. The m6A/m5C-lncRNAs prognostic signature was selected to construct a RiskScore model for survival prediction, and their correlation with the immune microenvironment and immunotherapy response was analyzed. A total of 606 m6A/m5C-lncRNAs were screened, and ESCC cases in the TCGA cohort were stratified into three clusters, which showed significantly distinct in various clinical features and immune landscapes. A RiskScore model comprising ten m6A/m5C-lncRNAs prognostic signature were constructed and displayed good independent prediction ability in validation datasets. Patients in the low-RiskScore group had a better prognosis, a higher abundance of immune cells (CD4 + T cell, CD4 + naive T cell, class-switched memory B cell, and Treg), and enhanced expression of most immune checkpoint genes. Importantly, patients with low-RiskScore were more cline benefit from immune checkpoint inhibitor treatment (P < 0.05). Our findings underscore the potential of RiskScore system comprising ten m6A/m5C-related lncRNAs as effective biomarkers for predicting survival outcomes, characterizing the immune landscape, and assessing response to immunotherapy in ESCC.

Distinct MRI characteristics of spinal cord diffuse midline glioma, H3 K27-altered in comparison to spinal cord glioma without H3 K27-alteration and demyelination disorder

BACKGROUND

An applicable magnetic resonance imaging (MRI) biomarker for diffuse midline glioma (DMG), H3 K27-altered of the spinal cord is important for non-invasive diagnosis.

PURPOSE

To evaluate the efficacy of conventional MRI (cMRI) in distinguishing between DMGs, H3 K27-altered, gliomas without H3 K27-alteration, and demyelinating lesions in the spinal cord.

MATERIAL AND METHODS

Between January 2017 and February 2023, patients with pathology-confirmed spinal cord gliomas (including ependymomas) with definite H3 K27 status and demyelinating diseases diagnosed by recognized criteria were recruited as the training set for this retrospective study. Morphologic parameter assessment was performed by two neuroradiologists on T1-weighted, T2-weighted, and contrast-enhanced T1-weighted imaging. Variables with high inter- and intra-observer agreement were included in univariable correlation analysis and multivariable logistic regression. The performance of the final model was verified by internal and external testing sets.

RESULTS

The training cohort included 21 patients with DMGs (13 men; mean age = 34.57 ± 13.489 years), 21 with wild-type gliomas (10 men; mean age = 46.76 ± 17.017 years), and 20 with demyelinating diseases (5 men; mean age = 49.50 ± 18.872 years). A significant difference was observed in MRI features, including cyst(s), hemorrhage, pial thickening with enhancement, and the maximum anteroposterior diameter of the spinal cord. The prediction model, integrating age, age2, and morphological characteristics, demonstrated good performance in the internal and external testing cohort (accuracy: 0.810 and 0.800, specificity: 0.810 and 0.720, sensitivity: 0.872 and 0.849, respectively).

CONCLUSION

Based on cMRI, we developed a model with good performance for differentiating among DMGs, H3 K27-altered, wild-type glioma, and demyelinating lesions in the spinal cord.

Advances in Molecular Pathology, Diagnosis and Treatment of Spinal Cord Astrocytomas

Spinal cord astrocytoma (SCA) is a rare subtype of astrocytoma, posing challenges in diagnosis and treatment. Low-grade SCA can achieve long-term survival solely through surgery, while high-grade has a disappointing prognosis even with comprehensive treatment. Diagnostic criteria and standard treatment of intracranial astrocytoma have shown obvious limitations in SCA. Research on the molecular mechanism in SCA is lagging far behind that on intracranial astrocytoma. In recent years, huge breakthroughs have been made in molecular pathology of astrocytoma, and novel techniques have emerged, including DNA methylation analysis and radiomics. These advances are now making it possible to provide a precise diagnosis and develop corresponding treatment strategies in SCA. Our aim is to review the current status of diagnosis and treatment of SCA, and summarize the latest research advancement, including tumor subtype, molecular characteristics, diagnostic technology, and potential therapy strategies, thus deepening our understanding of this uncommon tumor type and providing guidance for accurate diagnosis and treatment.

Long-term survival after cordectomy in a case of spinal cord diffuse midline glioma, H3K27-altered: illustrative case

BACKGROUND

Spinal cord diffuse midline glioma, H3K27-altered, is an extremely rare entity with a poor prognosis. However, its optimal treatment remains poorly defined. Although cordectomy was introduced in the early 20th century, its efficacy has been questioned and shrouded behind the scenes.

OBSERVATIONS

A 76-year-old male with recent-onset paraparesis of the lower extremities and paresthesia presented to our outpatient clinic. Magnetic resonance imaging revealed an intra-axial spinal cord tumor extending from T12 to L2. The patient underwent laminectomy and partial tumor resection, and the surgical specimen was histologically diagnosed as a diffuse midline glioma, H3K27-altered. Although standard chemoradiotherapy was implemented, the patient experienced local tumor recurrence 2 years later and underwent cordectomy at T9. The patient was alive at the 4-year follow-up after cordectomy without tumor recurrence. According to the literature, patients with lesions in the lower thoracic cord below T8 achieved a longer survival than those with lesions in the upper thoracic cord above T5.

LESSONS

Cordectomy benefits selected cases of high-grade spinal cord gliomas. Maximal prevention of cerebrospinal fluid dissemination by tumor cells is indisputably important, and tumors located below the lower thoracic spine may be the key to success in establishing a long-term prognosis after cordectomy.

Molecular Characterization and Treatment Approaches for Pediatric H3 K27-Altered Diffuse Midline Glioma: Integrated Systematic Review of Individual Clinical Trial Participant Data

Diffuse midline glioma (DMG), H3 K27-altered are highly aggressive, incurable central nervous system (CNS) tumors. The current standard palliative treatment is radiotherapy, with most children succumbing to the disease in less than one year from the time of diagnosis. Over the past decade, there have been significant advancements in our understanding of these heterogeneous tumors at the molecular level. As a result, most of the newer clinical trials offered utilize more targeted approaches with information derived from the tumor biopsy. In this systematic review, we used individual participant data from seven recent clinical trials published over the past five years that met our inclusion and exclusion criteria to analyze factors that influence overall survival (OS). We found that the most prominent genetic alterations H3.3 (H3F3A) and TP53 were associated with worse OS and that ACVR had a protective effect. In addition, re-irradiation was the only statistically significant treatment modality that showed any survival benefit. Our findings highlight some important characteristics of DMG, H3 K27-altered and their effects on OS along with the importance of continuing to review clinical trial data to improve our therapies for these fatal tumors.