Treatment decisions in IDH-mutant oligodendrogliomas are shaped by tumor aggressiveness, underscoring the need for objective grading of these malignant brain tumors. We collect 302 primary and recurrent resections from oligodendrogliomas and perform Ki-67 staining, proteomics, and DNA methylation profiling. During tumor progression, DNA methylation of oligodendrogliomas changes along a continuum. This continuum is linked to increased epigenetic aging, methylation of transcription factors and Ki-67+ cell density, and large-scale DNA demethylation. Demethylation correlates with CpG flanking sequences preferred by TET enzymes. We confirm these findings in previously profiled astrocytomas, indicating IDH-mutant gliomas progress along a shared epigenetic axis. We develop an objective DNA methylation-based prognostic continuous grading coefficient (CGCψ) that captures these changes and outperforms the World Health Organization (WHO) grading for oligodendrogliomas. Our findings underscore the potential of DNA methylation-based grading to more accurately reflect tumor biology and inform clinical decision-making in IDH-mutant gliomas.

Background:A brain tumor can lead to functional impairment, which is particularly concerning for adolescents and young adults (AYA). Patient-reported outcomes (PROs) have typically been examined as isolated domains, rather than as covarying symptoms. This study modeled PRO networks, symptom clustering, and topology among AYA oncology survivors. Methods:Patient-reported outcome networks from 4005 survivors were compared in topology between survivors of primary CNS tumors (n = 164) and non-CNS tumors (n = 3841). Survivors were diagnosed between 1999 and 2015 at ages 18 to 39 years, who completed the EORTC QLQ-SURV100 (Mdn follow-up = 12.31 years). Group-specific networks were estimated based on 33 health-related quality of life (HRQoL) scale scores using graphical LASSO. Wilcoxon rank-sum tests and the Network Comparison Test assessed group differences in the original PRO scales and their network centrality, respectively. Within the CNS subgroup (n = 164), associations with tumor-related and treatment-related characteristics were explored. Results:Survivors of central nervous system (CNS) tumors reported higher symptom burden on most PRO scales, along with a more diffuse network showing weaker within-domain cohesion (lower nodal strength and expected influence) and limited cross-domain integration (lower bridge strength). A small subset of nodes showed higher bridge expected influence (ie, fatigue, physical functioning, sexual problems when sexually active, work), which may represent key targets for intervention. Across both groups, negative health outlook, health distress, and physical functioning emerged as consistent core targets. Conclusion:Core symptoms may warrant prioritization in clinical follow-up and treatment of cancer survivors. These findings contribute to further development and optimization of tailored neurorehabilitation programs in neuro-oncological care.

B-cell maturation antigen (BCMA) directed CAR T-cell therapy has emerged as an innovative and effective treatment for patients with relapsed/refractory multiple myeloma, demonstrating high response rates and durable remissions. However, its use is associated with a broad spectrum of toxicities, ranging from well characterized common events to rarer, less well described complications. A comprehensive understanding of both common and rare toxicities is essential for timely recognition and management to prevent non-relapse mortality. Frequently observed toxicities include cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome (ICANS), immune effector cell-associated hematotoxicity, and infections. In addition, less frequent adverse events have been reported, including non-ICANS neurotoxicity such as parkinsonian-like movement disorders, immune-mediated enterocolitis, hemophagocytic lymphohistiocytosis, and secondary malignancies. The timing and severity of these toxicities is variable and may be influenced by the extent of CAR T-cell expansion and persistence, as well as patient-specific factors. In this review, we summarize currently available evidence with respect to the safety profile of approved BCMA-targeted CAR T-cell therapies, emphasizing both common and rare toxicities, their possible underlying mechanisms, and management strategies.

BACKGROUND:While severe fatigue is common in patients with diffuse glioma, no evidence-based treatment is currently available. The objective of this RCT was to evaluate the efficacy of blended cognitive behavioral therapy (bCBT) for severe fatigue. METHODS:Severely fatigued patients (Checklist Individual Strength, fatigue-severity subscale [CIS-fatigue] ≥ 35) with diffuse glioma and stable disease were randomized to 12 weeks of bCBT or a waiting list condition (WLC). The primary endpoint was fatigue severity 2 weeks after intervention. This Bayesian adaptive trial included prespecified interim analyses for efficacy at n = 40, 50, 60, 70, and 80. Secondary outcomes-health-related quality of life (HRQoL), anxiety, future uncertainty, and depression-were assessed at 2 and 12 weeks after intervention. RESULTS:The trial was stopped for efficacy at the first interim analysis. Of 47 patients randomized, 40 patients reached the primary endpoint (mean age 53 years, 47% female). The posterior probability that CIS-fatigue scores were lower with bCBT than with WLC was 99.94%, with a large standardized effect size (Cohen's d) of 1.12 [95% CI: 0.43-1.81]. At 2 weeks after intervention, 68% of patients were no longer severely fatigued after bCBT, compared to 24% in WLC. At 12 weeks follow-up, fatigue was still significantly lower in the bCBT group compared to WLC (d = 1.22). bCBT also demonstrated beneficial effects (d = 0.42-1.19) on anxiety, HRQoL, and future uncertainty. CONCLUSIONS:bCBT significantly reduces fatigue and improves anxiety and HRQoL in patients with diffuse glioma. These findings enable evidence-based supportive care strategies for reducing fatigue and enhancing HRQoL in this population.

PURPOSE:Myelotoxicity is a well-known adverse effect of alkylating chemotherapy for glioblastoma. While risk factors during first-line therapy are established, little is known about myelotoxicity recurrence in second-line treatment. This study investigates whether first-line myelotoxicity therapy predisposes patients to recurrence in the second-line setting. PATIENTS AND METHODS:We conducted a retrospective cohort study of 589 patients with glioblastoma treated at the Brain Tumor Centre Amsterdam (2005-2022). Of these, 178 received second-line lomustine or rechallenge temozolomide. Myelotoxicity severity was predominantly assessed using nadir hematological values and its duration. A log-link generalized linear model evaluated associations between first-line and second-line myelotoxicity severity, adjusting for covariates. Cox proportional hazards models assessed time to myelotoxicity onset. RESULTS:We included 151 patients (mean age 57.1 ± 11.8 years; 66.9% male). Lomustine was given to 66.9%. Myelotoxicity occurred in 73.5% of patients, with 19.9% developing severe toxicity. First-line myelotoxicity severity was significantly associated with second-line severity (β = 1.3, P < .001). Lomustine correlated with higher myelotoxicity severity than temozolomide (β = 1.4, P = .002). Higher first-line myelotoxicity scores predicted earlier onset of any-grade (HR = 1.4, P < .001) and severe (HR =2.1, P < .001) myelotoxicity in second-line therapy. CONCLUSION:First-line myelotoxicity for glioblastoma predicts its recurrence and earlier onset in second-line therapy. Patients with toxicity in first-line have an increased risk of severe hematological toxicity upon re-exposure. Lomustine carries a higher risk for myelotoxicity than temozolomide. These findings suggest an inherent predisposition to alkylating chemotherapy-induced myelotoxicity for a subgroup of patients. Integrating prior myelotoxicity history into second-line treatment decisions may improve risk stratification and guide monitoring.

Adolescent and young adult cancer survivors (AYAs; 18–39 years old at initial cancer diagnosis) face unique challenges throughout their disease trajectory and are, therefore, a distinct population within the oncology community. A common side effect of some cancer treatments is neuropathy, which can affect patients’ quality of life ongoing. AYA-specific studies on long-term effects, such as neuropathy, are lacking. This study investigated the prevalence of, and factors associated with self-reported peripheral neuropathic symptoms in long-term AYA cancer survivors. This questionnaire study (SURVAYA study) examined patient-reported outcomes among long-term AYA cancer survivors (5–20 years post-diagnosis). Data were collected through a questionnaire and by the Netherlands Cancer Registry. Analyses included descriptive statistics and multivariable logistic regression. Three thousand seven hundred forty-one AYAs were included in this secondary analysis. Overall, the prevalence of self-reported peripheral neuropathic symptoms was 19.8

BACKGROUND:Three subgroups of adolescent and young adult patients (AYAs; 18-39 at diagnosis) with an uncertain or poor cancer prognosis (UPCP-those diagnosed with advanced disease, who will likely die prematurely) were previously identified: those receiving traditional treatments (chemotherapy and/or radiotherapy), newer treatments (immunotherapy or targeted therapy), and patients with glioma. This study examines differences in health-related quality of life (HRQoL) among these subgroups, and comparisons between AYAs with a UPCP, recently diagnosed AYAs, and a healthy control group. METHODS:Data were collected from two AYA cohorts: CORD-AYA (n = 155), including AYAs with a UPCP any moment post-diagnosis, and COMPRAYA (n = 549), including AYAs within 6 months after diagnosis. A healthy control group, matched by age and sex, was also included (n = 430). All completed the EORTC QLQ-C30. RESULTS:No significant HRQoL differences emerged between the traditional versus new treatment group. However, patients with glioma reported significantly lower cognitive functioning compared to patients on newer therapies. AYAs with a UPCP scored lower across all HRQoL scales than the control group. Despite being further along in their disease trajectory, UPCP patients reported HRQoL levels comparable to newly diagnosed patients. AYAs with a UPCP experienced higher financial burden but reported better global quality of life than COMPRAYA patients. CONCLUSIONS:No significant differences in HRQoL were found between treatment groups, but patients with glioma should be considered a distinct subgroup as they have shown reduced cognitive functioning, necessitating specialized care. Individualized care is crucial, as a lack of personalized support may lead to long-term functional impairment, especially among UPCP patients.

The aim of this study was to evaluate the long-term results of seizure recurrence after antiseizure medication (ASM) withdrawal vs continuation in patients with diffuse glioma, grades 2 and 3. A prospective multicenter observational study was conducted, and patients were recruited from January 2014 until May 2016 from 3 neuro-oncology outpatient clinics in the Netherlands. The main inclusion criteria were as follows: history of ≥1 seizure, for which ASM was started; clinically and radiologically stable disease for ≥12 months; and seizure freedom for ≥12 months from the date of last antitumor treatment or seizure freedom for ≥24 months from the last seizure if seizures occurred after the last antitumor treatment. The primary outcome was time to recurrent seizure. A competing risk model was used to estimate cumulative incidences of recurrent seizure for ASM groups (i.e., ASM withdrawal vs ASM continuation) with death as the competing event. The proportional hazard assumption was violated for the ASM group; therefore, 2 Cox models were constructed for different time intervals (<48 months and ≥48 months since study inclusion). A total of 71 patients were included (39 men [55%] and 58 older than 40 years [82%]); 46 patients with glioma (65%) were in the ASM withdrawal group and 25 (35%) in the ASM continuation group. The cumulative incidence of a recurrent seizure at 48 and 96 months was 48% (95% CI 33%-61%) and 66% (95% CI 48%-78%) for the ASM withdrawal group vs 28% (95% CI 12%-46%) and 52% (95% CI 31%-70%) for the ASM continuation group. The risk of a recurrent seizure differed in the 2 time intervals between the ASM continuation group (reference) and the ASM withdrawal group (cause-specific adjusted hazard ratio [aHR] 2.32 [95% CI 0.93-5.81], p = 0.071, during <48 months, and cause-specific aHR 0.73 [95% CI 0.21-2.49], p = 0.611, during ≥48 months since study inclusion). Risk of recurrent seizure when withdrawing ASM was not statistically significantly higher in patients continuing ASM. However, a clinically relevant higher percentage of patients had a recurrent seizure in the ASM withdrawal group compared with the ASM continuation group. The lack of a statistical difference may be explained by the small sample size. Larger studies are needed to confirm these findings. Our results suggest that ASM withdrawal should be initiated cautiously and only when necessary. This study provides Class III evidence that withdrawal of ASM does not significantly increase the risk of recurrent seizures in patients with glioma with stable disease and no seizures for >1 year. Confidence intervals do not exclude a clinically important increased risk of seizures.

Astrocytomas and oligodendrogliomas are slow-growing and treatment-sensitive IDH-mutant gliomas diagnosed at ages 30-50. Local tumor regrowth and treatment resistance is inevitable resulting in 3-10 year astrocytoma and up to >20 years oligodendroglioma survival. We sought to identify genetic changes associated with tumor evolution in response to therapy through multi-timepoint whole-genome/whole-exome sequencing of 206 IDH-mutant glioma patient samples collected through the Glioma Longitudinal Analysis (GLASS) Consortium. We validated known genomic markers of tumor progression, including hypermutation and CDKN2A homozygous deletion, and discovered novel genetic alterations that distinguish the response to treatment in astrocytomas compared to oligodendrogliomas. Point mutations in PIK3CA , PIK3R1 , and NOTCH1 were newly acquired in recurrent oligodendrogliomas and associated with increased mutation rates. Focal oncogene amplifications, together with CDKN2A homozygous deletions, were associated with an increase in recurrence-specific chromosomal imbalances in astrocytomas. Mutational signature analysis revealed additional differences and detected enrichment for the SBS11, and SBS119 mutational signatures after temozolomide treatment in both IDH-glioma subtypes, whereas astrocytomas showed increased ID8 signatures after radiotherapy. These signatures suggest that the genomes of oligodendroglioma and astrocytoma adapt to the selective pressures of tumor progression and treatment in different ways. However, in both IDH-mutant glioma subtypes we observed a convergence of acquired driver gene alterations with genome-wide changes and worse patient outcomes, signaling selection of treatment-refractory clones. By identifying new prognostic markers and delineating the genomic divergence of oligodendrogliomas and astrocytomas after diagnosis, our results suggest that different DNA damage response mechanisms are engaged following chemo- and radiation therapy.

As the prognosis for adolescents and young adults (AYAs) with breast cancer has improved, long-term health-related quality of life (HRQoL) has become increasingly important. This study aimed to analyze the long-term HRQoL of AYA breast cancer survivors compared to an age-matched normative population and to identify factors associated with HRQoL. Secondary analyses were conducted using data from the SURVAYA study. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ-C30) was used to assess HRQoL. The Mann–Whitney U test was used to compare HRQoL scores of AYA breast cancer survivors with those of the normative population (n = 409). Linear regression models were constructed to identify patient and treatment characteristics associated with HRQoL. A total of 944 female AYA breast cancer survivors were included, with a median age of 36.0 years and a median follow-up of 12.2 years. AYA breast cancer survivors scored significantly lower on five functional scales: physical, role, emotional, cognitive, and social, and higher on five symptom scales: fatigue, pain, dyspnea, insomnia, and financial impact compared to the normative population. Being in a relationship, having a positive body image, and adaptive coping were positively associated with HRQoL, while older age, chemotherapy, unemployment, and maladaptive coping were negatively associated. AYA breast cancer survivors experience significantly compromised long-term HRQoL compared to an age-matched normative population. These results highlight the need for tailored follow-up care and long-term support, as well as the importance of shared decision-making about the benefits and risks of treatments before initiation.

Adolescent and young adult (AYA) malignant brain tumour (BT) survivors are at risk of adverse health outcomes, which may impact their health-related quality of life (HRQoL). This study aimed to investigate the (1) prevalence of physical and psychological adverse health outcomes, (2) the HRQoL, and (3) the association of adverse health outcomes and HRQoL among long-term AYA-BT survivors. Adverse health outcomes and HRQoL were compared to other AYA cancer (AYAC) survivors. A cross-sectional secondary data analysis of the SURVAYA study among 133 AYA-BT and 3877 AYAC survivors was conducted. Participant self-reported adverse health outcomes and HRQoL scores were analysed and compared between the two populations. Associations with HRQoL were assessed using linear regression modelling with AIC-based backward elimination. AYA-BT survivors faced significant issues of fatigue (47.6

Background. Thrombocytopenia is a major temozolomide-induced adverse event during the standard treatment of glioblastoma. Consequently, platelet transfusions and treatment modifications may impact quality of life and long-term treatment outcomes. Understanding the impact of thrombocytopenia on healthcare utilization is crucial to mitigate the need for healthcare resources in glioblastoma patients. Here, we assess the influence of thrombocytopenia-related healthcare among patients diagnosed with glioblastoma. Methods. We retrospectively collected patient information treated at the Brain Tumor Center Amsterdam between 2008 and 2021. The occurrence of thrombocytopenia, patient demographics, treatment details, and healthcare utilization data were gathered from patients who received standard glioblastoma treatment. Associations between temporal severity of thrombocytopenia as categorized by the Common Terminology Criteria for Adverse Events, patient characteristics, and healthcare utilization were analyzed using Generalized Linear Mixed Models. Results. We included 206 patients with a median age of 58 years, 35.9% were female and we found that thrombocytopenia (any grade) occurred in 61.1% of patients. The occurrence of thrombocytopenia during CRT was associated with increased healthcare utilization and was largest in females who developed grade 4 thrombocytopenia compared to those who did not develop thrombocytopenia (OR = 5.9, P < .001 in females vs OR = 4.4, P < .001 in males). Grade 4 thrombocytopenia was also associated with heightened healthcare utilization during the adjuvant phase (OR = 7.6, P < .001), and was comparable between sexes. Conclusions. Severe thrombocytopenia during glioblastoma treatment is linked to increased healthcare utilization, disproportionally impacting females. These data suggest that prevention and early management of thrombocytopenia can reduce healthcare utilization in patients with glioblastoma. Key Points Thrombocytopenia occurs in over half of glioblastoma patients receiving treatment. Thrombocytopenia results in increased healthcare utilization. Females are mainly affected in healthcare use when thrombocytopenia occurs.

The evolutionary processes that drive malignant progression of IDH-mutant astrocytomas remain unclear. Here, we performed multiomics on matched initial and recurrent tumor samples from a cohort of 105 patients and overlaid the data with detailed clinical annotation. We identified overlapping features associated with malignant progression that are derived from three molecular mechanisms: cell cycling, tumor cell (de)differentiation and remodeling of the extracellular matrix. Together, they provide a rationale of the underlying biology of tumor malignancy. DNA methylation levels decreased over time, predominantly in tumors with malignant transformation, and co-occurred with poor prognostic genetic events. We identified a DNA methylation-based signature strongly associated with survival, which allows objective, molecular-based grading of IDH-mutant astrocytomas to aid clinical decision making. Our findings were validated on large, independent cohorts of IDH-mutant astrocytoma samples. Lastly, in this retrospective study, we found little effect of radiotherapy or chemotherapy on the molecular features associated with malignant progression. Vallentgoed et al. integrate clinical and multiomic data from persons with matched initial and recurrent IDH-mutant astrocytomas to identify progression-associated mechanisms and report a DNA methylation-based signature associated with survival.

Health-related quality of life (HRQoL) is a commonly assessed patient-reported outcome that might be especially relevant for the adolescent and young adult (AYA) cancer survivor population. However, limited data is available regarding the HRQoL of long-term AYA cancer survivors compared to a matched normative population and associated factors. AYA cancer survivors (18–39 years at initial diagnosis; 5–20 years post-diagnosis), identified by the Netherlands Cancer Registry (NCR), were invited for participation in the SURVAYA questionnaire study. Participants self-reported their socio-demographics, health-related conditions, healthcare use, positive life outlook, and HRQoL (EORTC QLQ-C30). An age- and sex-matched normative population was randomly composed. Clinical data were retrieved from the NCR. A total of 3745 AYAs (on average 32 years old at diagnosis, 12 years post-diagnosis) and 517 peers without cancer (normative population) were included. All functioning scales showed significant differences, with AYA cancer survivors scoring lower: cognitive (77.9 vs. 92.2), role (83.2 vs. 91.3), social (87.9 vs. 93.6), physical (91.5 vs. 94.3), and emotional functioning (79.5 vs. 83.4). No significant difference was observed in global QoL. Female sex, lower educational attainment, older age at diagnosis, several tumor types, radiotherapy, chemotherapy, higher stage, more health-related conditions, and more healthcare visits were negatively associated with several HRQoL scales. AYA cancer survivors face worse HRQoL compared to peers in all functioning domains, but it is most pronounced in cognitive functioning. This study underlines the need for timely cancer survivorship care to regain, improve, and ensure the quality of life of current and future AYA cancer survivors. NCT05379387.

Osimertinib, a tyrosine kinase inhibitor (TKI), treats non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutations. However, its efficacy may vary due to heterogeneous drug distribution, assessable through microdosed radiolabeled drugs and positron emission tomography (PET). Precision dosing using microdosed TKI-PET encounters challenges due to pharmacokinetic (PK) variations between micro- and therapeutic doses. This study aims to predict osimertinib's tissue concentration-time profiles for both microdose and therapeutic dose scenarios using a whole-body physiologically based pharmacokinetic (PBPK) model, which incorporates nonlinear PK processes and target site occupancy. A target site PBPK model for osimertinib was developed to predict drug distribution across various tissues, including lung tumor, based on a previously published PBPK model. The model incorporated tissue-specific parameters and accounted for both linear and nonlinear pharmacokinetic processes, including EGFR-binding dynamics and tumor dynamics. Model predictions were verified with microdosed [11C]C-osimertinib PET imaging data and clinical pharmacokinetic profiles to assess accuracy and reliability. The developed target site-PBPK model accurately predicted osimertinib pharmacokinetics across multiple (tumor) tissues and dose levels within 2-fold error compared to observed PET data. This study underscores the utility of PBPK modeling in predicting osimertinib's pharmacokinetics across diverse tissues, offering insights into drug distribution and predictions of target engagement in NSCLC patients using microdose PET imaging data. The developed model serves as a promising tool for optimizing dosing strategies and evaluating novel EGFR-TKIs in NSCLC treatment.

Table S6: Deconvolution cell proportions and probe-signature matrix S6A: Methylcibersort cell proportions S6B: Methylcibersort cell reference mixture

Background. Low-grade gliomas (LGG) are among the most frequently occurring tumors in adolescent and young adult (AYA) patients (aged 18-39 years old at primary diagnosis). These tumors have a variable prognosis, presenting challenges for patients in shaping their future. This study aimed to identify the age-specific experiences and needs of AYA patients with LGG in their daily lives. Methods. In-depth interviews were conducted with AYA patients diagnosed with LGG. Thematic analysis was performed to derive the age-specific codes, looking for overarching themes and sub-themes. Results. Sixteen patients participated in this study. The cognitive symptoms of the disease (including difficulty concentrating, memory issues, and speech problems) are invisible to others but caused significant disruptions in many domains that were particularly important to AYA patients (eg, employment, family life, and autonomy). Additionally, the uncertainty regarding their life expectancy led to difficulties in making decisions about the future. They also perceived a lack of control over their future and the time they had left. Conclusions. LGG have a significant impact on AYA patients. However, this impact is not fully understood by others close to them. The results highlight the importance of providing these patients with appropriate peer support, interventions tailored to both their disease and life phase, utilizing a multidisciplinary approach, and maintaining a focus on long-term support for these patients. It is crucial to provide AYA care for these patients within the neurology department, as LGG involve both tumor- and age-specific problems.

Table S2: List of 132 pairs (ID of Initial and Recurrent samples)

Table S5: Treatment-related probes and samples (Related to Figure 3) S5A: List of 69 IDHmut pairs with treatment information (ID of Initial and Recurrent samples and group assignment) S5B: List of differentially methylated probes associated with treatment in IDHmut gliomas S5C: List of differentially methylated probes associated with treatment in IDHmut astrocytomas S5D: List of CpG-gene pairs (epigenetic regulation associated with treatment)