The intrinsic and microenvironmental features of diffuse midline glioma: implications for the development of effective immunotherapeutic treatment strategies
Keywords: 
Diffuse intrinsic pontine glioma (DIPG)
Diffuse midline glioma (DMG)
Immuno-oncology
Immunotherapy
Pediatric high-grade glioma (HGG)
Car t-cells
Potential therapeutic target
Pediatric high-grade
H3.3K27M mutation
Children
Survival
B7-H3
Glioblastoma
Pathways
Issue Date: 
2022
ISSN: 
1522-8517
Note: 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: 
Persson, M. L.; Douglas, A. M.; Alvaro, F.; et al. "The intrinsic and microenvironmental features of diffuse midline glioma: implications for the development of effective immunotherapeutic treatment strategies". Neuro-oncology. 24 (9), 2022, 1408 - 1422
Abstract
Diffuse midline glioma (DMG), including those of the brainstem (diffuse intrinsic pontine glioma), are pediatric tumors of the central nervous system (CNS). Recognized as the most lethal of all childhood cancers, palliative radiotherapy remains the only proven treatment option, however, even for those that respond, survival is only temporarily extended. DMG harbor an immunologically cold tumor microenvironment (TME) with few infiltrating immune cells. The mechanisms underpinning the cold TME are not well understood. Low expression levels of immune checkpoint proteins, including PD-1, PD-L1, and CTLA-4, are recurring features of DMG and likely contribute to the lack of response to immune checkpoint inhibitors (ICIs). The unique epigenetic signatures (including stem cell-like methylation patterns), a low tumor mutational burden, and recurring somatic mutations (H3K27M, TP53, ACVR1, MYC, and PIK3CA), possibly play a role in the reduced efficacy of traditional immunotherapies. Therefore, to circumvent the lack of efficacy thus far seen for the use of ICIs, adoptive cell transfer (including chimeric antigen receptor T cells) and the use of oncolytic viruses, are currently being evaluated for the treatment of DMG. It remains an absolute imperative that we improve our understanding of DMG's intrinsic and TME features if patients are to realize the potential benefits offered by these sophisticated treatments. Herein, we summarize the limitations of immunotherapeutic approaches, highlight the emerging safety and clinical efficacy shown for sophisticated cell-based therapies, as well as the evolving knowledge underpinning the DMG-immune axis, to guide the development of immunotherapies that we hope will improve outcomes.

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