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INFORM is a prospective, multinational registry gathering clinical and molecular data of relapsed, progressive, or high-risk pediatric patients with cancer. This report describes long-term follow-up of 519 patients in whom molecular alterations were evaluated according to a predefined seven-scale target prioritization algorithm. Mean turnaround time from sample receipt to report was 25.4 days. The highest target priority level was observed in 42 patients (8.1%). Of these, 20 patients received matched targeted treatment with a median progression-free survival of 204 days [95% confidence interval (CI), 99–not applicable], compared with 117 days (95% CI, 106–143; P = 0.011) in all other patients. The respective molecular targets were shown to be predictive for matched treatment response and not prognostic surrogates for improved outcome. Hereditary cancer predisposition syndromes were identified in 7.5% of patients, half of which were newly identified through the study. Integrated molecular analyses resulted in a change or refinement of diagnoses in 8.2% of cases.Significance:The pediatric precision oncology INFORM registry prospectively tested a target prioritization algorithm in a real-world, multinational setting and identified subgroups of patients benefiting from matched targeted treatment with improved progression-free survival, refinement of diagnosis, and identification of hereditary cancer predisposition syndromes.See related commentary by Eggermont et al., p. 2677.This article is highlighted in the In This Issue feature, p. 2659

Supplementary Table from The Pediatric Precision Oncology INFORM Registry: Clinical Outcome and Benefit for Patients with Very High-Evidence Targets

Supplementary Figure from The Pediatric Precision Oncology INFORM Registry: Clinical Outcome and Benefit for Patients with Very High-Evidence Targets

Representative images of immunohistochemical stainings of the isotype controls IgG and IgG1 in normal brain (NB) tissues, astrocytomas (WHO{degree sign}II: n = 10; WHO{degree sign}III: n = 10), and oligodendrogliomas (WHO{degree sign}II: n = 10; WHO{degree sign}III: n = 10). Scale bar: 50 µm.

TissueQuest gating strategy and Kaplan-Meier plots of significant clinical parameters.

(A) IFN-� ELISpot raw data of all HLA-A*02:01 patients analyzed (n = 7) showing the IFN-� spots / 1x105 T-cells for patient cells against TAAs vs. patient cells against the negative control (human immunodeficiency virus (HIV) gag/pol, 9 amino acids). Grey bars indicate a significantly increased immunogenicity compared to negative control (solid line). (B) Homogenous levels of stimulation while comparing the total immune response by mean of IFN-� spot numbers among astrocytomas (red) and oligodendrogliomas (blue) to a certain reactive epitope. (n.s., not significant, *, p < 0.05; **, p < 0.01)

IFN-� ELISpot raw data to validate antigen immunogenicity in patients of origin. Antigens with a significant increased immunogenicity (grey bars and asterisks) or 1.3-fold increased levels of immune responses (grey bars) were further validated in a bigger study sample of healthy individuals and lower-grade glioma patients. Solid line represents mean background of negative control (IgG1). (*, p < 0.05; **, p < 0.01; ***, p < 0.001)

Further information on antibodies, differentially expressed genes, clinical characteristics, survival analysis, mutations, and methylation.

Purpose:To provide a better understanding of the interplay between the immune system and brain metastases to advance therapeutic options for this life-threatening disease.Experimental Design:Tumor-infiltrating lymphocytes (TIL) were quantified by semiautomated whole-slide analysis in brain metastases from 81 lung adenocarcinomas. Multi-color staining enabled phenotyping of TILs (CD3, CD8, and FOXP3) on a single-cell resolution. Molecular determinants of the extent of TILs in brain metastases were analyzed by transcriptomics in a subset of 63 patients. Findings in lung adenocarcinoma brain metastases were related to published multi-omic primary lung adenocarcinoma The Cancer Genome Atlas data (n = 230) and single-cell RNA-sequencing (scRNA-seq) data (n = 52,698).Results:TIL numbers within tumor islands was an independent prognostic marker in patients with lung adenocarcinoma brain metastases. Comparative transcriptomics revealed that expression of three surfactant metabolism-related genes (SFTPA1, SFTPB, and NAPSA) was closely associated with TIL numbers. Their expression was not only prognostic in brain metastasis but also in primary lung adenocarcinoma. Correlation with scRNA-seq data revealed that brain metastases with high expression of surfactant genes might originate from tumor cells resembling alveolar type 2 cells. Methylome-based estimation of immune cell fractions in primary lung adenocarcinoma confirmed a positive association between lymphocyte infiltration and surfactant expression. Tumors with a high surfactant expression displayed a transcriptomic profile of an inflammatory microenvironment.Conclusions:The expression of surfactant metabolism-related genes (SFTPA1, SFTPB, and NAPSA) defines an inflamed subtype of lung adenocarcinoma brain metastases characterized by high abundance of TILs in close vicinity to tumor cells, a prolonged survival, and a tumor microenvironment which might be more accessible to immunotherapeutic approaches.

Purpose: Successful immunotherapies for IDHmut gliomas require better knowledge of T-cell target antigens. Here, we elucidated their antigen repertoire recognized by spontaneous T-cell responses using an unbiased proteomic approach.Experimental Design: Protein fractionations of tissue lysates from IDHmut gliomas (n = 4) were performed. Fractions were tested by IFNγ ELISpot assay for recognition through patients' T cells. Proteins of immunogenic fractions were identified by mass spectrometry and validated by in silico-predicted synthetic long peptides in patients of origin, additional IDHmut glioma patients (n = 16), and healthy donors (n = 13). mRNA and protein expression of immunogenic antigens was analyzed in tumor tissues and IDHmut glioma stem-like cells (GSC). HLA-A*02–restricted T-cell epitopes were functionally determined by short peptides and numbers of antigen-specific T cells by HLA-peptide tetramer analysis.Results: A total of 2,897 proteins were identified in immunogenic tumor fractions. Based on a thorough filter process, 79 proteins were selected as potential T-cell antigens. Twenty-six of these were recognized by the patients’ T cells, and five of them (CRKII, CFL1, CNTN1, NME2, and TKT) in up to 56% unrelated IDHmut glioma patients. Most immunogenic tumor-associated antigens (TAA) were expressed in IDHmut gliomas and GSCs, while being almost absent in normal brain tissues. Finally, we identified HLA-A*02–restricted epitopes for CRKII, NME2, and TKT that were recognized by up to 2.82% of antigen-specific peripheral cytotoxic T cells in IDHmut glioma patients.Conclusions: By analyzing the repertoire of T-cell target antigens in IDHmut glioma patients, we identified five novel immunogenic TAAs and confirmed their expression on IDHmut tumors and GSCs. Clin Cancer Res; 24(12); 2951–62. ©2018 AACR.

(A) Applied gating strategy (one representative patient, NCH645) for the expression analysis of tumor-associated antigens in IDHmut lower-grade glioma and secondary glioblastoma GSCs, analyzed by flow cytometry in regard to an adequate isotype control. (B) Fluorescence intensity measurements for the isotype control and the antigen expressing (positive) GSC population, showing counts in percentage [%] over the mean PE-intensity.(C) Gating strategy, including the markers pacific orange (PO), CD3, and CD8, used for quantification of antigen-specific peripheral cytotoxic CD3+CD8+ T-cells by flow cytometry and (D) antigen-loaded pMHC I-tetramers (PE-conjugated) and the respective positive (Influenza M1) as well as negative control HLA-A*02-tetramers. GSCs: glioma stem-like cells, HIV: human immunodeficiency virus, HLA: human leukocyte antigen, MHC: major histocompatibility complex, PE: Phycoerythrin, pos: positive, US: unstained.

Peptide information of potential T cell target antigens, tested by IFN-γ ELISpot

Clinical data of IDHmut LGG patients

Usage of RNA Seq TCGA data of IDHmut LGG tumors to compare mRNA expression levels with T-cell infiltration. Significant increased expression of NME2 in the TCGA IDHmut LGG dataset was shown to be positively correlated with the expression of CD3E (encoding CD3-ε as part of the CD3 T-cell receptor complex) (r = 0.2352). Stronger correlation in the histology of astrocytomas (r = 0.3693**) than in oligodendrogliomas (r = 0.1919**). (*, p < 0.05; **, p < 0.01; ***, p < 0.001)

(A) Semi-quantitative evaluation on immunohistochemically stained sections of the frequency of tumor cells expressing the potential T-cell target antigens CRKII, CFL1, NME2, and CNTN1 in astrocytoma (WHO{degree sign}II: n = 10, WHO{degree sign}III: n = 10) and (B) oligodendroglioma (WHO{degree sign}II: n = 10, WHO{degree sign}III: n = 10) tumor tissues.

Representative multicolor stainings of CFL1, CRKII, NME2, and CNTN1 on acetone-fixed cryosections with markers for common cell types in IDHmut LGGs: anti-GFAP (tumor cells, #Z0334, DAKO), anti-CD68 (microglia/ macrophages, #M0718, DAKO), anti-CD31 (endothelial cells, #223609, BD Pharmingen). Detection was performed by using fluorochrom-conjugated secondary antibodies (anti-mouse AF647 (#A-21463, Invitrogen), anti-rabbit AF555 (#A-21428, Invitrogen), DAPI (#D1306, ThermoFisher), and the Zenon AF488 mouse IgG1 Labeling Kit (#Z25001, ThermoFisher)) according to the manufacturer`s protocol (scale bar: 50 µM, scale bar zoom: 10 µM).

(A) Significantly increased immune responses in IDHmut lower-grade glioma patients (P) vs. healthy donors (HD) seen for the potential T-cell target antigens CRKII, CFL1, CNTN1, NME2, and TKT. Homogenous levels of stimulation while comparing IFN-� spot numbers among astrocytomas (red) and oligodendrogliomas (blue) to a certain TAA as well as (B) the total immune response. (C) IFN-� ELISpot raw data showing the spot count / 1x105 T-cells upon stimulation with autologous dendritic cells loaded with antigens (CRKII, CFL1, CNTN1, NME2, or TKT, black bar) vs. negative control (IgG1, grey bar) for each patient (P) (n = 16). Highlighted in green: significant immune responses (p < 0.05) with an > 2-fold increased spot count compared to the negative control (IgG) (*, p < 0.05; **, p < 0.01; ***, p < 0.001)

Background Plexiform neurofibromas can transform into atypical neurofibromas (ANF) and then further progress to aggressive malignant peripheral nerve sheath tumors (MPNST). ANF have been described to harbor distinct histological features and frequent loss of CDKN2A/B. However, histological evaluation may be rater-dependent, and detailed knowledge about the molecular mechanisms of malignant transformation is scarce. In general, malignant transformation can be accompanied by significant epigenetic changes, and global DNA methylation profiling is able to differentiate relevant tumor subgroups. Therefore, epigenetic profiling might provide a valuable tool to distinguish and characterize ANF with differing extent of histopathological atypia from neurofibromas and MPNST. Methods We investigated 40 tumors histologically diagnosed as ANF and compared their global methylation profile to other peripheral nerve sheath tumors. Results Unsupervised class discovery and t-SNE analysis indicated that 36/40 ANF cluster with benign peripheral nerve sheath tumors with clear separation from MPNST. 21 ANF formed a molecularly distinct cluster in proximity to schwannomas. Tumors in this cluster had a frequent heterozygous or homozygous loss of CDKN2A/B and significantly more lymphocyte infiltration than MPNST, schwannomas, and NF. Few ANF clustered closely with neurofibromas, schwannomas, or MPNST, raising the question, whether diagnosis based on histological features alone might pose a risk to both over- and underestimate the aggressiveness of these lesions. Conclusions Our data suggest that ANF with varying histological morphology show distinct epigenetic similarities and cluster in proximity to benign peripheral nerve sheath tumor entities. Future investigations should pay special respect to correlating this methylation pattern to clinical outcomes.

The preoperative grading of non-enhancing glioma (NEG) remains challenging. Herein, we analyzed clinical and magnetic resonance imaging (MRI) features to predict malignancy in NEG according to the 2021 WHO classification and developed a clinical score, facilitating risk estimation. A discovery cohort (2012–2017, n = 72) was analyzed for MRI and clinical features (T2/FLAIR mismatch sign, subventricular zone (SVZ) involvement, tumor volume, growth rate, age, Pignatti score, and symptoms). Despite a “low-grade” appearance on MRI, 81% of patients were classified as WHO grade 3 or 4. Malignancy was then stratified by: (1) WHO grade (WHO grade 2 vs. WHO grade 3 + 4) and (2) molecular criteria (IDHmut WHO grade 2 + 3 vs. IDHwt glioblastoma + IDHmut astrocytoma WHO grade 4). Age, Pignatti score, SVZ involvement, and T2/FLAIR mismatch sign predicted malignancy only when considering molecular criteria, including IDH mutation and CDKN2A/B deletion status. A multivariate regression confirmed age and T2/FLAIR mismatch sign as independent predictors (p = 0.0009; p = 0.011). A “risk estimation in non-enhancing glioma” (RENEG) score was derived and tested in a validation cohort (2018–2019, n = 40), yielding a higher predictive value than the Pignatti score or the T2/FLAIR mismatch sign (AUC of receiver operating characteristics = 0.89). The prevalence of malignant glioma was high in this series of NEGs, supporting an upfront diagnosis and treatment approach. A clinical score with robust test performance was developed that identifies patients at risk for malignancy.

INFORM is a prospective, multinational registry gathering clinical and molecular data of relapsed, progressive, or high-risk pediatric patients with cancer. This report describes long-term follow-up of 519 patients in whom molecular alterations were evaluated according to a predefined seven-scale target prioritization algorithm. Mean turnaround time from sample receipt to report was 25.4 days. The highest target priority level was observed in 42 patients (8.1%). Of these, 20 patients received matched targeted treatment with a median progression-free survival of 204 days [95% confidence interval (CI), 99–not applicable], compared with 117 days (95% CI, 106–143; P = 0.011) in all other patients. The respective molecular targets were shown to be predictive for matched treatment response and not prognostic surrogates for improved outcome. Hereditary cancer predisposition syndromes were identified in 7.5% of patients, half of which were newly identified through the study. Integrated molecular analyses resulted in a change or refinement of diagnoses in 8.2% of cases. Significance: The pediatric precision oncology INFORM registry prospectively tested a target prioritization algorithm in a real-world, multinational setting and identified subgroups of patients benefiting from matched targeted treatment with improved progression-free survival, refinement of diagnosis, and identification of hereditary cancer predisposition syndromes. See related commentary by Eggermont et al., p. 2677 . This article is highlighted in the In This Issue feature, p. 2659

The survival rate among children with relapsed tumors remains poor, due to tumor heterogeneity, lack of directly actionable tumor drivers and multidrug resistance. Novel personalized medicine approaches tailored to each tumor are urgently needed to improve cancer treatment. Current pediatric precision oncology platforms, such as the INFORM (INdividualized Therapy FOr Relapsed Malignancies in Childhood) study, reveal that molecular profiling of tumor tissue identifies targets associated with clinical benefit in a subgroup of patients only and should be complemented with functional drug testing. In such an approach, patient-derived tumor cells are exposed to a library of approved oncological drugs in a physiological setting, e.g., in the form of animal avatars injected with patient tumor cells. We used molecularly fully characterized tumor samples from the INFORM study to compare drug screen results of individual patient-derived cell models in functional assays: (i) patient-derived spheroid cultures within a few days after tumor dissociation; (ii) tumor cells reisolated from the corresponding mouse PDX; (iii) corresponding long-term organoid-like cultures and (iv) drug evaluation with the corresponding zebrafish PDX (zPDX) model. Each model had its advantage and complemented the others for drug hit and drug combination selection. Our results provide evidence that in vivo zPDX drug screening is a promising add-on to current functional drug screening in precision medicine platforms.

Fusion proteins involving the BRAF serine/threonine kinase occur in many cancers. The oncogenic potential of BRAF fusions has been attributed to the loss of critical N-terminal domains that mediate BRAF autoinhibition. We used whole-exome and RNA sequencing in a patient with glioblastoma multiforme to identify a rearrangement between TTYH3, encoding a membrane-resident, calcium-activated chloride channel, and BRAF intron 1, resulting in a TTYH3-BRAF fusion protein that retained all features essential for BRAF autoinhibition. Accordingly, the BRAF moiety of the fusion protein alone, which represents full-length BRAF without the amino acids encoded by exon 1 (BRAF

The “pediatric targeted therapy” (PTT) program aims to identify the presence and activity of druggable targets and evaluate the clinical benefit of a personalized treatment approach in relapsed or progressive tumors on an individual basis. 10 markers (HDAC2, HR23B, p‐AKT, p‐ERK, p‐S6, p‐EGFR, PDGFR‐alpha/beta, p53 and BRAFV600E) were analyzed by immunohistochemistry. Pediatric patients with tumors independent of the histological diagnosis, with relapse or progression after treatment according to standard protocols were included. N = 61/145 (42%) cases were eligible for analysis between 2009 and 2013, the most common entities being brain tumors. Immunohistochemical stainings were evaluated by the H‐Score (0–300). In 93% of the cases potentially actionable targets were identified. The expressed or activated pathways were histone deacetylase (HDACs; 83.0% of cases positive), EGFR (87.2%), PDGFR (75.9%), p53 (50.0%), MAPK/ERK (43.3%) and PI3K/mTOR (36.1%). Follow‐up revealed partial or full implementation of PTT results in treatment decision‐making in 41% of the cases. Prolonged disease stabilization responses in single cases were noticed, however, response rates did not differ from cases treated with other modalities. Further studies evaluating the feasibility and clinical benefit of personalized diagnostic approaches using paraffin material are warranted.

Introduction: Tumors with histological features of pilocytic astrocytoma but with increased mitotic activity and additional high grade features (i.e. microvascular proliferation, necrosis) have been designated anaplastic pilocytic astrocytomas (APA). Patients with such tumors are thought to have an [for full text, please go to the a.m. URL]