Patient-Derived Surgical samples reveal patterns of glioblastoma infiltration and tumor microenvironment at the tumor margin

Background

Glioblastoma (GBM) is a highly aggressive cancer with near-universal recurrence, often due to residual tumor cells that persist after aggressive standard of care treatment. This study aimed to characterize tumor infiltration and microenvironment in the GBM periphery.

Methods

We prospectively collected 161 radiologically guided biopsies from 45 GBM patients and conducted an immunohistochemical analysis. We also integrated single-cell RNA sequencing data to select specific markers for immune, glial, and vascular cells. We measured the expression of these genes in samples from contrast-enhancing (CE) and non-enhancing (nCE) tumor areas, vasogenic edema, and radiologically normal tissue. Correlations with resection extent and clinical outcomes were evaluated.

Results

nCE biopsies exhibited neoplastic features similar to those of the tumor core. However, tumor infiltration was also found in regions classified radiologically as edema, particularly in elderly patients. We found important differences in the composition of the peripheral microenvironment between male and female GBM patients. Prognostic associations with specific cell types, such as myeloid cells, showed intertumor heterogeneity, with variations depending on patient sex, age and extent of resection. Furthermore, in our cohort, minimal residual CE tumor following surgery was associated with significantly poorer patient survival.

Conclusions

The GBM periphery includes regions of active tumor growth that are visible on MRI, as well as infiltrated areas that resemble edema radiologically. Tumor infiltration and microenvironmental features are influenced by patient sex and age, which has major implications for recurrence rates, highlighting the need to tailor surgical and therapeutic strategies based on tumor biology and patient subgroup.

Key points

nCE areas show similar neoplastic traits to the CE tumor.

GBM infiltrates edema tissue, predominantly in older adult patients.

Prognostic value of the peritumoral phenotype depends on resection extent and patient age/sex.

Importance of the study

This study shows that the impact of peripheral and core cellular features on prognosis differs between patients who undergo complete versus incomplete CE tumor resection. Our results suggest a paradigm shift in the classification and management of these patients, encouraging the inclusion of detailed post-surgical MRI analyses to guide the design of future clinical trials according to the nature and extent of the residual disease. Furthermore, our data confirm the presence of tumorigenic features in non-enhancing areas, supporting the benefits of supratotal resections according to the new RANO classification. Our findings also underscore the need to refine surgical and therapeutic strategies based on a more detailed understanding of the tumor microenvironment beyond the GBM core. This understanding may help identify novel targets for more effective and personalized GBM therapies.