Diffuse midline glioma (DMG; a subtype of pediatric high-grade glioma) is a fatal disease in children, due to the localization in critical structures of the central nervous system, its invasive nature, and limited treatment options. Molecularly, DMG with loss of histone 3 K27 trimethylation (mostly through the typical K27M-mutation in histone 3) have been relatively well characterized, however, no unambiguous Achilles' heel for targeted therapeutic approaches could be identified to date. This study integrates detailed molecular characteristics of pediatric DMGs with clinical data in a large, international cohort in order to contribute to a better understanding necessary for further development of therapeutic approaches. A total of 162 DMG tumors were analyzed within the INFORM registry from 01/2015 to 11/2023 using comprehensive molecular profiling (including exome, whole-genome and RNA next-generation sequencing approaches, complemented with DNA methylation analysis). Molecular results were correlated with clinical data of the respective patients including the treatment regimen applied and patients' outcomes. This well-defined cohort of histone 3 K27-altered DMG according to the current WHO classification showed typical molecular alterations for this entity, with differences in frequencies in specific subgroups. The presence of TP53 mutation and the absence of MAPK pathway alteration in the tumors were associated with worse outcomes. In a substantial proportion of patients, genetic alterations serving as targets for potential therapeutic approaches could be identified. This large, international, prospective DMG cohort combines comprehensive molecular characterization of the tumors with registry-level clinical data, thereby contributing to a better understanding of the underlying tumor biology, potential prognostic and predictive markers and the potential impact of targeted therapies.

Aghia Sophia Children's Hospital ERN PeadCan Center Athens Greece

Center for Pediatric Neuro Oncology Motol University Hospital Prague Czech Republic

Childhood Cancer Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden

Clinical Cooperation Unit Neuropathology German Cancer Research Center Heidelberg Germany

Clinical Cooperation Unit Pediatric Oncology German Cancer Research Center Heidelberg Germany

Core Facility Omics IT and Data Management Heidelberg Germany

Department of Neuropathology Institute of Pathology Heidelberg University Hospital Heidelberg Germany

Department of Oncology and Children's Research Center University Children's Hospital Zurich Eleonoren Foundation Zurich Switzerland

Department of Paediatric Haematology and Oncology 2nd Faculty of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Pediatric Hematology Oncology and BMT University of Wroclaw Wrocław Poland

Department of Pediatric Oncology and Hematology Oslo University Hospital Oslo Norway

Department of Pediatric Oncology Hematology Immunology and Pulmonology Heidelberg University Hospital Heidelberg Germany

Department of Pediatrics and Adolescent Medicine St Anna Children's Hospital Medical University of Vienna Vienna Austria

Department of Pediatrics and Adolescent Medicine University Hospital Jena Friedrich Schiller University Jena Jena Germany

Department of Pediatrics Gynecology and Obstetrics Faculty of Medicine CANSEARCH Research Platform for Pediatric Oncology and Hematology University of Geneva Geneva Switzerland

Division of Pediatric Glioma Research German Cancer Research Center Heidelberg Germany

Division of Pediatric Hematology and Oncology Department of Pediatrics Gynecology and Obstetrics University Hospital of Geneva Geneva Switzerland

Division of Pediatric Hematology and Oncology University Medical Center Goettingen Göttingen Germany

Division of Pediatric Hematology Oncology 1st Department of Pediatrics Aghia Sophia Children's Hospital National and Kapodistrian University of Athens Athens Greece

Division of Pediatric Hematology Oncology Astrid Lindgren Children's Hospital Karolinska University Hospital Stockholm Sweden

Division of Pediatric Neurooncology German Cancer Research Center Heidelberg Germany

Faculty of Medicine and Health Technology Tampere Center for Child Adolescent and Maternal Health Research Tampere University Tampere Finland

Faculty of Medicine Hebrew University of Jerusalem Jerusalem Israel

German Cancer Consortium partner site Essen University Hospital Essen Essen Germany

Hopp Children's Cancer Center Heidelberg Heidelberg Germany

National Center for Tumor Diseases NCT Heidelberg a partnership between DKFZ and Heidelberg University Hospital Heidelberg Germany

National Center for Tumor Diseases partner site Essen University Hospital Essen Essen Germany

Pediatric Hemato Oncology Unit Wilf Children's Hospital Shaare Zedek Medical Center Jerusalem Israel

Pediatric Hematology and Oncology Ghent University Hospital Ghent Belgium

Pediatrics 3 West German Cancer Centre Essen University Hospital Essen University of Duisburg Essen Essen Germany

Princess Máxima Center for Pediatric Oncology Utrecht The Netherlands

Tays Cancer Center Tampere University Hospital Tampere Finland

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