MF OI Onkologijos ir hematologijos klinika (04.05.01)

Background: Toxic epidermal necrolysis (TEN) is a rare but life-threatening complication that may occur in patients after allogeneic hematopoietic stem cell transplantation (allo-HSCT), particularly in the context of extensive drug exposure. In this population, TEN can closely resemble severe acute graft-versus-host disease (GVHD), making diagnosis and management challenging. Case presentation: We report the clinical course of an allo-HSCT recipient who developed a rapidly progressive skin rash early after transplantation, and we analyzed the clinical features, histopathology, treatment and outcome. Results: The patient developed rapidly progressive epidermal detachment with severe oral, ocular, and genital mucosal involvement shortly after exposure to trimethoprim/sulfamethoxazole (TMP-SMX). Disease severity was reflected by a SCORTEN score of 5, corresponding to a very high predicted mortality risk. The clinical picture raised concern for both TEN and severe acute GVHD, while histopathological findings favored TEN but were not definitive. Management included systemic corticosteroids, intravenous immunoglobulin, ruxolitinib, and intensive supportive care. The patient gradually re-epithelialized and recovered without long-term sequelae. Conclusions: This case underscores the diagnostic difficulty of distinguishing TEN from severe acute GVHD in the early post-transplant period. Careful assessment of drug exposure, clinical evolution, and multidisciplinary evaluation are essential to guide timely and appropriate management.

The field of oncology has witnessed remarkable progress with the integration of high-tech innovations in tumor ablation. Tumor ablation therapies, such as radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo), irreversible electroporation (IRE), and electrochemotherapy (ECT) have evolved beyond conventional boundaries, offering patients less invasive, highly targeted therapeutic options. Since it works across cancer histologies, tumor ablation is being integrated into cancer care at several levels. Tumor ablation is even considered curative in selected patients with small primary or secondary tumors, e.g. in the liver. Furthermore, it is central in treatment of oligometastatic disease or oligoprogression. Finally, ablation is widely used for symptomatic relief when tumors lead to symptoms affecting quality of life. Knowledge about ablative therapies and their inclusion at multidisciplinary team decision making enables effective and more personalized treatment for patients. This review synthesizes emerging applications of these therapies, focusing on artificial intelligence-driven personalization, robotic-assisted precision, and hybrid models combining ablation with systemic treatments, immunotherapy or targeted drug delivery. It also discusses the infrastructural, educational, regulatory, and ethical challenges that influence the clinical adoption of such treatments. Finally, the review presents strategic recommendations for integrating advanced ablation therapies into healthcare systems while ensuring equity, patient trust, and global accessibility.

Laryngeal cancer is a relatively uncommon malignancy with predisposing genetic factors that remain unclear. Single-nucleotide polymorphisms (SNPs) in genes involved in innate immune signaling may contribute to the development and progression of laryngeal carcinoma. This study aimed to evaluate the association of TLR4 (rs7037225, rs11536889, rs7037117) and MYD88 (rs7744, rs6853) polymorphisms with the risk of laryngeal squamous cell carcinoma (LSCC), as well as its clinical and pathological characteristics and survival. A retrospective case–control study involving 172 LSCC patients and 220 healthy controls was conducted. Genotyping was performed using real-time PCR from venous blood samples. MYD88 rs7744 was significantly associated with tumor size and lymph node involvement. Survival analysis showed a significant association between rs7744 and recurrence-free survival (RFS), with the AG and GG genotypes linked to poorer outcomes. Conversely, carriers of the TLR4 rs7037225 CT genotype showed significantly improved RFS, with p ranging from 0.024 to 0.037 across models. Considering the significant roles of TLR4 and MYD88 in Toll-like receptor signaling, these findings may reflect the involvement of innate immune pathways in LSCC progression. In summary, MYD88 rs7744 was associated with clinicopathological features and RFS, while TLR4 rs7037225 appeared to have a potential protective effect on survival.

Despite significant therapeutic progress, the development of protocols that maximize tumour regression without compromising systemic safety continues to be a critical unmet need in cancer treatment. This study evaluates a multi-modal therapeutic strategy combining pulsed electric fields (Irreversible Electroporation (IRE) and reversible Electroporation (EP)) with chemotherapy and immunotherapy (programmed cell death protein 1 (PD-1) blockade). The aim was to determine whether integrating these triggers for localized tumour ablation and enhanced drug delivery could achieve improved tumour suppression while maintaining the highest possible survival rate. In this experiment, a triple-negative breast cancer model was established using female BALB/c mice. Each mouse was administered a single subcutaneous injection of 100 µL containing 2∙106 4T1 cells. Once tumours reached the target volume, mice were randomized into experimental groups, including monotherapies and various combinations. Electroporation was performed using eight 99 µs pulses at 1 Hz, with field strengths of 2.8 kV/cm for IRE and 1.5 kV/cm for EP. Mice in the chemotherapy groups received a single 0.088 mg intravenous dose of cisplatin (1 mg/mL), whereas the immunotherapy groups were administered anti-PD-1 monoclonal antibody 0.2 mg (10 mg/mL) intraperitoneally every two days for a total of four injections. Results demonstrated that all therapeutic interventions significantly inhibited tumour growth compared to the control (537.30 ± 67.0 mm3 ). The greatest reduction was observed in the triple-combination group (electroporation + chemotherapy + immunotherapy), which achieved a 55.2% reduction in tumour volume, resulting in the lowest final volume of 240.56 ± 40.12 mm3 . Notably, while most groups maintained a 100% survival rate, mortality was exclusively observed in mice that were treated with IRE. Survival decreasing to 80% in the IRE monotherapy and 85.71% in the anti-PD-1 + IRE group. These findings suggest that the triple combination of immune checkpoint inhibition, platinum-based chemotherapy, and reversible electroporation offers the optimal balance between maximum anti-tumour efficacy and systemic safety.

Background and Objectives Breast cancer remains the most commonly diagnosed cancer among women globally. The complicated tumor microenvironment, aggressive behavior, heterogeneous nature, elevated proliferation rate, and treatment resistance are among the most characterized hallmarks of breast cancer. Many of these processes relate to the capacity of cancer cells to avoid apoptosis. Overexpressing anti-apoptotic genes is one strategy by which cancer cells prevent apoptosis. Consequently, anti-apoptotic gene expression reduction can promote the apoptosis mechanism and enhance the cells' sensitivity to cancer therapy. Chemical therapies are effective in treating cancer, but their adverse effects and resistance frequently result in treatment failure. Consequently, plant-based substances have recently received a lot of attention for their ability to inhibit cancer cell survival and increase sensitivity to treatment. One of these phytochemicals is sulforaphane (SFN), which can be found in cruciferous vegetables like broccoli and cauliflower. SFN possesses various attributes, including anti-inflammatory, cardioprotective, antioxidative, cytoprotective, and antimicrobial properties; however, its anticancer property is the most significant. Several studies demonstrated that SFN might induce apoptosis and inhibit the expression of cancer-specific genes. Thus, this study aimed to investigate the in vitro effects of SFN on breast cancer cells by evaluating BCL2 and BCL2L1 expression at both the gene and protein levels. Material and Method In this study, MCF-7 and MDA-MB-231 breast cancer cell lines were used. Cells were seeded in plates and incubated overnight. The next day, cells were treated with 25 µM and 50 µM concentrations of SFN or with DMSO as a control (0 µM). After 48 hours of incubation time, the expression of BCL2 and BCL2L1 genes was determined using reverse transcription-quantitative PCR (RT-qPCR). The total RNA was extracted from cells using the RNeasy Mini Kit. One microgram of total RNA was converted into cDNA using the High-Capacity RNA-to-cDNA Kit. RT-qPCR analysis was performed on a QuantStudio3 Real-Time PCR System. Relative gene expression was normalized to β-actin. BCL-2 and BCL-XL protein levels were assessed using Western blot analysis, involving separation by gel electrophoresis and transfer onto a membrane utilizing the semi-wet transfer unit Mini Blot module. Target proteins were detected using specific primary and secondary antibodies. The visualization of chemiluminescent imaging was done utilizing the Azure 280 system. The target protein expression level was normalized using the GAPDH protein as an internal control. Statistical analysis was performed using IBM SPSS Statistics 30 (version 30.0.0.0), and statistical significance was defined as a p-value less than 0.05. Results In MCF-7 cells, after the treatment with 25 µM and 50 µM concentrations of SFN, the BCL2 gene expression was reduced to 0.44 and 0.33, and BCL2L1 gene expression was 0.83 and 0.73, respectively. Additionally, BCL-2 protein levels decreased to 0.56 and 0.33 after the same SFN concentrations. The level of the BCL-XL protein did not alter significantly. In MDA-MB-231 cells, the BCL2 gene expression reduced to 0.88 and 0.82, and BCL2L1 gene expression was 0.73 and 0.32 after the treatment with 25 µM and 50 µM concentrations of SFN, respectively. Also, the concentrations of SFN used statistically significantly reduced protein levels. BCL-2 protein levels decreased to 0.85 and 0.78, and BCL-XL was 0.84 and 0.63. Conclusions and Recommendations Our study results revealed that SFN reduce the gene expression and protein levels of BCL2 and BCL2L1 in breast cancer cells. This suggests that SFN may be a potential anticancer agent whose effects are associated with the regulation of BCL-2 family proteins in the treatment of breast cancer.

Background and Objectives Breast cancer (BC) is a biologically heterogeneous disease with diverse molecular subtypes and clinical outcomes, strongly influenced by genetic factors. ATP-binding cassette (ABC) transporters play an important role in transmembrane processes, including drug efflux, cellular detoxification, and the maintenance of intracellular homeostasis. Variants in genes such as ABCB1 and ABCB8 may contribute to interindividual differences in tumor behavior, influencing clinicopathological characteristics and potentially affecting disease progression and treatment response. This study evaluated the association of two single nucleotide polymorphisms (SNPs), ABCB1 rs1128503 and ABCB8 rs56198402, with BC clinicopathological features. The findings aim to clarify their role in tumor biology and assess their potential as prognostic biomarkers, contributing to a better understanding of the genetic background of BC heterogeneity. Material and Method The study population comprised 170 female patients with histopathologically confirmed early-stage primary BC, aged 30 to 74 years (median age: 46 years). Clinical and tumor pathomorphological data, including tumor size, lymph node involvement, presence of metastases, degree of differentiation, estrogen (ER) and progesterone (PR) receptor status, human epidermal growth factor receptor 2 (HER2) status, disease progression, and mortality, were obtained from oncologists and the follow-up period extended until November 30, 2024. Genomic DNA was extracted from peripheral blood leukocytes using a column-based commercial DNA isolation kit in accordance with the manufacturer’s instructions. Genotyping of ABCB1 rs1128503 and ABCB8 rs56198402 was performed using TaqMan probe-based assays on the QuantStudio™ 3 Real-Time PCR System. The strength of associations between SNPs and BC clinicopathological characteristics was estimated using crude odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Survival outcomes were assessed using Kaplan-Meier analysis. Statistical analysis was conducted using IBM SPSS Statistics, version 30.0.0.0, and a p-value < 0.05 was considered statistically significant. The study protocol was approved by the Kaunas Regional Biomedical Research Ethics Committee (approval numbers BE-2-10 and P1-BE-2-10/2014). Results Significant associations were identified between ABCB1 rs1128503 and PR status, metastatic disease, disease progression, and mortality. Specifically, GA genotype carriers had higher odds of progesterone receptor positivity than GG (OR=2.038; 95% CI 1.016–4.091; p=0.045), which was corroborated by allele-based analysis, showing similarly increased odds among A allele carriers (OR=1.986; 95% CI 1.034–3.816; p=0.039). Conversely, GA carriers demonstrated reduced odds of metastasis (OR=0.301; 95% CI 0.122–0.742; p=0.009), disease progression (OR=0.387; 95% CI 0.171–0.877; p=0.023), and mortality (OR=0.361; 95% CI 0.144–0.907; p=0.030). Furthermore, tumor size and lymph node involvement were also significantly associated (p-value < 0.05) with the studied genotype, indicating a protective effect against more advanced disease features. A significant difference in progression-free survival was observed across ABCB1 rs1128503 genotypes, with the GA genotype associated with more favorable outcomes (p-value < 0.05). No significant associations were found between the ABCB8 rs56198402 and clinicopathological characteristics of BC. Conclusions and Recommendations The ABCB1 rs1128503 was significantly associated with several breast cancer clinicopathological features, including progesterone receptor status, metastasis, disease progression, and progression-free survival, suggesting a potential protective effect of the GA genotype. In contrast, no significant associations were found for the ABCB8 rs56198402 variant. Further studies with larger cohorts are needed to confirm these findings and clarify the biological role of ABCB1 variants in breast cancer progression and prognosis.

Background and Objectives Electroporation is a method that applies controlled electrical pulses to enhance the permeability of the cell membrane, thereby enabling improved intracellular delivery of therapeutic agents or inducing direct cytotoxic effects. Checkpoint inhibitor therapy, a form of immunotherapy, targets inhibitory signaling pathways exploited by cancer cells to evade immune detection, thereby restoring and amplifying the host’s antitumor immune response. Recent studies suggest that combining electroporation-based therapies with immunotherapy may further enhance antitumor efficacy [1]. This study aims to determine whether a multimodal treatment strategy provides greater tumor control than single-modality interventions. Specifically, we investigated the therapeutic efficacy of combining cytotoxic drugs (Cisplatin or Oxaliplatin) with electroporation and checkpoint inhibitor therapy in the treatment of tumors in mouse models. Results Experiments were performed using the 4T1 murine breast cancer cell line (ATCC). Cells were cultured in RPMI medium (Sigma-Aldrich, St. Louis, MO, USA) supplemented with 1% penicillin–streptomycin and 10% fetal bovine serum. Experimental scheme Eight- to twelve-week-old female BALB/c mice were used in this study. Tumors were induced by a single 100 μL subcutaneous injection of 4T1 cells (20 × 10⁶ cells/mL), resulting in one tumor per mouse. Tumors were allowed to develop until they reached a volume of approximately 150–500 mm³, after which treatment was initiated (~10 days post-injection), depending on tumor growth rate. Mice were assigned to experimental groups based on tumor volume to ensure balanced distribution across groups. A total of ten groups were included: untreated control (CTRL) (n = 8), Oxaliplatin (Ox) (n = 8), Ox + EP (n = 8), Cisplatin (Cis) (n = 8), Cis + EP (n = 8), EP (n = 8), checkpoint inhibitor therapy (Nivolumab, Ch.P) (n = 8), Ch.P + EP (n = 4), Ch.P + EP + Ox (n = 8), and Ch.P + EP + Cis (n = 8). Prior to treatment, the tumor-bearing area was shaved and depilated. Mice were anesthetized with ketamine (80 mg/kg) and xylazine (7.5 mg/kg, i.p.) to ensure adequate sedation during procedures. Electroporation Electroporation was performed using a BTX T820 electroporator (Harvard Apparatus, San Diego, CA, USA). Reversible electroporation (EP) was applied to groups 3, 5, 6, 8, 9, and 10 using the following parameters: 1.5 kV/cm × 8 pulses, 99 µs, 1 Hz. Treatment with drugs Cisplatin (88 μL, 1 mg/mL) was administered as a single dose via the tail vein (groups 4, 5, and 10). Oxaliplatin (33 μL, 5 mg/mL) was administered in the same manner (groups 2, 3, and 9). As a checkpoint inhibitor therapy, Nivolumab (200 μg) was administered intraperitoneally (i.p.) every two days for a total of four injections (groups 7, 8, 9 and 10). Evaluation of tumor sizes Tumors were measured every 2 days, starting on day 1 (the day of treatment) and continuing until day 19. Tumor dimensions were determined using a digital caliper. Tumor volume (mm³) was calculated according to the formula: V = (π × l × w × h) / 6, where l denotes length, w width, and h height of the tumor [2]. Tumor growth analysis revealed time-dependent differences between treatment groups. In the early phase (days 2–6), statistically significant reductions in tumor volume compared to CTRL (Dunnett test, p < 0.05) were observed in the Cis + EP, EP, and Ch.P + EP + Cis groups, indicating an early therapeutic response. Due to technical limitations (insufficient reliable measurements), the Ch.P + EP group was excluded from comparative analysis. By the intermediate phase (day 10), the Ch.P + EP + Cis combination demonstrated the strongest and most consistent antitumor effect, achieving nearly a 2-fold reduction in tumor volume compared to CTRL. A strong but less consistent effect was also observed in the Ch.P + EP + Ox + Cis group. In the late phase, these groups maintained approximately 2.0–2.2-fold lower tumor volumes compared to control; however, differences were not statistically significant, likely due to increased variability. EP alone also showed a consistent ~2-fold inhibitory effect. Notably, the addition of Oxaliplatin, a chemotherapeutic agent with reported immunomodulatory properties, appeared to reduce treatment efficacy in combination regimens (~1.2–1.3-fold reduction), suggesting a potential antagonistic interaction. These findings indicate that while electroporation enhances checkpoint inhibitor therapy, certain drug combinations may attenuate this effect and require further investigation. Conclusions and Recommendations Ch.P + EP demonstrated the strongest antitumor effect, achieving ~2-fold tumor reduction compared to control, while the addition of Oxaliplatin reduced efficacy, suggesting a potential antagonistic interaction. Further studies are needed to clarify underlying mechanisms and optimize combination strategies.

Background and Objectives Breast cancer (BC) is a heterogenous disease characterized by substantial variability in tumor biology and clinical behavior. This heterogeneity is reflected in clinicopathological features, including hormone receptor status, human epidermal growth factor receptor 2 (HER2) expression, tumor histological grade, tumor size, and disease stage, which describe tumor features and are key determinants of prognosis. Single nucleotide polymorphisms (SNPs) have been proposed as potential contributors to inter-individual differences in these tumor features and clinical outcomes; however, their role in early-stage BC remains insufficiently defined. In this study, polymorphisms in the RRP1B gene, specifically rs2838342 and rs2051407, were investigated for their potential associations with BC features and outcomes. Material and Method Study population. A total of 191 adult female patients with primary stage I-II BC were enrolled. All participants provided written informed consent, and the study was approved by the Kaunas Regional Ethics Committee for Biomedical Research (nos. BE-2-10 and P1-BE-2-10/2014). Peripheral blood samples were collected for genetic analysis. DNA extraction and genotyping. Genomic DNA was extracted from peripheral blood using a spin column-based extraction method with a commercially available kit. SNP genotyping was performed using TaqMan allelic discrimination assays on a Quanstudio 3 Real-Time PCR System. Statistical analysis. Associations between SNPs and clinicopathological features as well as binary clinical outcomes (disease progression, metastasis status, and mortality status) were evaluated using logistic regression under an additive genetic model. Both univariate and age-adjusted multivariable analyses were performed. Sensitivity analyses using alternative genetic models were conducted for selected SNPoutcome associations showing non-linear patterns in genotype distributions. Progression-free, overall, and metastasis-free survival (MFS) were analyzed using Kaplan-Meier with log-rank tests and Cox proportional hazards regression models under an additive genetic model. Multivariable Cox models were adjusted for established clinicopathological prognostic factors. To account for multiple testing, the Benjamini-Hochberg false discovery rate (FDR) correction was applied separately for clinicopathological features (n = 12), binary clinical outcomes (n = 6), and Cox models (n = 6), using p-values from fully adjusted additive models. Kaplan-Meier analyses were considered descriptive and were not included in correction. Adjusted p-values (q-values) < 0.05 were considered significant. All statistical analyses were performed using IBM SPSS Statistics 30.0.0.0. Results Genotype distributions were as follows: for rs2838342, AA 30.9% (n = 59), AG 51.8%, (n = 99), and GG 17.3% (n = 33); for rs2051407, CC 36.6% (n = 70), CT 45.5 % (n = 87), and TT 17.8% (n = 34). The minor allele frequencies were 43.2% for rs2838342 and 40.6% for rs2051407. Genotype frequencies for both SNPs were consistent with Hardy-Weinberg equilibrium (p > 0.05). In age-adjusted additive logistic regression models, rs2838342 was associated with tumor size (p = 0.022) and histological grade (p = 0.032), although neither association remained significant after correction for multiple testing. Under a recessive genetic model, rs2838342 was associated with estrogen receptor (ER) status after adjustment for age group (OR = 0.38, 95% CI 0.17-0.85, p = 0.018), suggesting a lower likelihood of ER positivity among GG homozygotes. A similar nonsignificant trend under the same genetic model was observed for rs2051407 (p = 0.072). Kaplan-Meier analyses showed no statistically significant differences in survival outcomes across genotype groups. Consistently, no associations were observed in Cox regression analyses under unadjusted or multivariable-adjusted models accounting for age and clinicopathological variables. All results remained non-significant after Benjamini-Hochberg FDR correction. Conclusions and Recommendations No statistically significant associations were observed between the studied SNPs and clinicopathological or survival outcomes after multiple testing correction. However, nominal and model-specific associations for rs2838342 indicate a potential role in tumor biology requiring validation in larger, independent cohorts.

Background and Objectives Germline pathogenic or likely pathogenic (P/LP) variants account for 5–10% of all breast cancer (BC) cases, with a higher prevalence of 10–20% observed in specific BC molecular subtypes, such as triple-negative breast cancer (TNBC). P/LP variants in established BC susceptibility genes are associated with an increased risk of BC and may contribute to distinct tumor phenotypes and clinical outcomes. This study aimed to evaluate the distribution of germline P/LP variants and their associations with clinicopathological features and clinical outcomes in BC patients. Material and Method A total of 85 female patients with stage I-II BC, including hormone receptor-positive (HR+)/HER2-negative (HER2−) (n=60) and TNBC (n=25), were included. Inclusion criteria required complete clinicopathological data (age at diagnosis, tumor size, tumor histological grade, lymph node involvement, and clinical outcomes) and absence of clinically significant comorbidities. Exome sequencing of germline DNA from peripheral blood was performed to identify variants in 13 BC susceptibility genes (BRCA1, BRCA2, CDH1, PTEN, STK11, TP53, ATM, CHEK2, PALB2, RAD51C, RAD51D, BARD1, and NF1). Variant analysis was conducted using the Franklin platform (Qiagen), and pathogenicity was re-evaluated according to current ENIGMA, ClinGen, and CanVIG guidelines. For statistical analysis, patients were stratified into P/LP variant carriers and non-carriers. Associations with clinicopathological features and clinical outcomes were assessed, with age included as a continuous covariate for adjustment. The study was approved by the Kaunas Regional Biomedical Research Ethical Committee (Nos. BE-2-10 and P1-BE-2-10/2014). Results Overall, 11 distinct P/LP variants were identified (six in BRCA1, three in CHEK2, and one each in BRCA2 and ATM). These variants were detected in 20/85 patients (23.5%), including 10/60 (16.7%) with HR+/HER2− BC and 10/25 (40%) with TNBC. Only one HR+/HER2− BC patient carried two variants; all others had a single variant. P/LP variants were significantly associated with BC molecular subtype (p=0.021), with carriers more likely to have TNBC (OR=3.33, 95% CI 1.17−9.52, p=0.025), although this was not significant after age adjustment (p=0.158). Carrier status was also associated with tumor grade (p=0.039), disease progression (p=0.007), and distant metastasis (p=0.035), but only the association for increased risk of disease progression for patients carrying P/LP variants remained significant after age adjustment (OR=3.09, 95% CI 1.01–9.43, p=0.048). In the TNBC subgroup, P/LP variant carrier status was statistically associated with lymph node involvement (p=0.009), with carriers having higher odds of lymph node involvement, even after age adjustment (OR=15.18, 95% CI 2.01–113.35, p=0.008), although this finding should be interpreted cautiously due to the small sample size. Survival analysis showed a significant association between P/LP variant carrier status and progression-free survival (PFS) in the overall cohort (p=0.011), which was likely driven by the HR+/HER2− BC subgroup (p=0.030) but not TNBC (p=0.154). In HR+/HER2− patients, carriers had a higher risk of shorter PFS in univariate analysis (HR=2.8, 95% CI 1.05–7.54, p=0.039), which was not significant after age adjustment (p=0.084). For metastasis-free survival (MFS), a significant difference was observed in the overall cohort (p = 0.039), but not in subtype-specific analyses. Although carriers showed a higher risk of shorter MFS in univariate analysis (HR=2.41, 95% CI 1.02– 5.72, p=0.046), this did not remain significant after adjustment for age (p=0.073). Conclusions and Recommendations Germline P/LP variants were identified in a substantial proportion of BC patients, with a higher prevalence in TNBC. Although carrier status was associated with more aggressive disease features, particularly disease progression, most associations did not remain significant after adjustment for age. These findings suggest that P/LP variants may contribute to BC heterogeneity, although their independent prognostic value appears limited and requires further investigation in larger cohorts.

Introduction and Aim Glioblastoma (IDH-wildtype) is the most aggressive primary brain tumor in adults, with a median overall survival of 12–15 months. Only around 5% of patients survive beyond five years, and extreme long-term survivors living 10 or more years represent less than 1% of all cases. The biological and clinical factors that allow some patients to achieve such outcomes remain largely unknown. We report four patients with histologically confirmed IDH-wildtype glioblastoma diagnosed between the ages of 42 and 46, all of whom achieved 17-18 years of progression-free survival, aiming to contribute to the understanding of biological heterogeneity in this disease. Case report We retrospectively reviewed four patients treated at our institution from 2007 to 2008. Three patients were female and one male; age at diagnosis ranged from 42 to 46 years (median 44 years). Histology included glioblastoma multiforme cases and one glioblastoma with rhabdoid differentiation. All patients underwent surgical resection followed by concurrent chemoradiotherapy with temozolomide (75 mg/m² for 42 days) and adjuvant temozolomide (female, age 42: 5 cycles; female, age 46: 6 cycles; male, age 43: 3 cycles, female with rhabdoid differentiation, age 45: 6 cycles). MGMT promoter methylation status was unavailable due to archival tissue limitations. All patients achieved 17-18 years of progression-free survival with no radiological evidence of recurrence on long-term follow-up imaging, and all remain alive at current ages of 59-65 years. Discussion All four patients were a relatively young at diagnosis, which is a recognised favourable prognostic factor in glioblastoma. Younger patients typically have better performance status, tolerate treatment better, and more likely to undergo gross total resection. However, younger age alone is unlikely to explain survival of this magnitude, as most patients in this age group still have a median survival of approximately 15 months. One particularly notable case is the patient with rhabdoid glioblastoma, a subtype associated with early leptomeningeal dissemination and very poor prognosis. Reported median survival is under 18 weeks, and a previously documented maximum of 9 months, with only rare cases exceeding several months, making this prolonged disease-free survival highly unusual. Due to the age of the histological material, it was not possible to perform additional molecular tests. The absence of MGMT promoter methylation data is an important limitation. MGMT methylation has been reported in a high proportion (95%) of long- term glioblastoma survivors in some series, and its absence is generally associated with poorer outcomes. However, recent registry data suggest that a subset of long-term survivors - particularly those without recurrence - may harbour MGMT-unmethylated tumours at a surprisingly high rate, suggesting they may represent a biologically distinct glioblastoma subtype. This challenges the assumption that MGMT methylation is a prerequisite for exceptional outcomes. Additionally, long-term survival in IDHwildtype glioblastoma has been associated with reduced expression of genes such as CHI3L1, SERPING1, and IGFBP2, although their clinical significance remains uncertain. Conclusions This case series suggests that very long-term, progression-free survival is possible in IDH-wildtype glioblastoma, including the rhabdoid variant, which is typically associated with poor prognosis. Standard prognostic markers available in our cohort do not adequately explain these outcomes, pointing to the likely presence of additional biological factors not captured by routine diagnostics. Comprehensive molecular profiling, including MGMT promoter methylation, TERT promoter mutation, and immune microenvironment characterisation, may help identify mechanisms underlying guide more individualised treatment strategies.