International Journal of Medical Sciences

Int J Med Sci 2026; 23(6):2108-2138. doi:10.7150/ijms.132708 This issue Cite

Review

Current Status and Evolution of Immunotherapy in Glioma Management

Jiaying Liu¹, Guangzhao Yang³, Zhengcong Cao², Haozhe Qin^2,3, Maorong Zhu², Cheng Zou², Xiao Liu^2,3, Yalong He³ , Jintao Gu²

1. Basic Medical College, The Fourth Military Medical University, Xi'an, 710000, China.
2. State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, Xi'an, 710000, China.
3. Department of Neurosurgery, Xijing Hospital, Xi'an, 710000, China.

✉ Corresponding authors: Jintao Gu, MD., State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, Xi'an, 710000, China (gujintaoedu.cn). Yalong He, MD., Department of Neurosurgery, Xijing Hospital, Xi'an, 710000, China (heyl.fmmucom). More

Received 2026-2-5; Accepted 2026-4-9; Published 2026-5-1

Abstract

Gliomas, especially glioblastoma (GBM), are the most aggressive primary brain tumors, and their treatment faces multiple challenges. These challenges include incomplete surgical resection, the blood-brain barrier (BBB) that limits drug delivery, and an immunosuppressive tumor microenvironment (TME). Despite the "cold tumor" nature of gliomas, significant progress has been made in immunotherapy strategies. In this review, we focus on the following four strategies: 1) Cancer vaccines, especially personalized vaccines based on neoantigens, can activate specific immune responses; 2) Immune checkpoint inhibitors (ICIs) to reverse T cell exhaustion (e.g., anti-PD-1/PD-L1 antibodies); 3) Adoptive immune cell therapies, particularly chimeric antigen receptor T-cell (CAR-T) therapy, have shown encouraging results in preclinical trials; 4) Oncolytic viruses, which have dual roles of directly lysing tumor cells and stimulating immune responses. Immunotherapy offers a new paradigm to overcome the limitations of conventional glioma therapy. However, tumor heterogeneity, BBB limitation, target selection, and immunosuppressive microenvironment remain major obstacles. Future research should focus on developing combination therapies such as immunotherapy combined with radiotherapy, targeted therapy, exploring novel targets, and using biomarkers for patient stratification, which may help improve the survival outcomes of glioma patients. This review comprehensively evaluates the latest clinical progress of glioma immunotherapy, assesses the current limitations, and explores future directions.

Keywords: glioma, immunotherapy, immune checkpoint inhibitors, CAR-T cell therapy, cancer vaccine, oncolytic virus

Introduction

Glioma is a central nervous system tumor arising from glial cells. It is the most common and most aggressive primary brain tumor in adults [1]. The pathogenesis of glioma is complex, involving various genetic and molecular alterations [1]. The 2021 WHO Classification (5th edition) has shifted the classification of adult-type diffuse gliomas from a purely histologic grading system to an integrated paradigm that combines histologic features with molecular biomarkers [2]. These tumors are primarily categorized into three subtypes: 1) IDH-mutant astrocytoma: cases with CDKN2A/B homozygous deletion are directly assigned WHO grade 4, irrespective of classic histologic features such as microvascular proliferation or necrosis [3]; 2) IDH-mutant oligodendroglioma with 1p/19q codeletion [3]; 3) IDH-wildtype glioblastoma, which is strictly defined as IDH-wildtype grade 4 astrocytoma and represents the most malignant and aggressive subtype [2]. Furthermore, distinct genetic alterations are increasingly recognized to shape the tumor immune microenvironment and consequently modulate the response to immunotherapeutic interventions [4]. Although its incidence is relatively low, the median survival for GBM patients is only approximately 15 months, indicating a very poor prognosis [5].

Standard treatment includes surgical resection, radiotherapy, and temozolomide (TMZ) chemotherapy [6]. Additional therapeutic options include DNA damage response (DDR) inhibitors and targeted molecular therapies [7]. Despite these measures, patient outcomes remain poor, with high recurrence rates [7].

The poor prognosis stems from multiple factors. First, the highly invasive nature of glioma cells enables diffuse infiltration into normal brain tissue, precluding complete surgical resection [8]. Second, the BBB severely hinders effective drug delivery, limiting systemic therapy efficacy [5]. Third, the glioma microenvironment is highly immunosuppressive. It features abundant M2-polarized tumor-associated macrophages (TAMs), increased infiltration of regulatory T cells (Tregs) and myeloid-derived suppressor cells (MDSCs), exhausted cytotoxic T lymphocytes, and upregulation of multiple immune checkpoints [1]. These factors, together with metabolic suppression (e.g., tryptophan catabolism via the IDO pathway) and hypoxia-driven immunosuppression, collectively shape the "cold tumor" phenotype of gliomas [9]. Furthermore, glioma has a relatively low tumor mutational burden and high intra- and inter-tumoral heterogeneity. This further weakens the immune system's ability to recognize and eliminate the tumor [1]. Together, these factors present unique challenges, prompting the exploration of immunotherapy as a new strategy.

Despite inherent immunosuppression, immunotherapy for glioma is feasible [10]. Recent re-evaluation of central nervous system (CNS) immune privilege and the discovery of skull-meningeal channels and intracranial lymphatic vessels provide new perspectives on brain tumor immunology [10]. Studies show that inducing immunogenic cell death (ICD) can transform the glioma microenvironment from "cold" to "hot", promote Th17 cell migration to the tumor, and enhance immunotherapy efficacy [11]. Additionally, immune cell infiltration patterns in the TME correlate with patient prognosis. Stronger immune cell infiltration often predicts better survival [11]. These findings provide a theoretical basis for developing immunotherapies for glioma.

Current glioma immunotherapy mainly includes four classic strategies. Cancer vaccines introduce tumor-specific dendritic cells (DCs) or tumor-associated antigens (TAAs) to activate anti-tumor immune responses [12]. Personalized vaccines, especially those targeting neoantigens, show great potential [1]. ICIs like PD-1, PD-L1, and CTLA-4 inhibitors aim to reverse T cell exhaustion and reactivate anti-tumor immunity [1]. Based on the available literature, adoptive immune cell therapy has not yet demonstrated satisfactory clinical efficacy in glioma studies, and its safety profile requires further investigation [13-15]. However, breakthroughs in new therapies such as universal CAR-T, fourth-generation CAR-T, and novel-target CAR-T in preclinical research have brought hope for improving the prognosis of glioma patients. Oncolytic viruses have a dual mechanism: directly killing tumor cells and activating immune responses. They have made breakthrough progress in clinical trials [1]. This review comprehensively evaluates recent clinical progress in these four main immunotherapy strategies for glioma. It critically analyzes limitations and provides insights into future directions.

1. Cancer Vaccines

Cancer vaccines aim to induce the immune system to recognize and attack TAAs or tumor-specific antigens (TSAs) [12] (Figure 1). In early exploration (around the 1990s), the main type of tumor vaccine was the whole tumor cell vaccine [16]. They had manageable safety but limited clinical efficacy [16]; In the early 2000s, DC vaccines emerged. They are made by isolating monocytes from patients' blood, differentiating them into DCs in vitro, loading them with tumor antigens (e.g., cell lysates, synthetic peptides), and reinfusing them to activate specific T cells [17]. In a large Phase 3 trial of a dendritic cell vaccine, the median overall survival (OS) among 331 patients was 23.1 months. Among the 131 patients with MGMT promoter methylation, the 3-year survival rate reached 46.4%. These findings provide strong evidence supporting the survival benefit of the DC vaccine [16]; Around the 2010s, molecularly targeted peptide vaccines appeared. They use defined immunodominant epitope peptides to induce precise immune responses [18]. IMA950 is the first multi-peptide vaccine targeting glioblastoma to enter clinical trials [19]. In its first-in-human Phase I study, it successfully met the safety and immunogenicity endpoints, marking a transition in glioma vaccine development from cell-based approaches to precision molecular targeting [19]. Since 2015, personalized/neoantigen vaccines have developed rapidly. These are peptide-based personalized cancer vaccines composed of immunogenic mutant epitopes derived from the patient's specific glioma [20].

1.1 Dendritic Cell Vaccines

Based on literature from 2015-2025, 14 DC vaccine studies entered clinical trials. Comparative analysis preliminarily confirmed the safety and tolerability of DC vaccines [21-25], demonstrating good prospects in the field of glioma immunotherapy. Representative studies include 1) Wilms Tumor 1 (WT1) mRNA vaccine [21]; 2) autologous tumor antigen (ATA) vaccine [23, 24]; 3) ICT-107 [25]; 4) DC vaccines loaded with glioma stem cell (GSC) (A2B5⁺) antigen [26]; 5) DC vaccines targeting CMVpp65 [27-29]. First, in a single-arm Phase I/II study of advanced solid tumors, WT1 mRNA-electroporated autologous DCs (WT1-mRNA/DC) demonstrated promising therapeutic activity. The induced type 1 T-cell responses were associated with improved OS [21]. Second, the ATA vaccine's antigens come from self-renewing irradiated autologous tumor cells in culture. It contains personal neoantigens and any GBM TAAs, but not normal cell antigens, offering potential advantages over autologous tumor lysate [23]. However, its production requires sufficient tumor tissue, limiting use in advanced patients [23]. Finally, the efficacy and safety of ICT-107 and GSC antigen-loaded DC vaccines need further validation in larger trials [25, 26].

Specific pretreatment of DC vaccines (e.g., using tetanus-diphtheria (Td) toxoid [28, 29]) combined with adjuvants (e.g., keyhole limpet hemocyanin, KLH) [21] or cytokines (e.g., GM-CSF) [25], or using activators (e.g., IFNγ or lipopolysaccharide [25]), can enhance vaccine potency and patient immune responses to TSAs. This may improve patient outcomes [21, 25]. Many studies indicate that patients with O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation, combined Telomerase Reverse Transcriptase (TERT) promoter and Isocitrate Dehydrogenase 1/2 (IDH1/2) mutations, low B7-H4 expression, Human Leukocyte Antigen A2 (HLA-A2) positivity, and high immune responses are more sensitive to DC vaccines. This may be associated with better prognosis [25, 26, 30].

1.2 Molecularly Targeted Peptide Vaccines

Representative studies from 2015 to 2025 include 1) the Epidermal Growth Factor Receptor variant III (EGFRvIII) targeted vaccine (Rindopepimut/CDX-110) [31, 32]; 2) IDH mutation-targeted vaccine (IDH1-vac) [33]; 3) Survivin-targeting peptide vaccine (SurVaxM) [34, 35]; 4) and WT1 peptide vaccine [36] as single-target vaccines. Multi-target peptide vaccines include 1) IMA950 [19, 37]; 2) WT1 peptide cocktail vaccine [38]; 3) VEGFR1-VEGFR2 peptide vaccine [39]; 4) glioma-associated antigen (GAA) synthetic peptide vaccine [40].

1.2.1 Single-Target Vaccines

First, Rindopepimut is a single-target peptide vaccine against EGFRvIII. It consists of an EGFRvIII-specific peptide conjugated to KLH. In the ACT III trial, Rindopepimut successfully induced specific immune responses, achieving a 5.5-month PFS rate of 66%, significantly exceeding the preset null hypothesis of 53% (P=0.0168) [32]. In terms of safety, vaccine-related adverse events were common but generally tolerable [32]. However, the subsequent Phase III ACT IV trial showed that Rindopepimut did not improve survival in patients with newly diagnosed glioblastoma (nGBM) [31]. The ACT III trial demonstrated promising efficacy; however, the subsequent Phase III ACT IV trial failed to confirm these findings. Several factors may account for this discrepancy: 1) Patient selection bias. ACT III enrolled a highly selected population with favorable responses to initial therapy [32]. Comparing their survival outcomes with unselected historical controls likely overestimated the therapeutic benefit of the vaccine [32]. 2) Improvements in standard of care. In ACT IV, the median OS in the Rindopepimut arm (20.1 months) was consistent with that observed in ACT III, indicating stable vaccine activity [31]. However, advances in standard therapy likely prolonged survival in the control group relative to historical data, thereby diluting the relative benefit of Rindopepimut and rendering the difference statistically nonsignificant [31]. 3) Instability of target expression. In a small subset of ACT IV patients, EGFRvIII expression was lost at recurrence in approximately 60% of cases, irrespective of treatment received [31]. This finding suggests that single-target strategies against EGFRvIII may be limited and supports the exploration of multi-target approaches in future studies [31]. Second, the IDH1(R132H) peptide vaccine (IDH1-vac) showed good safety in its first trial, but the pseudoprogression rate was high, correlating with increased peripheral T cell responses [33]. Third, SurVaxM has good safety and tolerability [34, 41]. Clinically, benefit was observed in both methylated and unmethylated patients, with longer survival in the former. Notably, this clinical benefit was associated with upregulation of tumor-associated B cells, which predicted better outcomes [35]. However, it is essential to interpret such early-phase findings with caution. A well-documented challenge in GBM research is the frequent discrepancy between encouraging Phase I/II results and the outcomes of subsequent Phase III trials. Initial efficacy signals often fail to be reproduced in larger, more rigorous, and controlled settings, as exemplified by the Rindopepimut trials and other candidate immunotherapies in neuro-oncology [31, 32, 42, 43]. A large randomized trial of SurVaxM for nGBM (NCT02455557) was completed in March 2026, but the results have not yet been reported. Finally, the WT1 peptide (WT2725) vaccine is safe and tolerable but its efficacy needs confirmation [36].

1.2.2 Multi-Target Vaccines

First, IMA950 is a novel multi-target vaccine containing 11 tumor-associated peptides identified from HLA surface receptors in GBM tissue. It was used to induce antigen-specific peripheral CD8⁺ T cell responses in HLA-A*02-positive patients. In terms of safety, drug-related toxicity was relatively benign [19]. Second, combining TMZ with VEGFR1-VEGFR2 peptide vaccine showed synergistic activity [39]. Third, the GAA synthetic peptide vaccine targets IL-13Rα2, EphA2, WT1, and Survivin. The adjuvant poly-ICLC promotes type 1 polarization of T cell responses against these antigens, enabling effective T cell infiltration into brain tumors and therapeutic benefit [40]. Furthermore, patients with WHO grade II astrocytoma or oligoastrocytoma without prior non-surgical treatment may be particularly suitable for this vaccine [40]. Finally, the WT1 HLA class I/II peptide cocktail vaccine is safe in patients [38].

1.3 Personalized/Neoantigen Vaccines

Representative studies from 2015 to 2025 include 1) IDH1 mutation individualized peptide vaccine [20]; 2) personalized peptide vaccine (PPV) [44]; 3) Glioma Active Personalized Vaccine Consortium (GAPVAC) [45]; 4) autologous formalin-fixed tumor vaccine (AFTV) [46]. First, a clinical trial of a personalized neoantigen-targeting vaccine for IDH1-mutant glioma used whole-exome sequencing to customize treatment, which can cover tumor heterogeneity [20]. Results showed that the vaccine was well-tolerated and induced persistent T cell responses [20]. Moreover, patients with T cell responses to multiple neoantigens had a trend toward longer OS compared to those with no/few responses [20]. Additionally, detection of CDR3 sequences may help track CD4⁺ and CD8⁺ T cell clones in blood and tumor tissue [20]. However, this study was retrospective and non-randomized, with variability in the number of peptides administered and the timing of vaccinations. Therefore, the findings warrant further validation in prospective randomized controlled trials. Second, a PPV trial for HLA-A24-positive recurrent GBM (rGBM) found that SART2-93 positivity was a major factor limiting clinical benefit for all patients [44]. In contrast, biomarkers associated with better OS included lower proportions of CD11b⁺CD14⁺HLA-DR^low immunosuppressive monocytes, higher proportions of CD4⁺CD45RA^- activated T cells, and medium levels of CCL2, VEGF, IL-6, IL-17, and haptoglobin [44]. Third, AFTV is a personalized vaccine derived from formalin-fixed autologous glioblastoma specimens [46]. Theoretically, it preserves all tumor antigens, including neoantigens, obviating the need for HLA-based patient selection [46]. However, this strategy has two major limitations: the inability to monitor therapeutic response via specific antibody titers, and the dependence of vaccine yield on the amount of resected tumor tissue, precluding flexible dose escalation or prolonged administration. A Phase IIb double-blind randomized trial showed no significant difference in efficacy between the vaccine and placebo groups in the overall population, likely due to the small sample size and the high quality of surgery and TMZ therapy received by the placebo group (median OS 31.5 months) [46]. Subgroup analyses suggested that patients with gross total resection or p53-negative tumors may be more sensitive to AFTV. This hypothesis is being evaluated in a completed Phase III trial (UMIN000010602), the results of which have not yet been reported [46]. Finally, the GAPVAC vaccine consists of APVAC1 (a pre-manufactured unmutated antigen repertoire) and APVAC2 (targeting neoepitopes) for HLA-A*02:01⁺ or HLA-A*24:02⁺ nGBM patients [45]. Results showed that APVAC1 induced sustained central memory CD8⁺ T cell responses, while APVAC2 induced Th1-type CD4⁺ T cell responses against predicted neoepitopes [45]. Furthermore, both vaccines, administered with poly-ICLC and GM-CSF adjuvants, were considered safe and highly immunogenic [45].

1.4 New Preclinical Advances

Recent advances focus on new delivery systems/pathways, optimized antigen selection, immune microenvironment modulation, and personalized vaccine design.

1.4.1 New Delivery Systems

Nanotechnology offers promising solutions. Optimizing particle size, surface modification, and targeting ligands significantly improves brain enrichment and immune activation [47-50]. Representative platforms include lipid nanoparticles (LNPs), polymer nanoparticles, and inorganic nanomaterials. A key LNP-based preclinical study is the CVGBM vaccine. CVGBM is a novel multi-targeted mRNA-LNP vaccine encoding a fusion protein comprising eight tumor-associated antigen-derived epitopes [48]. Its platform efficacy was validated in a surrogate melanoma mouse model, and antigen presentation specificity was confirmed in vitro [48]. However, immunopeptidomics analysis detected the presentation of only four of the eight encoded epitopes, while the remaining four were not identified [48]. Currently, a Phase I trial for HLA-A*02:01⁺ MGMT unmethylated GBM is ongoing (NCT05938387) [48]. Although several mRNA-LNP vaccines have entered clinical trials for infectious diseases and cancer, their clinical translation remains limited by poor targeting precision, potential immunogenicity and toxicity, and the difficulty of developing universal delivery systems [51]. Biomimetic nano-DC vaccines show improved biocompatibility, targeting, and immune activation [52]. For example, conjugating biomimetic DC membranes with tumor-associated costimulatory molecules or paclitaxel nanoparticles, combined with ICIs, alleviated T cell exhaustion in mouse models, significantly extended survival, potentially overcoming GBM immunotherapy resistance [53, 54]. However, the clinical translation of cell membrane-coated nanoparticle technology is hindered by challenges in scalable production and purification, safety assurance, quality control, and analytical method development [52].

1.4.2 Delivery Route Selection and Optimization

Vaccine administration route, frequency, and timing significantly impact efficacy and require systematic optimization. 1) The intranasal route is an innovative strategy [49]. It bypasses the BBB, delivering vaccine directly to the brain and cervical lymph nodes [49]. It reduces systemic exposure and has good patient compliance [49]. Sequential targeted sonodynamic nanovaccine (Stars NV) [55], Survivin peptide-CpG nanovaccines (SPOD-NV) [49], and enhanced nanovaccines using biomineralizing virus-like particles [50] are delivered through the nasal cavity, with drug enrichment observed in the brain and lymph nodes [49, 50, 55]. 2) Intravenous delivery is an established technique, allows high dosing, and activates immune cells in systemic lymphoid organs [49]. Serum IgG titers were higher after intravenous delivery (IV) than after intranasal delivery [49]. However, challenges include poor brain/tumor penetration, rapid clearance by liver macrophages, potential cytokine storm, and systemic toxicity risk [49]. A sequential dosing strategy for SPOD-NV vaccine used 5 full IV, 5 full intranasal, or 3 intranasal + 2 IV injections, all combined with anti-CTLA-4 antibody [49]. Mice with full IV dosing had significantly longer median survival than full intranasal [49]. The 3 intranasal + 2 IV group extended survival to 41 days, with a 43% complete response rate [49]. This suggests combining intranasal and IV routes may synergize, producing local and systemic immunity, improving efficacy [49]. 3) Subcutaneous delivery allows antigen uptake by subcutaneous DCs, which migrate to regional lymph nodes [49]. In the SPOD-NV study, subcutaneous + IV sequential dosing was significantly less effective than intranasal + IV, highlighting the key role of intranasal delivery in GBM treatment [49]. Intratumoral delivery directly delivers drugs to the tumor, bypassing the BBB [56]. It enables local immune activation, remodels the TME, and reduces systemic exposure risk [56]. For example, intratumoral pIpC-Dox LNPs significantly increased infiltration and activation of TAMs, DCs, and T cells. Drawbacks include invasive procedure, difficulty covering infiltrative cells, and increased risk with multiple injections [56].

1.4.3 Optimized Antigen Selection

Neoantigens are antigens produced by specific mutations in tumor cells [20]. They are specific and immunogenic, and do not exist in normal tissues, thus becoming ideal vaccine targets [20]. Representative studies include the IDH1-R132H 20-mer peptide vaccine [20] and nanoshield vaccines [57]. The (multi-cationic protein (MCP))-muIDH1 nanoshield vaccine (NaV) uses a MCP scaffold, genetically fuses the muIDH1 neoantigen to MCP, and assembles carboxylated PEG into 100 nm spherical nanoparticles [57]. This enables lysosomal escape, enhanced cross-presentation, NLRP3 inflammasome activation, and prolonged in vivo retention [57]. In tumor-bearing mice, combining NaV with anti-PD1 delayed postoperative recurrence and increased median survival by over 40% [57].

TAAs are normal proteins overexpressed or over-presented on tumor cells [48, 49, 58, 59]. While less immunogenic than neoantigens, they are shared, potentially benefiting more GBM patients [48, 49, 58, 59]. Representative TAAs include 1) Survivin Baculoviral IAP Repeat Containing 5 [49]; 2) Ephrin type-A receptor 2 [49]; 3) Plasminogen activator urokinase receptor [48]; 4) Transforming growth factor beta 2 (TGFB2) [58]. Representative vaccines include 1) SurVaxM [49]; 2) CVGBM mRNA vaccine [48]; 3) and GVac [58]. GVac is a multi-epitope vaccine targeting TGFB2, and its antigen selection and screening have been strongly assisted by computer-aided design [58]. Allergenicity, antigenicity, toxicity, epitope selection, molecular docking, dynamics simulation, and immune simulation can be predicted computationally, theoretically enabling rapid screening of low-toxicity, highly immunogenic candidate vaccines with strong target affinity, though experimental validation is needed [58].

1.4.4 Immune Microenvironment Modulation

GBM's immunosuppressive TME limits vaccine efficacy [7]. New vaccine strategies remodel the TME by reprogramming TAMs, reducing Tregs, and enhancing T cell infiltration [47, 49, 55, 57, 60]. However, the observed TAM reprogramming is mediated not by the vaccine itself, but by secondary components such as sonosensitizers [55] or ICIs [61] incorporated into these strategies. The vaccine Star NV contains a sonosensitizer, the Toll-like receptor agonist R848 (which promotes M1 polarization), and CM-β-CD (for macrophage targeting) [55]. Mechanically, it uses ultrasound to activate sonosensitizers, generate reactive oxygen species (ROS) in tumor tissues to directly destroy GBM cells, and release R848 to achieve TAM transformation to M1 phenotype [55]. In vivo experiments in the glioma mouse model confirmed that this method could kill tumor cells and help to reshape the immunosuppressive microenvironment [55]. Clofazimine (CFZ), an anti-leprosy drug, has potent Wnt/β-catenin inhibitory activity [60]. Combining DC vaccine with CFZ inhibited the Wnt/β-catenin pathway in cancer stem cells, blocking glioma phenotypic heterogeneity/plasticity and β-catenin-mediated immune escape, thereby reducing immunosuppression [60]. Immune checkpoint synergy can also improve the TME. For example, nanoshield vaccine combined with anti-PD-1 improved postoperative relapse-free survival by over 40% in mouse models [57].

2. Immune Checkpoint Inhibitors

Immune checkpoint molecules limit autoimmunity by regulating T cell responses to self-antigens [62]. However, they also limit attacks on cancer cells [62]. ICIs block these molecules, enhancing T cell recognition and killing of cancer cells [62] (Figure 2). Between 1980 and 2000, key immune checkpoints, including CTLA-4 and PD-1 were identified, establishing the foundation for ICIs [63, 64]. In 1996, Allison and colleagues first demonstrated that CTLA-4 blockade enhances antitumor immunity in preclinical models [65]. PD-1 was cloned by Honjo's team in 1992, and its role as an immune checkpoint was elucidated by 2000 [63]. Following regulatory approval of the PD-1 inhibitors Nivolumab and Pembrolizumab in 2014, clinical trials in glioma were initiated. The first-in-human Phase I study of Nivolumab in recurrent glioblastoma (CheckMate 143) established its safety and tolerability [66]. However, the subsequent Phase III CheckMate 143 trial failed to demonstrate an OS benefit for Nivolumab over Bevacizumab in recurrent glioblastoma, underscoring the limitations of ICI monotherapy in this disease [67]. After 2015, ICI trials and combination therapies for glioma increased. According to the literature, ICIs used in trials in the past 10 years include: 1) anti-CTLA-4 (Ipilimumab) [42, 43, 68]; 2) anti-PD-1 (Nivolumab, Pembrolizumab) [42, 69]; 3) anti-PD-L1 (Atezolizumab) [70]. The efficacy of ICI monotherapy is limited, and clinical studies often combine multiple ICIs or other drugs or as adjuvant therapy [71].

2.1 Clinical Trials and Combination Therapies

Representative clinical studies from the past decade include: 1) Ipilimumab + Nivolumab for nGBM (two studies) [42, 43]; 2) Atezolizumab + Radiotherapy + TMZ Phase I/II trial (NCT03174197) [70]; 3) Evaluation of neoadjuvant Pembrolizumab in rGBM [69]; 4) Nivolumab + Ipilimumab before radiotherapy for nGBM Phase I trial [68]; 5) Bevacizumab + anti-PD-1 therapy (NCT05502991, NCT05540275) [72, 73].

The safety and efficacy of Ipilimumab + Nivolumab for nGBM were demonstrated in the NRG Oncology BN002 (Phase I) trial [42]. However, the randomized Phase II/III NRG Oncology BN007 trial for MGMT-unmethylated nGBM found that Ipilimumab + Nivolumab did not improve Progression-Free Survival (PFS) compared to TMZ [43]. Subsequently, multiple clinical trials have been completed, and despite the use of various immune checkpoint inhibitor regimens, none have demonstrated superiority of ICI monotherapy or combination therapy over standard treatment [43, 74, 75]. Thus, without molecular selection or biomarker guidance, ICIs confer extremely limited survival benefit [43]. Nonetheless, the identification of patients with specific genetic features or immune phenotypes sensitive to ICIs remains of great value, and relevant biomarker analyses are currently ongoing [43]. Atezolizumab + Radiotherapy + TMZ was well-tolerated in a Phase I/II trial (NCT03174197). Unlike DC vaccine sensitivity, this therapy was more effective in PTEN-mutant, mesenchymal subtype GBM patients, less effective in EGFR-mutant, proneural subtype, and significantly better in MGMT-methylated vs. unmethylated patients [70]. Additionally, GBM immune enrichment correlated highly with pre-treatment tumor mesenchymal subtype and patient gut microbiota [70]. Moreover, longer-surviving patients had enriched Bacillota phylum bacteria in stool samples [70]. A trial of neoadjuvant Pembrolizumab in rGBM showed that treatment activity correlated with shortened/reduced cell cycle and proliferation genes and increased T cell/interferon-related genes [69]. This suggests that combined transcription factors that reduce cell cycle/proliferation gene expression or increase T cell/interferon gene expression may improve efficacy [69]. Also, ICIs may have inherent resistance due to chronic inflammation in the TME, suggesting combining anti-inflammatory drugs might restore neoadjuvant ICI activity [69]. Phase I clinical trials of Nivolumab + Ipilimumab in the treatment of nGBM before radiotherapy found that advanced tumors have high LAG-3 levels, downregulation of PPAR signaling and up-regulation of TGF-β and ERBB signaling, and dysregulation of these pathways is associated with ICI resistance [68]. This suggests combining LAG-3 inhibitors, PPAR agonists, and TGF-β/ERBB pathway inhibitors might overcome resistance and improve efficacy [68]. Two studies (NCT05502991, NCT05540275) found that Bevacizumab plus anti-PD-1 significantly improved OS in patients with rGBM. Furthermore, tumor in situ fluid circulating tumor DNA technology can monitor therapeutic response and guide therapy [72, 73]. Collectively, these findings are promising, suggesting pre-treatment screening for patients likely to respond to Bevacizumab + anti-PD-1, refining the target population and reducing medical risk and cost.

2.2 New Preclinical Advances

ICIs show efficacy in many solid tumors but face challenges in glioma. Core challenges include the BBB limiting brain delivery, highly immunosuppressive TME, heterogeneity, scarce tumor-infiltrating lymphocytes (TILs), and dominant TAMs [11]. Recent research focuses on novel delivery systems, combination therapies, TME remodeling, and biomarker identification/patient stratification to improve ICI efficacy.

2.2.1 Novel Delivery Strategies

The BBB is a major obstacle that limits the access of ICIs to GBM tumor sites [5]. To overcome this, researchers utilized low-intensity pulsed ultrasound combined with intravenous microbubbles to achieve transient, reversible, and localized opening of the BBB, thereby enhancing the concentration of aPD-1 in the sonicated regions [76]. Additionally, various delivery systems have been developed, including extracellular vesicles (EV) [77], redox-responsive micelles [78], lipid nanocarriers [79], and nanovesicles [61]. These systems successfully crossed the BBB, achieving efficient brain delivery and tumor-specific accumulation of ICIs, improving treatment safety [61, 78, 79]. However, these delivery systems are still in the research phase and face translational challenges. For instance, although extracellular vesicles possess good biocompatibility and hold promise as therapeutic carriers, they remain limited by heterogeneity, low yields, inefficient drug loading, and rapid clearance by the mononuclear phagocyte system [80]. No EV-based therapy has yet received regulatory approval. Redox-responsive micelles face complex preparation and clinical translation challenges, including amphiphile amount [81], ligand density [82], linkage type [83], polymerization degree [84], reaction conditions [85], and branching degree. These factors collectively influence micelle formation, stability, and scalability. The clinical translation of nanocarriers is hindered by complex physiological barriers, off-target effects of targeting ligands, inherent issues of stability and toxicity, as well as challenges in scalable manufacturing and batch-to-batch consistency [86].

2.2.2 Combination Therapy Strategies

Single ICI efficacy is limited [71]. Researchers explored combinations with chemotherapy [79], radiotherapy [87], photodynamic therapy [88], CAR-NK therapy [89], etc., showing synergy. Moreover, dual/multiple immune checkpoint blockade (ICB) (e.g., PD-1/CTLA-4 [87], αVβ8/PD-1 [90]) enhances immune responses [87]. Furthermore, combining ICIs with epigenetic regulators such as Zinc Finger Protein 638 (ZNF638) inhibition [91] and CpG-STAT3ASO [81] has demonstrated potential to restore immune sensitivity in preclinical settings [91].

2.2.3 Tumor Microenvironment Remodeling

The GBM TME is highly immunosuppressive, dominated by TAMs and MDSCs [61]. Improving this state is key to enhancing ICI efficacy. Strategies include 1) TAM reprogramming (M2 to M1) via inhibiting difluoromethylornithine (DFMO) [61] or Actin Related Protein 2/3 Complex Subunit 1B (ARPC1B) [92]; 2) inhibiting immunosuppressive molecules (Nitric Oxide (NO), ROS, IL-10) to protect T cell function [93]; 3) modulating B cell function to overcome Transforming Growth Factor β (TGFβ)-mediated immunosuppression [90].

2.2.4 Biomarker Identification

Identifying predictive biomarkers is crucial for patient stratification and personalized therapy. Potential biomarkers explored include 1) molecular markers (PD-L1, ZNF638, ARPC1B) [91, 92]; 2) cellular markers (TAMs, B cells, NKT cells) [89, 90, 92]; 3) immune microenvironment features (double-stranded RNA (dsRNA), IFN signaling) [91]; 4) spatial transcriptomics revealing cell interaction networks [90].

3. Adoptive Immune Cell Therapy

Adoptive immune cell therapy is a treatment method in which immune cells with anti-tumor activity are screened, expanded, activated, or genetically engineered in vitro, and then infused back into the patient's body to help the patient's immune system recognize and attack cancer cells [94]. During the 1980s to 2000s, lymphokine-activated killer (LAK) cells and tumor-infiltrating lymphocytes (TILs) were explored clinically for glioma treatment [95]. Early studies by Jacobs et al. demonstrated the feasibility of intratumoral LAK cell injection [96]; however, clinical efficacy was limited and responses were transient, with subsequent trials confirming these therapeutic constraints [97, 98]. TIL-based approaches faced challenges including low TIL abundance in glioma and functional exhaustion within the immunosuppressive TME [99]. However, a recent study using IL-2/IL-15/IL-21-expanded TILs reported complete tumor regression in a glioblastoma patient, suggesting renewed potential for this strategy [100]. Around 2000s-mid 2010s, engineered T cells emerged. CAR-T therapy genetically modifies patient T cells to express CARs targeting specific TAAs, enabling tumor cell recognition and killing [101]. T cell receptor-engineered T cells (TCR-T) differ by introducing optimized TCR genes to recognize intracellular antigens presented by major histocompatibility complex (MHC) molecules [102]. From late 2010s-present, new generation therapies arose, including multi-target CAR-T, logic-gated CAR, armored CAR-T, CAR-NK, CAR-M, neoantigen-targeting CAR-T/TCR-T, combination therapies, and gene-edited universal products [103].

According to the data collected, most of the literature considers adoptive cell therapy to have a good safety profile, with the most serious adverse event usually grade 3 fever [104, 105]. However, recent literature has reported that this therapy is associated with the occurrence of cognitive impairment in patients, suggesting that its safety needs to be further reviewed. In glioma patients specifically, neurological events occur in approximately 41% of cases across early-phase trials [106]. Mechanistic studies in mouse models have demonstrated that CAR-T therapy can disrupt hippocampal neurogenesis and oligodendroglial homeostasis, leading to cognitive deficits [107], and similar reactive microglial states have been confirmed in human brain tissue from patients who received CAR-T therapy for brain tumors [107]. Furthermore, authoritative guidelines from the EBMT and reviews in Nature Reviews Neurology have identified movement and neurocognitive toxicity as emerging concerns across both hematologic and solid malignancies, including CNS tumors [108, 109]. These converging lines of evidence underscore the need for further scrutiny of the long-term safety of adoptive cell therapy.

3.1 Clinical Trials

Since 2015, CAR-T cell therapies for glioma have entered clinical trials. Targets in CAR-T trials primarily include 1) TAAs: EGFRvIII [13, 14, 110]; 2) Interleukin-13 Receptor subunit alpha-2 (IL13Rα2) [111, 112]; 3) Disialoganglioside GD2 (GD2) [113]; 4) Matrix Metalloproteinase-2 (MMP-2) [114].

3.1.1 EGFRvIII Target

EGFRvIII results from an in-frame deletion of exons 2-7 and mutation at the exon 1/8 junction [14]. It is a tumor-specific, oncogenic, immunogenic epitope [14]. Expressed in ~25-30% of nGBM cases, its expression is spatiotemporally heterogeneous, can re-emerge, and varies greatly within a tumor [14]. The efficacy of anti-EGFRvIII CAR-T cell therapy alone has proven to be limited [14]. After treatment, the upregulation of inhibitory molecules, especially PD-L1, in the TME is accompanied by increased infiltration of Tregs, suggesting that the combination of ICIs may improve the efficacy [14]. However, a Phase I trial of repeated anti-EGFRvIII CAR-T infusions + Pembrolizumab was ineffective [13]. While safe and tolerable, disease control was limited, with most patients progressing within months [13]. Reasons included limited peripheral CAR-T cell expansion/persistence, difficulty infiltrating the tumor, EGFRvIII heterogeneity/antigen loss, and increased Tregs/TAMs post-treatment, indicating Pembrolizumab alone couldn't reverse the highly suppressive TME [13]. A Phase I trial of bivalent CAR-T cells targeting EGFR epitope 806 and IL-13Rα2 via intracerebroventricular delivery for EGFR-amplified rGBM showed safety and feasibility [110]. 62% had tumor shrinkage, a few had durable control [110]. The trial enrolled EGFR-amplified patients but not based on IL-13Rα2 expression, potentially affecting efficacy [110]. In five re-infused patients, CAR-T expansion/persistence was worse than the first infusion, with short PFS, suggesting immune clearance or resistance mechanisms [110].

3.1.2 IL13Rα2 Target

IL13Rα2 is a high-affinity IL-13 decoy receptor, negatively regulating IL-13 signaling [111]. It is expressed in ≥ 75% of GBM patients, overexpressed in > 50%, correlating with shorter survival [111]. It is expressed on GSCs, differentiated tumor cells, and TAMs/MDSCs, but not significantly in normal brain [111]. Its expression correlates with the mesenchymal subtype [111]. This first-in-human trial evaluated an off-the-shelf, steroid-resistant allogeneic CAR-T therapy targeting IL13Rα2 in rGBM [112]. By using healthy donor T cells, it overcomes the manufacturing time, cost, and feasibility limitations of autologous CAR-T [112]. This therapy uses zinc-finger nucleases to knock out the glucocorticoid-receptor gene in T cells so that they remain functional in the presence of dexamethasone [112]. In terms of clinical outcomes, treatment was well tolerated, with local tumor necrosis or shrinkage in most patients [112]. However, antitumor activity was transient, and all patients eventually experienced disease progression [112]. The lack of durability of CAR-T cells is a major factor limiting efficacy, in part because of the use of first-generation CAR constructs (Figure 3) containing only the CD3ζ signaling domain, which lack the costimulatory domain and result in limited expansion and survival [112]. In addition, because HLA matching was not performed, one of the six patients developed anti-CAR antibodies, suggesting the presence of host immune rejection [112]. Future improvements include the use of second-generation or higher-generation CAR designs with costimulatory domains, optimized gene editing (e.g., knockout of the TCR to avoid graft-versus-host disease), and the exploration of manufacturing processes that preserve the stem-like properties of T cells and prolong their survival [112].

3.1.3 GD2 Target

GD2 is a disialoganglioside, and its expression is highly specific [113]. In normal tissues, it is mainly distributed in the neuronal cell membrane [113]. However, it is highly expressed in a variety of malignant tumors [113]. In GBM, GD2 is enriched on tumor cells and specifically overexpressed on GSCs. ~80% of diffuse intrinsic pontine gliomas express GD2 [113]. A trial of GD2-specific 4SCAR-T cells for GD2-positive GBM used a fourth-generation CAR design with an inducible suicide gene [113]. The results showed that both intravenous and intracavitary injections were safe and tolerable [113]. Median survival from infusion was 10 months [113]. Regarding CAR-T cell kinetics, they expanded in peripheral blood for 1-3 weeks, then persisted at low frequency [113]. Importantly, post-infusion tumor resection showed GD2 antigen loss (mechanism unknown), suggesting need for multi-target therapy [113]. Additionally, after treatment, TAMs increased and tumor-infiltrating NK cells decreased, suggesting that the immunosuppressive microenvironment still needs to be improved [113].

3.1.4 MMP-2 Target

Metalloproteinase MMP-2 is widely expressed in GBM cells, and its main role is to degrade collagen Ⅳ, the main component of the basement membrane of the extracellular matrix [114]. In gliomas, overexpression of MMP-2 is closely related to the malignant behavior of tumors [114]. It accelerates the malignant progression of glioma by destroying the BBB, inhibiting immune cell infiltration, and mediating immune evasion [114]. The CLTX-CAR T-cell study is the first to exploit the ability of CLTX, a peptide derived from scorpion venom, to treat patients with recurrent, MMP-2-expressing GBM through the mechanism of broad MMP-2 binding to glioma cells [114]. Pharmacokinetically, CAR T cells were persistently detected in tumor cavity fluid (TCF) and at low levels peripherally, proving intratumoral delivery allows transport [114]. In terms of safety and efficacy, intratumoral infusion was tolerable with manageable adverse events (AEs), achieving a disease control rate of 75%, although the small sample size precluded assessment of survival benefit [114]. However, several limitations were identified. MMP-2 expression on tumor vasculature, fibroblasts, and myeloid cells poses a potential risk [114]. Furthermore, the inhibitory TME may limit efficacy, as stromal and myeloid components may drive T cell exhaustion, suggesting that combination strategies targeting the TME could improve outcomes [114]. Future directions include modifying peptide ligand/CAR structure for better targeting, enhancing T cell persistence/proliferation, and combining therapies [114].

3.2 New Preclinical Advances

CAR-T therapy has demonstrated significant clinical efficacy in hematologic malignancies, but its application in glioma remains limited. Major challenges: 1) High antigen heterogeneity; 2) Immunosuppressive TME factors (TGF-β, PD-L1); 3) CAR-T cell exhaustion from chronic antigen exposure; 4) BBB limiting migration; 5) Antigen loss/downregulation post-treatment [94]. Recent innovations to overcome these include: 1) Universal targeting platforms (e.g., monomeric streptavidin 2-based Chimeric Antigen Receptor T cells (mSA2 CAR-T)) [115]; 2) Dual/multi-target CAR designs [116]; 3) Armored CAR-T cells [116]; 4) Sonogenetically controlled CAR-T [117]; 5) Combination therapies (e.g., with oncolytic viruses, small molecules) [118, 119]; 6) New targets (e.g., Glycoprotein A Repetitions Predominant, Human Leukocyte Antigen-E) [120, 121]. Conversely, several other CAR-T strategies have demonstrated limited efficacy or encountered significant challenges in preclinical glioma models. These include permanently expressed CAR constructs associated with off-tumor toxicity [122], and B7-H3-targeted CAR-T cells that have yet to overcome intratumoral heterogeneity [123]. Promising preclinical studies are listed below.

3.2.1 Universal CAR-T Platform: mSA2 System

The mSA2 CAR-T platform is a revolutionary universal strategy [115]. It uses mSA2 as the CAR's antigen-binding domain, mediated by biotinylated antibodies [115]. Its advantage is that the targeting specificity of CAR-T cells can be rapidly changed by simple replacement of biotinylated antibodies, without redesign and manufacture of new CAR constructs, so that rapid target switching, multi-target combination, overcoming antigen escape, and reducing manufacturing costs can be achieved [115]. Researchers developed biotinylated antibodies for GBM markers CD276 (B7-H3), EPHA2, CD70, IL13Rα2 [115]. In vitro, mSA2 CAR-T cells specifically recognized primary GBM cell lines antigen-dependently, simultaneously targeting heterogeneous subpopulations, clearing GBM cells within 20 hours via live imaging [115]. In immunodeficient mouse orthotopic GBM models, intracranial injection of mSA2 CAR-T pre-loaded with anti-CD70 or anti-CD276 antibodies significantly suppressed tumor growth, induced apoptosis, and extended survival [115]. This therapy provides a good safety foundation for clinical translation. In a mouse model of GBM, mSA2 CAR-T cells did not interact with brain endogenous biotin, thereby reducing the risk of off-target cross-reactivity [115].

3.2.2 Checkpoint Antibody Receptor-modified (ARMed) CAR-T Cells

The BBB blocks antibody entry into the CNS, a major reason for limited efficacy in anti-PD-1 + CAR-T trials [94]. To overcome this, researchers developed fourth-generation ARMed CAR-T, combining EGFRvIII-targeting CAR with anti-PD-1 minibody secretion [118]. The advantage of this therapy is that ARMed CAR-T is able to cross the BBB and secrete microantibodies at the tumor site, overcoming the BBB limitation of systemic delivery [118]. Mice treated with EGFRvIII ARMed CAR-T had significantly smaller brain tumors versus controls, with a median OS of 34 days and 10% surviving to day 50 (study end) [118]. Additionally, no dose-limiting toxicities were observed, and human T cells remained detectable in peripheral blood at day 29 post-infusion, comparable to CAR T cells alone [118].

3.2.3 NR4A3 Deficiency + FOS Overexpression Synergy Overcomes CAR-T Exhaustion

NR4A family genes (NR4A1, NR4A2, NR4A3) are upregulated in TILs, especially terminally exhausted T cells [124]. FOS expression is highest in CD8⁺ naive populations and is co-expressed with stemness genes including TCF7, CCR7, IL7R, and LEF1 [124]. Based on this, researchers knocked down NR4A3 and overexpressed FOS (FOS OE/NR4A3 KD) in CAR-T cells [124]. Modified CAR-T cells showed long-term tumor suppression, significantly extended mouse survival, and widespread tumor infiltration [124]. This provides a novel genetic modification strategy for solid tumor CAR-T, enhancing stemness and anti-exhaustion capacity by targeting NR4A3 and FOS, offering a preclinical basis for delaying progression [124].

3.2.4 CD44/CD133 Dual-Target IL7Rα Armored CAR-T Cells

IL7Rα is key for T cell survival/proliferation [116]. Armoring CAR-T with ΔIL7Rα intracellular domain enhances tumor-killing [116]. Targeting both CD44 and CD133, classic GSC biomarkers, aims to clear GSCs comprehensively, preventing antigen escape [116]. Since CD44 is also on T cells, to prevent CAR-T fratricide, researchers modified the CAR structure; Tanζ-T28 became the ideal base, successfully constructing Tanζ-T28 CAR-T cells [116]. Evaluating Tanζ-T28 CAR-T in glioblastoma organoid (GBO) models showed decreasing GBO volume, successful CAR-T infiltration, memory T cell enrichment in brain tissue, reduced checkpoint marker expression, and upregulated effector function genes [116]. In addition, a clinical trial (NCT05577091) is ongoing [116].

In recent years, with the continuous advancement of innovative research on CAR-T therapy, the field has encountered challenges in clinical translation. Overall, the clinical translation of CAR-T therapy is hindered by high costs, complex regulatory compliance, substantial quality variability in manufacturing processes, and a widespread shortage of infrastructure and specialized personnel [125]. However, universal platforms such as mSA2 CAR-T may help reduce costs and accelerate the clinical translation process [115].

4. Oncolytic Virus Therapy

Oncolytic virus therapy uses genetically engineered, weakly pathogenic viruses to selectively induce ICD in cancer and stromal cells [7] (Figure 4). It works via multiple mechanisms: direct oncolysis, immune activation, TME remodeling, and vascular disruption [126]. In the early 21st century, clinical trials initially verified the safety and feasibility of herpes simplex virus type 1 (HSV-1) G207 [127], reovirus adenovirus [128], NDV-HUJ oncolytic virus [129] and other modified viruses. A Phase I trial of G207 combined with radiotherapy demonstrated acceptable safety and radiographic responses in rGBM patients, with six of nine patients achieving stable disease or partial response [127]. By 2010, the safety and feasibility of DNX-2401 (Delta-24-RGD) and recombinant poliovirus (PVSRIPO) were established [130, 131]. A pivotal Phase I study of intratumoral DNX-2401 in rGBM reported a 20% 3-year survival rate, including one patient who achieved complete remission lasting three years [130]. Notably, post-treatment tumor analysis revealed CD8⁺ T-cell infiltration, providing clinical evidence of "cold"-to-"hot" tumor conversion [130]. Concurrently, a Phase I trial of PVSRIPO in rGBM demonstrated a 21% 3-year survival rate versus 4% in historical controls, highlighting its potential to induce durable antitumor immunity [131]. Since the late 2010s, emerging strategies have focused on combination approaches with ICIs, chemoradiotherapy, and the design of next-generation oncolytic viruses [126, 132-135].

4.1 Clinical Trials

Oncolytic virus platforms in trials over the past decade include: 1) measles virus [136]; 2) adenovirus [132, 137, 138]; 3) herpes virus [139, 140].

4.1.1 Oncolytic Measles Virus

Measles virus is a single-stranded, negative-sense RNA virus. It naturally targets cells via receptors (CD46, Nectin-4), which are often overexpressed on cancer cells [136]. Harnessing this property, oncolytic measles viruses are engineered for enhanced efficacy/safety, overcoming natural limits, and allowing replication monitoring [136]. A prime example is the Measles Virus-based Carcinoembryonic Antigen-expressing Oncolytic Virus (MV-CEA), derived from the safe Edmonston vaccine strain [136]. It causes minimal normal tissue damage, uses CD46 for selective infection, has a strong bystander effect, and expresses soluble CEA for monitoring replication [136]. In clinical testing, this therapy was well tolerated and safe, with a median OS of 11.6 months and a 12-month OS rate of 45.5% in patients with refractory rGBM, which was superior to historical controls [136]. Notably, pre-existing immunity did not prevent virus replication within the tumor [136]. Instead, tumor-intrinsic interferon-stimulated gene (ISG) levels emerged as the key determinant of viral replication [136]. Specifically, high ISG signaling inhibited viral replication, thereby limiting therapeutic benefit [136]. Therefore, this therapy may be best suited for low ISG patients; for high ISG, combining with JAK and STAT inhibitors could block interferon response and enhance replication [136]. Additionally, CD8⁺ T cell infiltration observed post-treatment waned in subsequent samples from some patients, suggesting single/limited treatments may not sustain long-term immune activation [136]. Future directions include developing measles strains expressing H. pylori neutrophil-activating protein for enhanced immunostimulation or combining measles virus with ICIs [136].

4.1.2 Oncolytic Adenovirus

Adenovirus is a non-enveloped dsDNA virus. Genetic modification enables tumor-selective replication [141]. Several adenoviral platforms have been clinically assessed for GBM, including Ad-TD-nsIL12 [137], DNX-2401 [132], and NSC-CRAd-S-pk7 [138]. Among these, Ad-TD-nsIL12 is a third-generation adenovirus with multiple genetic modifications [137]. Specifically, deletion of E1ACR2 and E3gp19K enabled tumor-specific replication, whereas deletion of E1B19K enhanced antitumor immunity, whereas E1B55K and E3B overcame previous limitations of impaired viral replication capacity and M2-type macrophage infiltration [137]. Furthermore, the IL-12 signal peptide was modified to create a non-secreting form (nsIL12), enabling sustained, low-level IL-12 expression within the TME while avoiding systemic IL-12 toxicity such as lethal inflammatory syndrome [137]. Clinically, a Phase I trial demonstrated that Ad-TD-nsIL12 was tolerable at 1×10¹⁰ vp, with dose-limiting toxicity occurring at 5×10¹⁰ vp. Most adverse events were grade 1-2 and resolved within 48 hours [137]. Median OS was 5.1 months (range: 3.1-21.2 months) [137]. Notably, one patient achieved complete response and one achieved partial response; both responders had IDH1 mutation and MGMT expression, suggesting that exploring IDH mutant sensitivity to oncolytic viruses warrants further investigation [137]. Mechanistically, late TME analysis revealed dominance by M2 macrophages (CD163⁺), which may promote tumor progression [137]. Therefore, combining Ad-TD-nsIL12 with M2 inhibitors or reprogrammers to promote M1 polarization could enhance therapeutic efficacy [137].

Another platform, DNX-2401 (tasadenoturev/Delta-24-RGD), is a conditionally replicating adenovirus featuring a 24-bp deletion in E1A for selective replication and an RGD peptide insertion in the fiber knob to improve GBM cell infectivity via integrin binding [132]. In a multicenter Phase I/II trial (NCT02798406), DNX-2401 combined with Pembrolizumab was safe and tolerable [132]. Median survival in GBM was 12.5 months, with an objective response rate (ORR) of 10.4%, which was not statistically different from the preset 5% control rate [132]. Importantly, post-treatment analysis revealed upregulation of several immune checkpoints (TIGIT, LAG3, B7-H3), suggesting that combining multiple ICIs post-treatment might improve efficacy [132]. Furthermore, an exploratory analysis suggested that patients with a TME^medium subtype characterized by moderate immune infiltration, medium PD-1 expression, and absence of multiple immunosuppressive factors may be more likely to derive clinical benefit from this approach [132].

4.1.3 Oncolytic Herpes Virus

HSV is a neurotropic dsDNA virus with a large genome (~150kb) [142]. Over the past decade, G47Δ has emerged as a key oncolytic HSV-1 variant [139, 140]. It is a third-generation, triple-mutated virus constructed by deleting the α47 gene and overlapping the US11 promoter from its parental virus G207, which enhances tumor-specific replication and immunogenicity [139]. In clinical studies, previous Phase I/II trials confirmed the safety of G47Δ in progressive GBM, with patients achieving a median survival of 7.3 months (range: 1-14 months) [140]. A subsequent Phase II trial for residual or recurrent GBM showed more impressive results: median OS from G47Δ start was 20.2 months, with a 1-year survival rate of 84.2%—far exceeding the 15% historical control [139]. Mechanistically, biopsy after treatment revealed a sustained increase in CD4⁺ and CD8⁺ T cells without an increase in Foxp3⁺ Tregs, suggesting that G47Δ can effectively improve the immunosuppressive microenvironment and promote immune infiltration [139]. Based on these findings, G47Δ was approved in Japan in June 2021, becoming the country's first oncolytic virus product [139]. However, distant new lesions, CSF dissemination, and local recurrence around the target were common, indicating that local therapy struggles to control systemic or diffuse progression [139]. Additionally, imaging proved inadequate for accurately evaluating efficacy, underscoring the critical need for novel assessment methods [139].

4.2 New Preclinical Advances

Oncolytic virus therapy shows great potential but faces challenges: poor targeting, high toxicity, poor drug control, systemic delivery limited by BBB, weak virus infiltration, host immune clearance, and immunosuppressive TME limiting immune activation. Recent strategies in preclinical research have made important progress. Innovations in virus platforms, delivery strategies, combination therapies, and metabolic regulation are summarized below.

4.2.1 New Oncolytic Virus Platforms

New platforms focus on improving targeting, reducing toxicity, and enabling drug control. 1) Zika virus (ZIKV), 2) infectious bursal disease virus (IBDV), 3) human cytomegalovirus (HCMV), and 4) myxoma virus (MYXV) platforms provide strong support [126, 133, 143-145]. 1) ZIKV shows selective targeting of GSCs, with natural neuroprogenitor tropism and SOX2⁺ cell preference [126, 143]. 2) IBDV is a dsRNA non-human virus, avoiding pre-existing immunity; it infects tumor and myeloid cells [133]. 3) HCMV based on AD169 strain: deleted UL1-UL20/UL/b regions to reduce virulence; restored pentamer complex (gH/gL/pUL128-131) function to enhance tropism; integrated paramyxovirus glycoprotein H/F complex for EGFR targeting; added tet-off system for drug-controlled IL-12 expression [144]. 4) MYXV is an enveloped dsDNA poxvirus. A MYXV construct lacking the M011L gene (vMyx-M011L-KO/EGFP) induced apoptosis in infected brain tumor-initiating cells [145].

4.2.2 Innovative Delivery Strategies

Cell carrier-mediated delivery, surface modification for BBB penetration, and combination with photodynamic therapy (PDT) improve virus delivery to tumors [145-148]. 1) Macrophage carriers protect virus from neutralizing antibodies, effectively infiltrate glioma tissue, and have strong tumor tropism [146]. 2) Adipose-derived stem cell carriers have low immunogenicity (allowing allogeneic use), strong tumor tropism, protect virus from antibodies/T cells, and maintain migration ability post-infection [145]. 3) Cholesterol-modified adenovirus (OA@Cho) uses LDL receptor-mediated transcytosis across BBB for precise glioma targeting/delivery [147]. 4) PDT-generated ROS damage cancer cells, increase tumor vascular permeability, induce ICD, thereby increasing virus susceptibility, promoting virus entry, and enhancing anti-tumor immunity [148].

4.2.3 Combination Therapy Strategies

Combining oncolytic viruses with chemotherapy, ICIs, metabolic inhibitors, PDT, etc., shows synergistic potential for improved efficacy [133-135]. For example, when IBDV is combined with TMZ, IBDV can enhance the cytotoxic activity of TMZ, and TMZ not only does not impair the susceptibility of GBM cells to IBDV, but can enhance the ability of viral replication and promote viral release [133]. Triple therapy (a bromodomain-containing protein 9 (BRD9) inhibitor + oHSV + anti-PD-1/CTLA-4) showed potent anti-tumor effect, nearly eradicating tumors; long-term survivors showed protective immunity upon re-challenge [134].

4.2.4 Metabolic Regulation Intervention

Metabolic reprogramming and targeting metabolic pathways can reduce virus-induced lipid peroxidation [135]. For example, combining oHSV with an IDH R132H inhibitor restored the sensitivity of IDH-mutant glioma to oHSV, inducing ferroptosis and anti-tumor immunity [135]. Mechanistically, this combination blocked glycolysis, cleared ROS, inhibited glutamine metabolism, and suppressed Protein Kinase C in immunocompetent mouse IDH-mutant tumor models, significantly improving virus therapy efficacy [135]. However, the use of metabolic reprogramming inhibitors must ensure selective toxicity to tumor cells, thereby preventing metabolic disruption in normal cells that could render them susceptible to oncolytic virus infection [149].

4.3 Biomarkers and Patient Stratification

Analysis of GBM trial (NCT03152318) data revealed several predictive biomarkers: 1) Low BRD9 mRNA expression correlated with significantly longer PFS [134]. 2) METTL14-low gliomas are more sensitive to oHSV-1 [150]. 3) Wild-type IDH gliomas are more sensitive to oHSV-1 [134]. 4) High PD-L1/PD-1 expression suggests potential benefit from combination ICB [135]. 5) High glycolysis patients may be sensitive to metabolic reprogramming. In these cases, consider combining glycolysis inhibitors [135]. 6) Patients with high oxidative phosphorylation may benefit from oHSV monotherapy [135]. 7) Immune "hot" tumors with rich T cell infiltration suit viral immunotherapy and may benefit from ICIs [134]. 8) Immune "cold" tumors with scarce T cell infiltration (especially GBM) need virus-induced immune activation. For such patients, consider higher doses, multiple administrations, or combining immunomodulators [134].

In recent years, advancements in oncolytic virotherapy have provided new strategies for the treatment of glioma. However, the translation of these therapies from research to clinical application remains hindered by multiple challenges, including safety risks and heterogeneity associated with animal-derived components, difficulties in maintaining viral activity and stability, and the urgent need to upgrade purification technologies toward large-scale, automated, and intelligent manufacturing [151].

5. Common Challenges Shared across Different Immunotherapies

Although the immunotherapeutic strategies described above have shown promise in preclinical models, they have largely failed to translate into durable survival benefit in clinical trials (Table 1). This suggests common barriers across different therapeutic modalities. This section systematically analyzes the core mechanisms underlying these failures, including 1) immunosuppression in the TME [152, 153], 2) tumor antigen heterogeneity and escape [13, 154], 3) blood-brain barrier limitations for drug delivery [155, 156], and 4) adaptive resistance under therapeutic pressure [153, 157].

5.1 Immunosuppression in the Tumor Microenvironment

Regardless of the immunotherapeutic strategy employed, its ultimate antitumor efficacy depends on the effective activation of a functional immune system [158] (Figure 5). However, the TME of glioma, particularly glioblastoma, is characterized by profound immunosuppression, rendering immune cells—whether vaccine-induced T cells [159] or CAR-T cells [13, 14]—prone to inactivation or exhaustion upon entry into the tumor site.

5.1.1 Impact on Vaccines

Vaccines require the presentation of antigens to DCs to subsequently activate T cells [160]. However, in the immunosuppressive TME, dendritic cell function is impaired, and activated T cells are also unable to effectively infiltrate and proliferate [160].

5.1.2 Impact on ICIs

The PD-1/PD-L1 immune checkpoint pathway is just one of many immunosuppressive mechanisms [161]. The TME also contains abundant Tregs, MDSCs, and inhibitory cytokines such as TGF-β and IL-10 [161]. Even upon PD-1/PD-L1 blockade, these additional mechanisms continue to effectively suppress T cell function [162].

5.1.3 Impact on CAR-T Cells

Even if CAR-T cells successfully reach the tumor site, they encounter the same immunosuppressive microenvironment, leading to poor persistence, rapid exhaustion, and an inability to sustain long-term antitumor effects [103].

5.1.4 Impact on Oncolytic Viruses

The primary mechanism underlying the antitumor effect of oncolytic viruses is a T cell-mediated, tumor-specific immune response [163]. However, the TME can inhibit T cell function through various mechanisms, thereby compromising the efficacy of this therapeutic approach [163].

5.2 Tumor Antigen Heterogeneity and Escape

Glioblastoma exhibits significant spatial and interpatient heterogeneity, which is a key factor contributing to immune evasion [164]. The expression of recognizable antigens on tumor cells is a prerequisite for vaccine-induced immune responses and for ICIs to relieve T cell suppression [165]. For oncolytic viruses, however, direct oncolysis depends on the expression of surface receptors on target cells, yet it does not require that all tumor cells express such receptors [166]. As long as a sufficient number of cells express the receptors and become infected, releasing ample damage-associated molecular patterns and tumor-associated antigens, an immune response can be activated to eliminate tumor cells that do not express the receptors [167].

Strategies such as multi-target vaccines [19], dual-target CAR-T cells [116], and "plug-and-play" CAR-T platforms (e.g., mSA2 CAR-T) [115] hold promise for overcoming immune evasion driven by tumor heterogeneity by enabling simultaneous targeting of multiple tumor-associated antigens or flexibly adapting to changes in antigen expression, positioning them as a key direction for future research.

5.3 Blood-Brain Barrier Constraints

Glioblastoma is located within the central nervous system, where the unique BBB not only acts as a physical obstacle to drug delivery but also restricts the entry of immune cells from the periphery into the tumor site [168].

5.3.1 Impact on Macromolecular Therapeutics and Oncolytic Viruses

Monoclonal antibodies (such as PD-1/PD-L1 antibodies), CAR-T cells, and oncolytic viruses are all macromolecules or nanoscale particles that are largely incapable of crossing an intact BBB under normal conditions [145-148]. Even though tumor growth can disrupt the local barrier, such disruption is heterogeneous and insufficient, resulting in suboptimal drug accumulation [156].

5.3.2 The Impact on Vaccines

Vaccines activate T cells in peripheral lymph nodes, and these activated T cells must successfully cross the BBB to exert their antitumor effects [169]. The presence of the BBB significantly limits the infiltration efficiency of these T cells [169]. Various delivery strategies, such as nanocarriers [61, 79] and focused ultrasound [76], offer potential approaches to overcome this physical barrier.

5.4 Adaptive Resistance and Tumor Evolution

Most studies suggest that tumors undergo dynamic evolution under therapeutic pressure. Even when an initial treatment is effective, tumors can acquire adaptive resistance through multiple mechanisms, including upregulation of alternative immune checkpoint molecules, metabolic reprogramming, or activation of bypass growth signaling pathways [68, 132]. However, a few studies have also demonstrated that tumors can evolve even in the absence of pharmacological intervention, under natural conditions [31].

For instance, following treatment with PD-L1 inhibitors, tumors may upregulate the expression of other checkpoint molecules (such as LAG-3, TIM-3, TIGIT, and CTLA-4), thereby achieving "bypass escape" [170]. For CAR-T therapy, in addition to direct antigen loss, tumors can also evade immune recognition by downregulating antigen processing and presentation machinery components, such as MHC class I molecules, thereby impairing the antitumor response of endogenous T cells and indirectly promoting immune evasion [171]. For vaccines, under the immune pressure induced by treatment, tumor cells may escape immune recognition by directly downregulating target antigen expression or by downregulating antigen processing and presentation machinery components, such as MHC class I molecules, thereby hindering the killing of tumor cells by CD8⁺ T cells [172]. Oncolytic virus infection of tumor cells depends on specific cell surface receptors [173]. Under therapeutic pressure, tumor cells can resist viral infection by downregulating or losing these receptors [173].

This mechanism reveals the underlying reasons for the transient efficacy of monotherapy and highlights the importance of combination therapy. The advantages of combination therapy can be summarized as follows: 1) Broader target coverage. Whether through the combination of ICIs [70], multi-target vaccines [19], or universal CAR-T platforms [115], the range of target coverage exceeds that of monotherapy, enabling more effective elimination of heterogeneous tumor cell populations. 2) Broader coverage of mechanisms of action. Under therapeutic pressure, tumors can acquire adaptive resistance through multiple mechanisms [68, 132]. To circumvent this, combining therapies with distinct mechanisms—such as ICIs with epigenetic modulators [91] or with oncolytic viruses [134]—makes it more difficult for tumors to escape. 3) Synergistic effects. The combination of certain therapies, such as chemotherapy with immunotherapy, can produce synergistic effects that achieve "1+1 > 2" therapeutic outcomes, surpassing the simple additive effects of individual agents [39]. 4) Improved safety. In a combination therapy setting, the dosage of each therapeutic agent can be reduced accordingly, thereby alleviating target organ toxicity and enhancing the safety and tolerability of treatment [174]. In line with the growing recognition of combination strategies, several ongoing clinical trials are evaluating the efficacy of immunotherapy combined with other modalities (Table 2).

In summary, glioma immunotherapy faces a series of interrelated and overlapping challenges, including a complex immunosuppressive TME, high tumor heterogeneity, the restrictive nature of the BBB, and tumor adaptive resistance and evolution. In the future, strategies such as multi-target approaches, optimization of delivery systems, remodeling of the TME, and the development of rational combination therapies hold promise for overcoming these obstacles one by one, ultimately achieving breakthroughs in glioma immunotherapy.

6. Biomarkers: From Classification to Combination Strategies

The biomarkers discussed in this manuscript have distinct functional roles in clinical practice. To establish a unified classification framework, this section categorizes them into three groups: predictive biomarkers, prognostic biomarkers, and biomarkers guiding combination therapy selection.

6.1 Predictive Biomarkers

Predictive biomarkers are defined as biological characteristics that can be objectively measured and indicate the likelihood of response to a specific therapeutic intervention [175]. These markers are critical for patient selection in targeted therapy and immunotherapy, enabling the identification of patients most likely to derive clinical benefit while minimizing unnecessary toxicity [175]. Table 3 summarizes key predictive biomarkers discussed in this review, along with their associated therapies and current evidence.

6.2 Prognostic Biomarkers

6.2.1 IDH-wildtype glioblastoma

MGMT promoter methylation is one of the most well-established prognostic biomarkers in IDH-wildtype glioblastoma, with its methylation status associated with significant improvements in OS and PFS [176], and it retains prognostic value even in the context of adjunctive therapies such as tumor-treating fields [177]. TERT promoter mutations occur in approximately 80% of IDH-wildtype glioblastomas [178]; however, their prognostic significance remains controversial. Some studies have associated TERT promoter mutations with poorer survival [179], whereas others suggest a synergistic interaction between TERT promoter mutations and MGMT methylation status, with patients harboring both alterations exhibiting the longest survival [180]. In addition, chromosome 7 gain and chromosome 10 loss, along with EGFR amplification, are characteristic genomic alterations in IDH-wildtype glioblastoma [181] and are closely associated with worse OS and PFS [182]. PTEN mutations, observed in approximately 40% of cases, are likewise associated with poor prognosis and treatment resistance [183].

6.2.2 IDH-mutant astrocytomas

In IDH-mutant diffuse astrocytomas, tumor grade is a key prognostic factor, with grade 3 tumors exhibiting a median OS of 8.1 years, whereas grade 4 tumors show a significantly shorter median OS of 4.7 years (p < 0.05) [184]. Homozygous CDKN2A/B deletion is strongly associated with worse survival outcomes; patients with this deletion have a median OS of only 1.8 years compared with 5.5 years in those without the deletion (p < 0.001) [2]. The presence of IDH mutation has now been established as a favorable prognostic factor in diffuse astrocytomas and oligodendrogliomas [185]. MGMT promoter methylation is more prevalent in IDH-mutant gliomas and is independently associated with improved OS and PFS when treated with TMZ; however, its predictive value appears to be largely limited to grade 4 tumors [186]. In addition, TP53 mutations and ATRX loss frequently co-occur, indicating genomic instability, and are generally associated with favorable prognosis [187]; patients with ATRX mutations are younger and have longer OS [188].

6.2.3 IDH-mutant and 1p/19q-codeleted oligodendroglioma

Oligodendrogliomas have long been recognized as having a favorable prognosis, with their defining feature being the concurrent presence of IDH1/2 mutations and 1p/19q codeletion [2]. The molecular landscape of oligodendrogliomas includes frequent TERT promoter mutations [189], retained ATRX expression, and absence of p53 accumulation, which is consistent with the mutual exclusivity between 1p/19q codeletion and TP53 or ATRX alterations [190]. In a subset of cases, CDKN2A/B deletions may be detected, an alteration associated with more aggressive tumor behavior and poorer prognosis [191].

6.3 Biomarkers for Combination Therapy Selection

The rational design of combination therapies increasingly relies on biomarkers that identify synergistic vulnerabilities. Table 4 outlines representative biomarkers and their associated combination approaches.

7. Conclusions

Recent progress in glioma immunotherapy has been substantial, particularly in efficacy [136, 139], BBB penetration [47-50, 76], TME remodeling [47, 49, 55, 57, 60], overcoming heterogeneity [46, 115], and controlled release with reduced toxicity [144]. However, several critical research gaps remain to be addressed. 1) Target selection. Many targets, such as EGFRvIII, exhibit unstable expression and are prone to loss following treatment, leading to resistance [31]. An ideal target should be closely associated with tumor cell growth, proliferation, and invasion, while maintaining stable expression that is less likely to be lost [192]. Therefore, the identification and screening of optimal targets constitute a critical priority, as this will help mitigate off-target effects and reduce the incidence of therapeutic resistance. 2) Biomarker identification and patient stratification. The identification of reliable biomarkers in glioma faces unique challenges compared with many other solid tumors. (a) The presence of the blood-brain barrier (BBB) severely restricts the release of tumor-derived biomolecules into the peripheral circulation, resulting in extremely low abundance of circulating biomarkers, including circulating tumor DNA (ctDNA) and circulating tumor cells (CTCs) [193, 194]. Studies have shown that the detection rate of plasma ctDNA in patients with glioma is currently below 20%, which is considerably lower than that reported for other malignancies [194]. (b) Glioma exhibits high tumor heterogeneity, making it difficult for a single biopsy or a single biomarker to fully capture the overall tumor status [195]. This characteristic often manifests in clinical trials as a lack of statistically significant overall outcomes or statistically significant efficacy only in specific subgroups, suggesting that current patient stratification strategies remain insufficiently refined [49]. (c) The TME of glioma is highly immunosuppressive, characterized by a low tumor mutational burden (TMB) and a paucity of high-quality neoantigens, which further limits the identification and application of immune-related biomarkers [196]. (d) The expression of certain biomarkers in glioma is dynamic, whereas clinical detection still relies primarily on pathological biopsy, making it difficult to capture real-time changes during treatment [197]. (e) Owing to the infiltrative growth pattern of glioma, obtaining tissue samples carries significant risks; although liquid biopsy holds promise, standardized methods for its application have not yet been established [197]. 3) Preclinical model selection. The representativeness of certain models is limited. In immunotherapy studies in particular, a fully competent immune system is essential, yet the establishment of humanized models often relies on immunodeficient mice, which compromises the representativeness of efficacy assessments [48]. Selecting models that are reproducible, amenable to visualization, biomimetic, and easy to establish is crucial for facilitating clinical translation [198]. 4) Drug design. Drug design should take into account patient compliance, prioritizing convenient routes of administration. From the early stages of design, the involvement of pharmaceutical analysis experts is essential to develop analytical protocols that support preparation, purification, and scalable manufacturing. Additionally, aligning drug development with real-world manufacturing processes and patient needs is critical. The establishment of versatile platforms, such as the mSA2 system, can help shorten the research and development cycle and reduce costs [115]. 5) Drug development. The safety of CAR-T therapy requires further validation [106-109]. Enhancing the persistence of CAR-T cells in vivo [112, 114] and preventing the rapid clearance of oncolytic viruses by the host [145] remain key challenges. Currently, glioma immunotherapy continues to be constrained by the BBB, high tumor heterogeneity, the immunosuppressive microenvironment, and adaptive resistance accompanied by tumor evolution [13, 152-157]. Future progress is expected through improved delivery routes, combination strategies, the identification of optimal targets, and remodeling of the immune microenvironment. 6) Clinical trial considerations. (a) Patient selection bias. Enrolling patients without disease progression following standard therapy as trial subjects, compared with general patient populations, may lead to an overestimation of treatment efficacy [32]. (b) Control arm selection. With the advancement of standard-of-care treatments, OS in historical control groups has improved, making it difficult to reproduce promising results from early-phase trials in subsequent randomized studies [31]. (c) Control arm design. Immunotherapy trials should use standard therapy—at minimum TMZ—as the comparator to determine whether the investigational treatment offers improvements over existing therapies [66]. (d) Insufficient sample size. The low incidence and high mortality rate of gliomas make patient recruitment challenging, limiting the feasibility of many trials and resulting in underpowered analyses [26, 46, 114, 132]. Multicenter international collaboration is urgently needed, along with efforts to standardize treatment protocols. (e) Contradictory findings. Some studies suggest that immunotherapy requires minimal residual disease [46], whereas others have observed long-term survival benefits in patients without complete resection [31]. The rindopepimut trial found no correlation between antibody titers and survival benefit, suggesting that T-cell responses may serve as a more relevant selection criterion [31]; conversely, most trials, including AFTV, have reported that higher antibody levels correlate with better outcomes [46]. 7) Efficacy evaluation. Current imaging modalities are insufficient for assessing treatment response, highlighting the need for novel techniques [139]. Certain therapies, such as AFTV, contain theoretically all tumor antigens, making it impossible to evaluate efficacy based on specific antibody titers, necessitating the establishment of new evaluation criteria [46]. 8) Clinical translation. The production, quality control, and management of novel biological products require standardization [52]. Furthermore, biomarker-guided stratification or individualized treatment approaches are costly and require policy support [7]. Although each of the four major immunotherapy strategies faces distinct translational challenges [51, 52, 86, 125, 151], oncolytic virus therapy currently demonstrates the most promising translational potential. This approach has garnered significant attention due to its unique dual mechanism of "oncolysis plus immune activation" [199, 200]. G47Δ has been approved in Japan for the treatment of malignant glioma, with a Phase II trial reporting a one-year survival rate of 84.2% and a median OS of 20.2 months, marking a milestone in the field [139]. Furthermore, the combination of oncolytic viruses with ICIs has shown synergistic effects in preclinical and early-phase clinical studies, with the potential to convert "cold" tumors into "hot" tumors [134]. In contrast, ICIs are unlikely to confer additional survival benefits in the absence of molecular screening or specific biomarker guidance [43, 74, 75]. Tumor vaccines are limited in monotherapy due to tumor heterogeneity and antigen loss; however, their value as components of combination regimens should not be overlooked [31]. Adoptive cell therapies similarly face challenges such as antigen loss and limited in vivo persistence, resulting in modest efficacy as monotherapies [13, 112, 114]. Nonetheless, the recently developed mSA2 universal platform offers a promising strategy to address antigen loss by enabling simple exchange of biotinylated antibodies, providing new opportunities for this therapeutic modality [115].

Abbreviations

AEs: Adverse Events; AFTV: Autologous Formalin-fixed Tumor Vaccine; ARMed CAR-T: Checkpoint Antibody Receptor-modified Chimeric Antigen Receptor T-cell; ARPC1B: Actin Related Protein 2/3 Complex Subunit 1B; ATA: Autologous Tumor Antigen; BBB: Blood-Brain Barrier; BRD9: Bromodomain-containing Protein 9; CAR-T: Chimeric Antigen Receptor T-cell; CFZ: Clofazimine; CNS: Central Nervous System; DAMPs: Damage-associated molecular patterns; DDR: DNA Damage Response; DFMO: Difluoromethylornithine; DCs: Dendritic Cells; dsRNA: Double-stranded RNA; EGFRvIII: Epidermal Growth Factor Receptor Variant III; EV: Extracellular Vesicles; GAA: Glioma-associated Antigen; GAPVAC: Glioma Active Personalized Vaccine Consortium; GARP: Glycoprotein A Repetitions Predominant; GBM: Glioblastoma; GBO: Glioblastoma Organoid; GSC: Glioma stem cell; HCMV: Human Cytomegalovirus; HLA-A2: Human Leukocyte Antigen A2; HSV-1: Herpes Simplex Virus Type 1; IBDV: Infectious Bursal Disease Virus; ICB: Immune Checkpoint Blockade; ICD: Immunogenic Cell Death; ICIs: Immune Checkpoint Inhibitors; IDH1: Isocitrate Dehydrogenase; IDH1/2: Isocitrate Dehydrogenase 1/2; IDH1-vac: Isocitrate Dehydrogenase 1 Mutation-targeted Vaccine; ISG: Interferon-stimulated Gene; IV: intravenous delivery; JAK: Janus Kinase; KLH: Keyhole Limpet Hemocyanin; LAK: Lymphokine-activated Killer; LNPs: Lipid Nanoparticles; MCP: Multi-cationic Protein; MDSCs: Myeloid-derived Suppressor Cells; METTL14: Methyltransferase-like 14; MGMT: O-6-Methylguanine-DNA Methyltransferase; MHC: Major histocompatibility complex; mSA2 CAR-T: Monomeric Streptavidin 2-based Chimeric Antigen Receptor T-cells; MV-CEA: Measles Virus-based Carcinoembryonic Antigen-expressing Oncolytic Virus; MYXV: Myxoma Virus; NaV: Nanoshield Vaccine; nGBM: Newly Diagnosed Glioblastoma; NO: Nitric Oxide; nsIL12: Non-secreting Interleukin-12; OA@Cho: Cholesterol-modified Adenovirus; oHSV-1: Oncolytic Herpes Simplex Virus-1; OS: Overall Survival; PAMPs: Pathogen-associated molecular patterns; PBMCs: Peripheral blood mononuclear cells; PDT: Photodynamic Therapy; PFS: Progression-Free Survival; PPV: Personalized Peptide Vaccine; PVSRIPO: Poliovirus (Recombinant Nonpathogenic Poliovirus: Rhinovirus Recombinant); rGBM: Recurrent Glioblastoma; ROS: Reactive Oxygen Species; scFv: Single-chain variable fragment; SPOD-NV: Survivin Peptide-CpG Nanovaccine; Stars NV: Sonodynamic Nanovaccine; STAT: Signal Transducer and Activator of Transcription; SurVaxM: Survivin-targeting Peptide Vaccine; TAAs: Tumor-associated Antigens; TAMs: Tumor-associated Macrophages; TCF: Tumor Cavity Fluid; TCR-T: T Cell Receptor-engineered T Cells; TERT: Telomerase Reverse Transcriptase; TGFB2: Transforming Growth Factor Beta 2; TGFβ: Transforming Growth Factor Beta; TILs: Tumor-infiltrating Lymphocytes; TME: Tumor microenvironment; TMZ: Temozolomide; Tregs: Regulatory T Cells; TSAs: Tumor-specific Antigens; WHO: World Health Organization; WT1: Wilms Tumor 1; ZIKV: Zika Virus; ZNF638: Zinc Finger Protein 638.

Acknowledgements

All figures in this review were created using Figdraw.

Author Contributions

JG: Conceptualization, Writing-review & editing, Supervision, Funding acquisition, Visualization.

YH: Writing-review & editing, Supervision, Funding acquisition, Visualization.

JL: Writing-original draft, Writing-review & editing, Formal analysis, Validation, Project administration.

GY: Writing-review & editing, Formal analysis.

ZC, HQ, and MZ: Writing-review & editing, Software.

CZ and XL: Writing-review & editing, Data curation, Investigation.

Competing Interests

The authors have declared that no competing interest exists.

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Author contact

Corresponding authors: Jintao Gu, MD., State Key Laboratory of Cancer Biology, Biotechnology Center, School of Pharmacy, The Fourth Military Medical University, Xi'an, 710000, China (gujintaoedu.cn). Yalong He, MD., Department of Neurosurgery, Xijing Hospital, Xi'an, 710000, China (heyl.fmmucom).

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