Two pediatric supratentorial ependymal tumors with novel PLAG1 fusions

The 2021 World Health Organization (WHO) Classification of Central Nervous System (CNS) classification formalized routine molecular profiling, and DNA-methylation studies have since delineated PLAG-family-altered CNS entities: PLAGL1 fusion-positive supratentorial neuroepithelial tumors (NET_PLAGL1) and embryonal tumors with PLAGL1/PLAGL2 amplification. PLAG1 fusions with diverse partners have been reported in CNS embryonal tumors, but have not been described in supratentorial neuroepithelial tumors to date. We describe two pediatric supratentorial ependymal tumors with novel PLAG1 fusions that do not match any 2021 WHO-defined entity or any PLAG-family-related entity recently reported in the literature. Case 1 (4-year-old boy) had a 7.6-cm left lateral ventricular mass with edema and heterogeneous enhancement; gross total resection was performed without adjuvant therapy (alive at 8 months). Histology showed diffusely low cellularity with small- to medium-sized round nuclei, minimal atypia, and focal calcifications; no ependymal rosettes, branching vessels, or clear-cell change. Tumor cells were positive for GFAP and H3K27me3, and negative for Desmin, EMA, OLIG2, L1CAM, NF-κB and H3K27M. The MIB-1 labeling index was ~ 5%. RNA-seq identified TNC::PLAG1 fusion; FISH showed PLAG1 rearrangement. DNA methylation clustered with spinal subependymoma, despite supratentorial location. Case 2 (4-year-old girl) had a 1.4 × 1.1 cm left parahippocampal lesion; resected without adjuvant therapy (alive at 4 months). Histology showed low-to-moderate cellularity with diffuse microcystic change, focal clear/vacuolated cells, and delicate branching vessels. Tumor cells were positive for GFAP, EMA, L1CAM, H3K27me3 and ATRX, and negative for EMA, Desmin, NF-κB, OLIG2, H3K27M, and CD34 (MIB-1 ~ 2%). RNA-seq identified TXNIP::PLAG1 fusion. Methylation did not reach a class threshold. Both cases ultimately warrant a final diagnosis of ependymal tumor, not elsewhere classified. To our knowledge, TNC::PLAG1 and TXNIP::PLAG1 are first-ever fusions reported in any tumor type. They also represent the first PLAG1 fusions identified in pediatric supratentorial ependymal tumors. These cases highlight the value of integrating histology, methylation profiling, and fusion detection, and suggest a new candidate supratentorial ependymal subtype with PLAG1 fusions, pending validation in larger series.