Clinicopathological and prognostic relevance of nestin in low- and high-grade gliomas: An immunohistochemical study

Abstract

BACKGROUND

Gliomas, the most prevalent primary malignant brain tumours, display remarkable heterogeneity in behaviour and prognosis. Mounting evidence implicates cancer stem cells and their associated markers in gliomagenesis and treatment resistance. Nestin, a class VI intermediate filament protein linked to neural stemness and cytoskeletal remodelling, has emerged as a potential prognostic biomarker.

AIM

To evaluate the association of nestin expression, tumour grade, and survival in glioma patients from Pakistan.

METHODS

This prospective cohort study included 128 histologically confirmed glioma cases (64 low-grade; 64 high-grade) diagnosed at Prime Teaching Hospital, a tertiary care teaching hospital in Khyber Pakhtunkhwa, Pakistan, between January 2023 and September 2024. Nestin expression was evaluated by immunohistochemistry using the Immunoreactive Score system and categorized as high or low expression. Associations were assessed using Fisher’s exact test or χ² test, and survival outcomes were analyzed using the Kaplan-Meier method.

RESULTS

High-grade tumours exhibited higher nestin overexpression rates compared to low-grade gliomas (90.6% vs 70.3%, P = 0.004), and the median overall survival was 3 months for high-grade tumours and 26 months for low-grade tumours. In patients with high nestin expression, shorter survival (8 months) was seen, while those with low expression showed longer survival (22 months, P = 0.025). When analysed in combination, a trend towards the poorest prognosis in high-grade gliomas with high nestin (median 2 months) and the best in low-grade with low nestin (26 months, P = 0.001) was observed. No significant association was observed with patients’ gender, age, or tumour site.

CONCLUSION

Nestin overexpression is associated with higher glioma grade and poorer overall survival across astrocytic and oligodendroglial tumors and may serve as a supplementary prognostic biomarker, particularly in settings with limited access to molecular diagnostics.

Key Words: Low-grade glioma; High-grade glioma; Cytoskeletal protein nestin; Survival analysis; Tumour grade

Core Tip: Gliomas show marked biological heterogeneity, necessitating accessible prognostic biomarkers, especially in resource-limited settings. This prospective study demonstrates that nestin overexpression is significantly associated with higher tumour grade and inferior overall survival in both low- and high-grade gliomas. High-grade tumours showed markedly increased nestin expression and substantially shorter survival compared to low-grade counterparts. Patients with high nestin expression experienced poorer outcomes, while the combined analysis revealed the worst prognosis in high-grade gliomas with high nestin levels. These findings highlight nestin as a practical supplementary prognostic marker that may aid risk stratification where advanced molecular testing is unavailable.

INTRODUCTION

Gliomas are the most common primary tumors of the central nervous system, arising from glial cells or their progenitors and characterized by infiltrative growth, marked biological heterogeneity, and variable clinical outcomes. Clinically, gliomas encompass a spectrum of neoplasms ranging from indolent low-grade lesions to highly aggressive high-grade malignancies, with prognosis influenced by tumor grade, histological subtype, and underlying molecular alterations[1]. Traditionally, gliomas were thought to develop through dedifferentiation of mature neural cells; however, accumulating evidence now supports a central role for cancer stem-like cells in gliomagenesis, tumor progression, and therapeutic resistance. Consequently, the conceptual framework of glioma development has shifted toward stemness-driven tumor biology[2].

Globally, the age-standardized incidence of all brain and central nervous system (CNS) tumors (including gliomas) is about 3.5 per 100000 per year. In 2022, an estimated 322000 new cases of brain and CNS tumors were diagnosed worldwide, of which gliomas made up a significant portion[3]. While epidemiological trends from high-income countries are well documented, real-world data from low- and middle-income regions remain limited[4].

In Pakistan, according to the International Agency for Research on Cancer statistics, the new cases of brain and CNS were 5342, and 4407 deaths were attributed to these conditions. In South Asia, including Pakistan, tumors of the brain and central nervous system account for a significant proportion of cancer-related morbidity and mortality, emphasizing the need for region-specific studies to better characterize tumor behavior and prognostic determinants in routine clinical practice.

The most prevalent primary brain tumors, gliomas, are a varied group of neoplasms that are categorized as low-grade (grades I and II) and high-grade (grades III and IV) tumors according to their molecular profiles and histological characteristics[5]. Although low-grade gliomas usually grow slowly and have a generally good prognosis, they have the capacity to develop into high-grade gliomas. Rapid growth, widespread infiltration, and resistance to standard treatments are characteristics of high-grade gliomas, especially glioblastoma, which are extremely malignant. High-grade glioma patients continue to have poor survival rates despite multimodal treatment regimens, making the discovery of reliable prognostic biomarkers essential for better patient management and stratification[6]. The five-year survival rate for glioblastoma (grade IV) is on the order of 5%-10%, while grade III anaplastic astrocytoma is in the range of 20%-45%[7].

Nestin’s link to stem-like characteristics in glioma cells has drawn interest in it as a biomarker[7]. Glioblastoma stem-like cells, which are believed to be responsible for tumor start, treatment resistance, and recurrence, express it[8]. Nestin, a class VI intermediate filament protein, is a well-known indicator of neural stem and progenitor cells and is essential for preserving the cytoskeleton’s structural integrity and flexibility[9]. It is significantly re-expressed in pathological situations, such as different types of cancer, even though its expression is primarily seen during early neurodevelopment[10]. Reactivation is thought to be a crucial aspect of tumour aggressiveness and advancement in gliomas, and it is correlated with poor clinical outcomes[11].

The presence of nestin in the vasculature of gliomas, along with cancer cells, indicates that nestin plays a role in tumour angiogenesis, which is an essential process in maintaining tumour spread and development[12]. Moreover, the increased invasive and migrating abilities, a characteristic of the aggressiveness of high-grade gliomas, have also been linked to high nestin expression[13]. It is established that nestin's biological functions are a significant predictor of tumour progression and its behaviour[14]. Survival analysis is required to examine the predictive significance of biomarkers such as nestin[15]. Tumour behaviour and patient prognosis across various glioma grades can be assessed by establishing a correlation between nestin expression levels and survival outcomes[16]. Patient stratification, along with the biology underpinning tumour development and resistance, can be achieved by understanding these relationships[17].

Although nestin has been widely recognized as a marker of glioma stemness and tumour aggressiveness, most existing studies have been conducted in Western and East Asian populations. There is a paucity of data from South Asian regions, particularly Pakistan, where epidemiological and genetic differences may influence tumour biology and biomarker expression. The present prospective study will, therefore, provide novel insights by evaluating nestin expression in a Pakistani glioma cohort using immunohistochemistry and correlating it with both histological subtypes and patient survival. To best of our knowledge, this is the first study in the region to integrate nestin expression with survival stratified by glioma type (astrocytic vs oligodendroglial), thereby expanding current understanding of its prognostic value in diverse populations. This study sought to prove nestin as a credible biomarker for glioma patients’ clinical outcome prediction by incorporating survival analysis into the inquiry. Glioma patients' survival and quality of life may be enhanced by more targeted and customized treatment options made possible by the study's insights[18,19]. The present study aimed to determine the prognostic significance of nestin in low and high-grade gliomas in a low-resource setting.

MATERIALS AND METHODS

This prospective cohort study comprised 128 patients with gliomas admitted to Prime Teaching Hospital, Khyber Pakhtunkhwa, Pakistan, between January 2023 and September 2024. Patients who received preoperative chemotherapy or radiation were excluded. To enable robust comparison between disease severity groups, an equal number of low-grade [World Health Organization (WHO) grades I-II] and high-grade (WHO grades III-IV) gliomas (64 cases each) were consecutively included. This balanced distribution was adopted to minimize group size-related bias and to enhance statistical power when evaluating differences in nestin expression patterns and survival outcomes across tumor grades.

The histology diagnosis was based on the WHO classification of brain tumours (WHO blue books). The grading system is based on particular histopathological features such as “cellularity, nuclear atypia, mitotic activity, microvascular proliferation and necrosis”[9,15]. Grades 1 and 2 were classified as low-grade gliomas, while grades 3 and 4 were classified as high-grade gliomas based on routine hematoxylin and eosin-stained sections. All cases were reviewed and categorized prior to immunohistochemical and survival analyses to ensure uniform application of grading criteria. This design allowed for direct comparison of nestin expression and prognostic impact across glioma grades within a single, well-defined cohort. All individuals data were recorded in a standardized proforma.

The present study was approved by the Institutional Ethical Committee of Khyber Medical University (No. KMU/IPMD/IEC/2022/08) and followed the Declaration of Helsinki protocol. In accordance with approved ethical guidelines, all patients were approached. After outlining the current study’s aim, objectives, and procedure, all 128 participants provided written informed consent. Patients were selected on their willingness, and they had the right to decline enrolment and cease participation at any moment.

Inclusion criteria

De novo patients of all age groups with gliomas diagnosed on biopsy in the Pakistani population of Khyber Pakhtunkhwa.

Exclusion criteria

Brain tumor patients diagnosed with non-glioma tumors on biopsy examination. All biopsy specimens with any kind of artefacts. Patients who had received chemotherapy and/or radiotherapy preoperatively.

Evaluation of immunohistochemical staining

Nestin immunohistochemistry was performed on formalin-fixed, paraffin-embedded tissue sections (4 μm thickness). Sections were processed using a standard immunohistochemical protocol, including deparaffinization, rehydration, and heat-induced antigen retrieval in citrate buffer (pH: 6.0) using a pressure-based antigen retrieval system at 121 °C for 10 minutes. Immunostaining was carried out manually using a humidified chamber, and slides were incubated with anti-nestin monoclonal antibody (Mouse monoclonal clone 10C2, dilution 1:1000, Vitro, GeneTex, GeneTex International Corporation, Hsinchu City, Taiwan, China). Detection was performed using a polymer-based horseradish peroxidase detection system, followed by visualization with 3,3′-diaminobenzidine chromogen. Hematoxylin was used for counterstaining. Stained slides were examined and evaluated using a light microscope. The intensity and proportion of nestin immunostaining were assessed using the Immunoreactive Score (IRS) system. The final IRS was calculated as the product of staining intensity and the percentage of positive tumour cells. For analytical purposes, nestin overexpression was defined as IRS > 4, whereas nestin underexpression was defined as IRS ≤ 4[20]. This threshold was applied uniformly across all tumour grades for comparative analysis. In both low and high grades of gliomas, nestin was expressed cytoplasmically in tumor cells (Figure 1).

Figure 1 Representative images of morphology and immunohistochemical staining of glioma tumors. A: Low-grade astrocytoma (World Health Organization grade II) on hematoxylin and eosin [hematoxylin-eosin (HE)] staining showing low-grade and uniform nuclei (HE, × 100); B: Cytoplasmic nestin expression on immunohistochemistry (IHC) staining in a low-grade glioma case (IHC for nestin, × 50); C: High-grade glioblastoma (World Health Organization grade IV) on HE staining with high-grade pleomorphic nuclei (HE, × 200); D: Strong cytoplasmic nestin expression on IHC staining in a high-grade glioma case (IHC for nestin, × 200).

Grouping of patients

For analytical purposes, patients were stratified into predefined groups based on tumor grade (low-grade gliomas vs high-grade gliomas), nestin expression status (low expression vs high expression according to the IRS cutoff), and combined tumor grade and nestin expression categories (low-grade/Low nestin, low-grade/high nestin, high-grade/Low nestin, and high-grade/high nestin).

Survival analysis

Survival analysis was conducted to evaluate the prognostic impact of nestin expression and tumor grade on overall survival (OS) in glioma patients. OS was defined as the interval between the date of histopathological diagnosis and the date of death from any cause or the last follow-up for censored cases. Patients who were alive or lost to follow-up at the end of the study period were censored. Kaplan-Meier survival curves were generated to estimate survival distributions for each group, and differences between curves were assessed using the log-rank test. Median survival times with corresponding 95% confidence intervals (CIs) were calculated for all comparison groups.

Statistical analysis

Statistical analysis was performed to evaluate associations between nestin expression and clinicopathological variables as well as survival outcomes. Categorical variables were compared using Fisher’s exact test or Pearson’s χ² test, as appropriate. OS was analyzed using the Kaplan-Meier method, with survival differences assessed by the log-rank test. Median survival times were reported with corresponding 95%CIs. A P-value < 0.05 was considered statistically significant. All analyses were performed using SPSS version 25.0 (IBM Corp., Armonk, NY, United States).

RESULTS

Patient characteristics

The clinicodemographic and histopathological characteristics of the study cohort are summarized in Table 1. A total of 128 glioma cases were included, comprising equal numbers of low-grade (n = 64) and high-grade (n = 64) tumors. The median age at diagnosis was 33.6 years (range: 3-75 years). Male patients constituted 66.4% of the cohort. The most frequent low-grade tumors were oligodendrogliomas and pilocytic astrocytomas, while glioblastomas represented the predominant high-grade histological subtype. The overall follow-up duration was 40 months. There was a significant association between nestin expression and glioma grade. In low-grade tumors, 70.3% of cases showed nestin overexpression, whereas in high-grade tumors, overexpression was observed in 90.6% of cases (P = 0.004) (Table 2). No statistically significant associations were found between nestin expression and patients’ age, gender, or tumor location, although a trend toward higher expression in younger patients was noted (P = 0.054).

Table 1 Clinicodemographic and histological distribution of glioma cases, n (%).

Variables	Values
Age, median (range), years	33.6 (3-75)
Sex
Male	85 (66.4)
Female	43 (33.61)
Histological type
Pilocytic astrocytoma (WHO Grade I)	32 (25)
Oligodendroglioma (WHO Grade II)	38 (29)
Anaplastic astrocytoma (WHO Grade III)	16 (12.5)
Anaplastic oligodendroglioma (WHO Grade III)	10 (7.8)
Glioblastoma (WHO Grade IV)	30 (23.4)
Gliosarcoma (WHO Grade IV)	2 (1.6)

Table 2 Correlation between nestin expression and clinicopathological parameters.

	Nestin underexpression	%	Nestin overexpression	%	P value
Tumor grades	Low grade = 19	29.7	Low grade = 45	70.3	0.004
	High grade = 6	9.4	High grade = 58	90.6
Age (years)	> 40 = 31	34.8	> 40 = 58	65.2	0.054
	< 40 = 7	17.9	< 40 = 32	82.1
Gender	Male = 25	29.4	Male = 60	70.6	0.92
	Female = 13	30.2	Female = 30	67.8
Tumor site	Supratentorial = 32	29.6	Supratentorial = 76	70.4	0.973
	Infratentorial = 6	30	Infratentorial = 14	70

Glioma grades and survival analysis

Kaplan-Meier survival analysis demonstrated a significant difference in patient outcomes based on tumor grade. There were 13 (20.3%) cases of low-grade and 3 (4.7%) of high-grade glioma, which were censored (lost to follow-up or outcome unknown at 40 months). The median OS was 26 months (95%CI: 20.2-31.8) for low-grade gliomas and 3 months (95%CI: 0.8-3.1) for high-grade gliomas. The OS was statistically significant (P < 0.001). Among low-grade tumors, patients with pilocytic astrocytoma showed the most favorable prognosis, with a median survival of 30 months, followed by oligodendroglioma (18 months). In contrast, all high-grade histological subtypes, including glioblastoma multiforme (GBM), anaplastic astrocytoma, anaplastic oligodendroglioma, and gliosarcoma, were associated with poor outcomes, with median survival times ranging from 2 months to 4 months (Table 3).

Table 3 Survival outcomes stratified by tumor grades and types.

Histologic diagnosis	n	Median survival (in months)	95%CI
Low-grade tumors	64	26	20.2-31.8
Pilocytic astrocytoma	32	30	24.7-35.2
Oligodendroglioma	32	18	11.6-24.3
High-grade tumors	64	3	2.0-3.9
Glioblastoma multiforme	16	2	0.8-3.1
Anaplastic astrocytoma	16	4	2.4-5.5
Anaplastic oligodendroglioma	30	2	0.5-3.4
Gliosarcoma	2	2	0.8-3.1

CI: Confidence interval.

The nestin expression and survival analysis

All patients with nestin expression were included in the survival analysis (Figure 2A). The Kaplan-Meier graph shows that the median survival was 22 months in low expression of nestin, while the median survival was 8 months in high expression of nestin, and the difference was statistically significant (P = 0.025).

Figure 2 Kaplan-Meier survival curves according to nestin expression status, glioma grades. A: It shows that the median survival was 22 months in low expression of nestin, while the median survival was 8 months in high expression of nestin; B: It shows that the median survival in low-grade and low nestin expression was 26 months, while the median survival was 2 months in high-grade tumors with high expression of nestin.

Combined analysis of tumor grades and nestin expression

When analysed in combination, the median survival in low-grade gliomas with low nestin expression was highest (26 months), while it was lowest (2 months) in high-grade tumors with high expression of nestin (Figure 2B).

DISCUSSION

Gliomas are a broad category of primary tumors of the CNS with a range of biological characteristics and clinical outcomes. While low-grade gliomas often advance more slowly and have comparatively better results, high-grade gliomas, such as GBM, are linked to a poor prognosis. To support clinical decision-making, reliable biomarkers that can differentiate tumor grades and forecast prognosis are desperately needed. Because of its correlation with stem-like tumor cell populations, cellular plasticity, and malignancy, nestin, a protein produced in brain stem/progenitor cells, has become an interesting prospective marker[21].

Nestin expression and glioma grades

The findings from this study demonstrate a strong and consistent increase in nestin expression with advancing tumor grades across both astrocytic and oligodendroglial lineages. High-grade gliomas exhibited significantly higher nestin overexpression rates compared to low-grade tumors, supporting the role of nestin as a marker of tumor aggressiveness. These findings are consistent with previous studies reporting increased nestin expression in higher-grade gliomas and its association with enhanced proliferative capacity, invasiveness, and stem-like tumor cell populations[7,16,22,23]. Re-expression of nestin in malignant gliomas is thought to reflect cellular dedifferentiation and increased plasticity, which are hallmarks of aggressive tumor behavior[13].

The well-known prognostic difference between high-grade tumors, which have a median survival of only three months, and low-grade gliomas, which have a median survival of 26 months, was validated by our data. Pilocytic astrocytomas had the best prognosis (30 months) among low-grade gliomas, but oligodendrogliomas had a lower survival (18 months), perhaps because of histologic and molecular heterogeneity. These results are consistent with international evidence that, despite multimodal therapy, GBM and anaplastic variations exhibit aggressive behaviour and have a poor prognosis. Beyond histology, the 2021 WHO molecular reclassification incorporating isocitrate dehydrogenase (IDH) mutation and 1p/19q co-deletion improves survival prediction.

Survival decreased from 30 months in grade I astrocytoma to 2 months in glioblastoma (P < 0.001), indicating a strong inverse link between tumor grade and survival. This is in line with recognized prognostic gradients and new large-scale research showing that higher histological grade is associated with worse outcomes because high-grade cancers have stem-like characteristics and increased proliferative potential. Prognostic accuracy within histological grade is improved by incorporating molecular markers such as IDH mutation and O-6-methylguanine-DNA methyltransferase (MGMT) promoter methylation status.

The median survival for grade II oligodendrogliomas was 18 months, while the median survival for grade III tumors was 2 months (P < 0.001), indicating a significant drop in survival with increasing oligodendroglioma grade. This is consistent with research demonstrating that higher-grade oligodendrogliomas have a worse prognosis and more proliferative activity even with similar treatment. Nestin is one of the stem-cell markers whose expression rises with grade development, indicating a change to a more aggressive phenotype. Combined molecular and histopathologic categorization has prognostic significance and is shown by molecular stratification based on 1p/19q co-deletion and IDH mutation, thereby revealing subgroups of grade III cancers with better outcomes classification.

Prognostic significance of nestin expression

The survival analysis revealed that patients with high nestin expression had significantly shorter OS compared to those with low expression. This observation aligns with prior reports demonstrating an association between nestin overexpression and adverse survival outcomes in glioma patients[16]. From a mechanistic perspective, nestin has been shown to contribute to tumor progression by maintaining cytoskeletal dynamics, facilitating mitotic spindle assembly, and promoting resistance to apoptosis, thereby enhancing tumor growth and therapeutic resistance[14,17].

Nestin’s role in prognosis was further strengthened by the fact that higher nestin expression was significantly correlated with lower median survival (8 months) compared to those that showed lower nestin expression (22 months, P = 0.025). This aligns with earlier studies that connected higher tumor invasiveness and shorter OS to nestin expression in high-grade gliomas. On the contrary, when molecular markers like IDH mutation and MGMT promoter methylation were taken into consideration in other studies, nestin alone showed low survival predictive value, advocating that its prognostic influence is dependent on context. Nonetheless, our study strongly suggests that nestin demonstrated a consistent value as a predictor of poor prognosis in glioma patients[24].

Combined impact of tumor grade and nestin expression

When nestin expression was examined along with tumour grade, it showed a significant correlation with survival. Median survival was greatest (26 months) in patients having low-grade gliomas with low nestin expression, while the worst prognosis was observed in patients having high-grade gliomas with high nestin levels (2 months, P = 0.001). This aligns with research done previously, which concluded that nestin overexpression in high-grade gliomas was linked to aggressive tumour biology, rapid progression, and reduced survival[16].

Association with demographic and anatomical factors

Nestin expression showed no significant association with patients’ age, sex, or tumor location, suggesting that its prognostic value reflects intrinsic tumor biology rather than demographic or anatomical factors. This finding is consistent with previous literature indicating that stemness-associated markers such as nestin are more closely linked to molecular and cellular tumor characteristics than to host-related variables[23]. Patients over 40 years had a marginally longer survival (12 months vs 5 months); however, there was no significant association between patients’ age and nestin expression (P = 0.66). Previous research on the relationship between age and nestin expression has produced conflicting results. Some have linked increased nestin levels in elderly patients to cumulative genetic changes and improved stem-like tumor characteristics. Tumor biology and grade are still thought to be more significant prognostic factors than age alone.

Context within contemporary molecular classification

The 2021 WHO classification of tumors of the CNS emphasizes molecular alterations, including IDH mutation, 1p/19q co-deletion, and MGMT promoter methylation, for glioma diagnosis and prognostication[24]. The absence of molecular data represents a limitation of the present study; however, prior research suggests that nestin expression is often inversely associated with favorable molecular features such as IDH mutation and 1p/19q co-deletion, and positively associated with markers of chemoresistance and poor outcome[7,16,23]. In this context, nestin immunohistochemistry may provide supplementary prognostic information, particularly in settings where molecular testing is not routinely available[25].

Future research should integrate molecular profiling with immunohistochemical assessment to confirm if nestin expression promotes prognostic value, both independently or additively. As a potential surrogate or supplementary biomarker for clinical stratification in areas where resources are constrained and where molecular testing is not readily available, nestin could be used. A speculative representation showing how nestin would be integrated with the WHO 2021 molecular categorization system is presented in Figure 3.

Figure 3 Proposed integration of nestin expression within the 2021 World Health Organization molecular classification framework for gliomas. It illustrates how nestin immunoexpression may complement molecular markers to refine diagnostic accuracy and prognostic assessment. High nestin expression is associated with stem-like, invasive tumor phenotypes and poor outcomes, while low expression correlates with differentiated morphology and improved survival. Incorporating nestin into the World Health Organization 2021 molecular framework may improve patient stratification and guide personalized therapy, particularly in settings with limited molecular testing capabilities. WHO: World Health Organization; IDH: Isocitrate dehydrogenase; IHC: Immunohistochemistry.

In summary, this study demonstrates a consistent increase in nestin expression with advancing glioma grade across both astrocytic and oligodendroglial lineages, accompanied by a corresponding decline in median survival. Patients with high-grade tumors and high nestin expression experienced the poorest outcomes, whereas low-grade tumors with low nestin expression showed the most favorable survival, highlighting the biological relevance of nestin in glioma aggressiveness. Importantly, nestin expression was not influenced by age, sex, or tumor location, underscoring its prognostic significance independent of demographic factors. Although molecular classification remains the standard, these findings suggest that nestin immunohistochemistry may provide clinically meaningful supplementary prognostic information, particularly in resource-limited settings where molecular testing is not routinely available.

Limitations

The molecular analysis (IDH mutation and 1p/19q co-deletion) of the glioma patients in this study was not carried out due to financial constraints, as all the patients were from a third-world country. Potential regional genetic or environmental impacts cannot be ruled out because all of the patients in this study were from Khyber Pakhtunkhwa, Pakistan. When compared to international cohorts, these could be responsible for slight differences in the distribution of histological subtypes or the prevalence of strong nestin expression. To validate these findings and investigate population-specific factors, more multicentre research is necessary.

Future directions

In view of the findings of this study, nestin immunohistochemical assessment may be considered a supplementary prognostic tool in glioma patients, particularly in healthcare settings where routine molecular testing is limited by financial or infrastructural constraints. The observed association between high nestin expression, higher tumor grade, and reduced OS supports its potential utility for identifying biologically aggressive tumors at diagnosis. Although nestin evaluation cannot substitute for molecular classification as recommended by the WHO, it may provide additional prognostic information when molecular data are unavailable[26,27]. Further multicenter studies incorporating integrated molecular profiling are warranted to validate these observations and clarify the role of nestin within contemporary glioma prognostic frameworks.

CONCLUSION

Nestin overexpression was consistently associated with higher glioma grade, aggressive histological features, and poorer OS across both astrocytic and oligodendroglial tumors. Increasing nestin expression paralleled tumor progression and declining survival, while remaining independent of patient age, sex, and tumor location, underscoring its relevance to intrinsic tumor biology. These findings support nestin as a practical prognostic biomarker that may complement histopathological grading and aid risk stratification, particularly in settings where access to molecular diagnostics is limited.