Patil et al have recently conducted an analysis of high-grade brainstem gliomas with Central Brain Tumor Registry of the United States (CBTRUS), in which the overall AAIR was higher in females.19 The other plausible explanation is that the SEER database might contain certain DIPG subtypes such as DIPG with ACVR1 (activin A receptor type 1) mutation at this age group, which has a predominance of a female with a 1.75:1 female to male ratio.20,21 Therefore, the higher AAMR in females relative to males within the 5-9 age group is likely attributed to the higher incidence rate in females.19 This evidence concerns the gene ACVR1 and brain stem glioma.