*3.9.1. Multimodal treatment*

This type of tumor is not amenable for surgical treatment. The single debate is related to the role of biopsy. The actual accepted strategy is that biopsy (open or stereotactic) is indicated only in atypical tumors. The term of atypical is somehow unclear, but generally it is accepted that the unilateral extension of tumor and the presence of cystic components or focal hemorrhages offer a rationale for surgery.

In centers with experience in stereotactic biopsy, this could be the method of choice. Otherwise, open surgery is performed, guided by the most superficial part of lesion or throughout the so-called "safe entry zone." In selected cases, surgical interventions can offer the opportunity of cytoreductive surgery, thus creating proper conditions for radiotherapy (**Figure 27**) [161].

Radiotherapy is the single recommendable therapy for this kind of lesions (**Figure 28**). A total dose between 54 and 60 Gy, administered in fractions of 1.8–2 Gy, is the actual recommendation of oncologists. No chemotherapy regimen was able to demonstrate a benefit in terms of survival. Corticosteroids are also administered during radiotherapy. After a period of symptom amelioration, the tumor will inevitably progress [162].

the pediatric ones show changes in the genes regulating chromatin structure and the genetic expression profile. Apart from the diffuse midline glioma, H3 K27 M-mutant, another mutation present in the same gene, but in the G34 rather than the K27 position, defines another entity usually encountered in youths. The location differs, as it is no longer situated in the midline area, but in the brain hemispheres. High-grade astrocytic pediatric tumors with a telencephalic location show the TP53, CDK2A, ATRX, and SETD2 mutations [164]. The genetic syndromes that favor the onset of brain tumors during childhood are type 1 neurofibromato-

**Figure 28.** (a) T2W sequence of a diffuse infiltrative brainstem astrocytoma, partially resected; the 18 months follow-up

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The 2016 brain tumor classification represents an important step forward in the introduction of molecular diagnosis in the daily current practice. This is also an important step toward a personalized patient-tailored multimodal management of brain tumors. Neurosurgeons, as part of a multidisciplinary team, need to be familiarized with all the aspects regarding specific brain tumors in order to offer the best chance to their patients and to prolong survival with a

We thank our colleagues Dr. Reka David for spectroscopy and DTI analysis, Dr. Alexandru Florian and Lecturer Bogdan Aldea for English language improvement and to Dr. Anne-

sis and Li-Fraumeni syndrome.

MRI (b) demonstrates a stable lesion after radiotherapy.

**4. Conclusions**

good quality of life.

**Acknowledgements**

Marie Constantin for manuscript editing.
