Treatment of elderly glioma patients is a challenge in neurosurgery/neuro-oncology. The International Society of Geriatric Oncology(SIOG)recommends that elderly cancer patients undergo comprehensive geriatric assessment(CGA). The CGA score proved to be a significant predictor of mortality in this cohort, and it could be a useful treatment decision tool. Because of the rapid aging of Japan’s population, clinical research focusing on elderly patients with cancer is urgently needed. The Japan Clinical Oncology Group(JCOG)has established a formal policy for research in geriatric cancers. Currently, the JCOG recommends that researchers perform CGA, including G8, to assess the tolerability of treatment for clinical trials in elderly cancer patients, including glioma. Under this policy, elderly cancer patients are categorized into three groups fit, vulnerable, and frail. For „unfit” glioma/glioblastoma patients, physicians will need to conduct appropriately reduced treatment. Hypofractionated radiotherapy(40.05 Gy/15 fractions)has been an established treatment for elderly patients with glioblastoma. The concurrent and adjuvant temozolomide have reported to have a survival benefit for „fit” elderly patients. Subsequently, alternative hypofractionated radiotherapy, including 34 Gy/10 fractions and monotherapy with temozolomide against MGMT methylated glioblastomas, have been reported as non-inferior alternative treatments. Physicians also need to consider the adverse events associated with anticonvulsants.Pediatric gliomas include various types of glioma broadly categorized as low- or hi-grade based on histopathological features. Clinically significant types include cerebellar astrocytomas, optic pathway / hypothalamic pilocytic astrocytomas, and brainstem gliomas. Neurosurgical roles vary for different kinds of pediatric gliomas. Since these representative tumors remain rare, the patients should be directed toward facilities with experienced neurosurgeons. Radiotherapy and chemotherapy are very important as either adjuvant or primary treatment modalities. Recent advancements in molecular biology have revealed unique genetic aberrations in different types of pediatric gliomas. The RAS/MAPK pathway anomalies, including BRAF-KIAA1549 fusion and BRAF V600E mutation, are present in most low-grade gliomas. BRAF/MEK-inhibitors have yielded promising clinical study results. Diffuse midline gliomas, including diffuse intrinsic pontine gliomas, often harbor H3 mutations such as H3K27M. Agents that target these molecular aberrations are unavailable. Because gliomas in infants are sub-categorized by their genetic abnormalities, novel agents targeting ALK, ROS1, or NTRK fusions are promising treatments.Lower-grade gliomas(LGGs)belong to the group of World Health Organization(WHO)grade II and grade III brain tumors and are slow-growing primary brain tumors. Surgical resection is the initial first-line treatment, followed by chemotherapy, while radiotherapy is often reserved in case of recurrence. Based on the WHO 2016 molecular classification, LGGs are genetically classified into three distinct subtypes based on isocitrate dehydrogenase(IDH)mutation status and codeletion of chromosome 1p and 19q(1p/19q). Due to the differences in tumor characteristics of these molecular subtypes, a standard therapy optimized for these subtypes should be established. This review shows the present evidence and recommended standard therapy for LGGs and discusses several issues to be considered.Glioblastoma, the most malignant and most common form of glioma, is known to portend very poor prognosis with the median overall survival of approximately 1.5 years. Its treatment requires a multidisciplinary approach, which consists of maximal safe resection followed by radiotherapy and chemotherapy with temozolomide. Bevacizumab is approved for newly diagnosed as well as recurrent malignant glioma in Japan. NovoTTF is a novel medical device that emits alternating electric fields; it inhibits the proliferation and growth of the tumor by interfering with tumor cell mitosis at anaphase. A photodynamic therapy with talaporfin sodium has been approved for primary malignant brain tumor including glioblastoma in Japan. For epilepsy secondary to glioblastoma, a novel class of antiepileptics such as levetiracetam and lacosamide is preferred given the lack of drug-drug interactions. Perampanel is a selective antagonist of AMPA receptors, the major subtype of ionotropic glutamate receptors; it may be a preferred antiepileptics for glioblastoma, given the in vitro and in vivo analyses suggesting that it decreases the proliferation and invasion of tumor cells. In this chapter, I describe the overview of the multidisciplinary treatments of glioblastoma. I also describe the future perspectives.While the medical equipment, treatment strategies, and drugs used for glioma patients are not much different among developed countries, leading to similar treatment outcomes, players involved in the management as well as the medical/social systems and environments differ greatly between Japan and North America. In North America, division of work is established and multiple departments consider patients as their „own,” and are therefore deeply committed to the patients’ care which makes the transition of care efficient and smooth for patients. The tumor board was one representative. Neurosurgeons can focus on surgery and clinics, and have dedicated research time allotted for weeks. Due to private insurance in the US, surgery is costly for patients. Religion is part of their life and influences the patients’ attitudes toward and ways of thinking about disease, and sometimes unfavorable treatment results. Admittedly, there are advantages and disadvantages in both the Japanese medical environment and those around the world, but it is worthwhile to consider how patients outside of Japan are treated and look back at our practice. It would then widen our perspective and make us recognize that the commonalities are truth.Malignant gliomas have a poor prognosis despite advances in surgical procedures, radiotherapy, and the emergence of new treatments have improved outcomes. One of these new treatments is gene therapy, which has been developed as a new therapeutic strategy. Recently, new methods and approaches have been developed. Gene therapy involves the introduction of genes or cells into a glioma, or the human body, to treat gliomas; various genes such as cancer-suppressing genes, immunomodulation cytokine-related genes, and suicide genes are used in this treatment. Viral therapy is a treatment that oncolytic viral replicates in tumor cells to destroy tumors. Various viral genes can also be used as therapeutic genes. Currently, the most well-studied and accumulated viruses are adenoviruses and HSV-1. Various clinical trials have been conducted using gene therapy and viral therapy, some of which are scheduled to be approved in the near future. Gene therapy and viral therapy have dramatically improved and have developed progressively since their first clinical use.Elucidation of the ecological characteristics of malignant tumors has shown that angiogenesis and an immunosuppressive status in the tumor microenvironment are important for resolving treatment resistance and poor prognosis. Vascular endothelial growth factor(VEGF) and components of related signaling pathway can be targeted by anti-angiogenic therapy. Suppression of abundant angiogenesis using anti-angiogenic agents in high-grade gliomas inhibits rapid neurological deterioration in patients. Additionally, as VEGF promotes the formation of an immunosuppressive tumor microenvironment, anti-angiogenic therapy is expected to contribute to improving the immune status in the tumor microenvironment. In this review, we discuss the role of VEGF-targeted therapy and immunotherapy targeting immune checkpoint inhibitors and macrophages in high-grade gliomas. The authors also discuss the possibility of using these as combination therapies.Chemotherapeutic treatment of malignant gliomas is extremely challenging. Tumor accumulation of systemically-administrated chemotherapy is always hindered by the blood-brain barrier(BBB). Although temozolomide administered orally or intravenously represents the standard of care for malignant gliomas, its efficacy is unsatisfactory. Local chemotherapy bypasses the BBB and, therefore, achieves a high drug concentration at the site the drug is administered. Carmustine wafers are clinically available local chemotherapeutic agents. However, their efficacy is limited because of limited drug penetration into the tumor. Combined with the highly chemoresistant features of glioma itself, ongoing chemotherapy is far from satisfactory in terms of efficacy. This review covers several important issues regarding temozolomide chemotherapy, including the reactivation of hepatitis B virus, assessment of MGMT promoter methylation, and pseudo-progression. Local chemotherapy for newly diagnosed resectable glioblastoma cases using carmustine wafers is currently under investigation with a randomized phase 3 trial (JCOG 1703), which will also be discussed. In addition, recent progress in convection-enhanced delivery of chemotherapeutics against gliomas has also been reported. Development of an alternative strategy to effectively deliver drugs to the tumor site may improve the efficacy of chemotherapy against gliomas in the near future.Gliomas are infiltrative tumors that are difficult to cure by surgery alone. Postoperative radiotherapy or chemoradiotherapy is the treatment option for patients with high-grade gliomas. However, most pathological types of glioma other than glioblastoma do not have enough evidence, especially concerning the dose-fractionation scheme and clinical target volume definition for radiotherapy. This study presents standard methods of radiotherapy for each pathological type of glioma and recent radiotherapy technologies including their significance and treatment results.The recent progress of neuroendoscopy and exoscopy has yielded new strategies in neurosurgery, especially in glioma surgery. Neuroendoscopic port surgery makes it possible to remove deep-seated gliomas with minimal invasiveness. In port surgery, it is important to control tumor bleeding during intratumoral removal. As exoscopic systems have high flexibility of the video camera position, the surgical approach can be selected with various visual axes, which is difficult when using microscopic systems. Considering the characteristics of exoscopes, exoscopic surgery can be applied for the removal of superficial gliomas, and exoscopes are useful for glioma resection under awake craniotomy. However, there are outstanding tasks to improve surgical devices for neuroendoscopic surgery. The video quality and deep lighting of exoscopes are insufficient for general usage. Moreover, there are few training courses available for these surgical techniques. In the near future, based on these developments, neuroendoscopic and exoscopic surgeries may become more common treatments.The sophisticated functional networks of the human brain are integral to life, controlling domains such as language understanding and production and social cognition, which are important for inter-personal communication. Glioma, a primary brain tumor, infiltrates into the brain tissue, forcing the normal brain to reorganize the neural networks(brain plasticity)to resist the invasion. Awake craniotomy for gliomas enables reliable intraoperative identification and preservation of not only the innate normal brain functional areas but also the brain functional networks that have adapted and changed in response to the tumor-invasive environment. Recent advances in neurosurgical techniques and anesthetics have enabled the performance of intraoperative mapping of various brain functions, while maintaining the patient at a high level of awake condition. Attempts have also been made to preserve not only the language functions in the left cerebral hemisphere but also the higher brain functions represented by the right frontal lobe.