兒童中樞神經(jīng)系統(tǒng)腫瘤2023.v1-NCCN（英文版）

NCCNClinicalPracticeGuidelinesinOncologyNCCNGuidelines?)PediatricCentralNervousSystemCancersersionJulyVersion1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.RalphErmoian,MD§ClevelandClinicTaussigCancerInstitute?MedicaloncologyPrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022RalphErmoian,MD§ClevelandClinicTaussigCancerInstitute?MedicaloncologyusSystemCancersdexjarMDChairjarMDChairdeChildrensResearchHospitalTherAnitaMahajan,MD/Vice-Chair§MayoClinicCancerCenterMDYnCancerCenteratBarnestalandWashingtonoolofMedicineClarkeAnderson,MD€YCityofHopeNationalMedicalCenterReubenAntony,MD,MBBCh,MRCPYUCDavisComprehensiveCancerCenterTejusBale,MD,PhD≠MemorialSloanKetteringCancerCenterjitBindraMDPhDAndreaFranson,MD,MS€YUniversityofMichiganRogelCancerCenterreyHelgagerMDPhDyofWisconsinCarboneCancerCenterLandiMDstituteChiLinMDPhDyofWisconsinCarboneCancerCenterLandiMDstituteChiLinMDPhD§PhillipStorm,MD?AbramsonCancerCenterheUniversityofPennsylvaniafettfettCancerCenterLauraMetrock,MDYO'NealComprehensiveCancerCenteratUABaNandaMDUCLAJonssonComprehensiveCancerCenterKatherineWarren,MD€nterJoshuaPalmer,MD§TheOhioStateUniversityComprehensiveCancerCenternterJoshuaPalmer,MD§TheOhioStateUniversityComprehensiveCancerCenter-JamesCancerHospitalandSoloveResearchInstituteiaPartapMDordCancerInstitutehippleMDMPHrInstituteattheUniversityofUtahnterSmilownterSmilowCancerHospitalwersMDnshensiveCancerCenterYSidneyKimmelComprehensiveCancerCenteratJohnsHopkinsTheUniversityofTexasAshleyPlant,MD€YieComprehensiveCancerfNorthwesternUniversitySunitPruthi,MDфngramCancerCenternMSngramCancerCentersMDsMDoNeurosurgeryFredHutchinsonoNeurosurgerySeattleCancerCareAlliancelRuggieriMDUniversityoflRuggieriMDUniversityofColoradoCancerCenteriicniversityIsogyFredHutchinsonCancerResearchCenter/YNeurology/Neuro-oncologySeattleCancerCareAlliance≠Pathology￥PatientadvocacyContinue€Pediatriconcology§Radiotherapy/Radiationoncology?Surgery/Surgicaloncology*DiscussionSectionWritingCommitteeesPanelDisclosuresVersion1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.rsiatricDiffuseHighGradeGliomasINTRORadiologicPresentation(PGLIO-1)AdjuvantTreatmentandFollow-up(PGLIO-2andPGLIO-3)eatmentforRecurrencersiatricDiffuseHighGradeGliomasINTRORadiologicPresentation(PGLIO-1)AdjuvantTreatmentandFollow-up(PGLIO-2andPGLIO-3)eatmentforRecurrencePGLIO?BrainandSpineTumorImaging(PEDCNS-A)?BrainTumorPathology(PEDCNS-B)?Surgery(PEDCNS-C)?RadiationTherapyManagement(PEDCNS-D)?SystemicTherapy(PEDCNS-E)Abbreviations(ABBR-1)usSystemCancersdexlievesthatthebestmanagementforanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.FindanNCCNMemberInstitution:/home/member-institutions.ofEvidenceanddationsotherwisedNCategoriesofEvidenceandConsensus.NCCNCategoriesofPreference:Allrecommendationsareconsideredappropriate.SeeNCCNCategoriesofPreference.TheNCCNGuidelinesareastatementofevidenceandconsensusoftheauthorsregardingtheirviewsofcurrentlyacceptedapproachestotreatmentAnyclinicianseekingtoapplyorconsulttheNCCNGuidelinesisexpectedtouseindependentmedicaljudgmentinthecontextofindividualstancestodetermineanypatientscareortreatmentTheNationalComprehensiveCancerNetworkNCCNmakesnorepresentationsorwarrantiesofanykindregardingtheircontentuseorapplicationanddisclaimsanyresponsibilityfortheirapplicationoruseinanywayTheNCCNationalComprehensiveCancerNetworkAllrightsreservedTheNCCNGuidelinesandtheillustrationshereinmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.?2022.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.masdexINTRODUCTIONTOPEDIATRICDIFFUSEHIGH-GRADEGLIOMAS1-4tralnervoussystemCNStumorsaAllpatientswithpediatricdiffusehigh-gradegliomasshouldbecaredfortralnervoussystemCNStumorsaEpidemiologyofPediatricDiffuseHigh-GradeGliomas?14.8%ofallintracranialneoplasmsareamongchildrenandadolescents(<19years).?Theincidenceofpediatricdiffusehigh-gradegliomasamongchildrenandadolescentsisroughly1.8per100,000population.?Incidencevarieswithage.?5-yearoverallsurvivalis<20%.?Prognosticfeaturesincludeageatpresentation(<3and>13years),tumorlocation,sex,extentofresection,andgenomicprofile.?Inheritedpredispositionstocancerinclude,butarenotlimitedto:pNeurofibromatosistype1(NF1)pLi-FraumenisyndromepTurcotsyndrome/Lynchsyndrome/constitutionalmismatchrepairdeficiency(cMMRD):?MutationsinAPC/familialadenomatouspolyposis(FAP)locus(moreoftenassociatedwithmedulloblastoma)?Mutationsinmismatchrepair(MMR)genes?Exposuretoionizingradiation:Therapeuticcranialradiationtreatmentsincreaseriskforpediatricdiffusehigh-gradegliomas.Presentation?Themostcommonsymptomsincludeeffectsofincreasedintracranialpressure,suchasheadache,nausea,andvomiting.?Otherpresentingsymptomsincludeseizure,hemiparesis,monoparesis,cranialnervedeficits,ataxia,hemisensoryloss,dysphasia,aphasia,andmemoryimpairment.?Presentingsymptomsamonginfantsincludeincreasedheadcircumferenceandlossofdevelopmentalmilestones.?Shorterlengthofsymptomsisassociatedwithworseprognosisinolderstudies.Treatment?Treatmentforpediatricdiffusehigh-gradegliomasfrequentlyincludessurgery,radiationtherapy(RT),andchemotherapy.?Goalsofsurgeryincludethesafereductionoftumor-associatedmasseffectandobtainingadequatetissueforhistologicandmolecularclassification.?Referralforcancerpredispositionevaluationand/orgeneticcounselingshouldbeconsidered.aAmultidisciplinaryteamthatincludespediatriconcologistsneurooncologistspediatricradiationoncologistspathologistswithexpertiseinneuropathologyandmolecularpathologypediatricneuroradiologistsandpediatricneurosurgeonsisstronglyencouraged.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.INTROOF2PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.masdex1234INTRODUCTIONTOPEDIATRICDIFFUSEHIGH-GRADEGLIOMASREFERENCESUdakaYT,PackerRJ.Pediatricbraintumors.NeurolClin2018;36:533-556.ColemanC,StollerS,GrotzerM,StucklinAG.Pediatrichemispherichigh-gradeglioma:targetingthefuture.CancerMetastasisRev2020;39:245-260.OstromQT,PatilN,CioffiG,etal.CBTRUSStatisticalReport:PrimaryBrainandOtherCentralNervousSystemTumorsDiagnosedintheUnitedStatesin2013–2017,Neuro-Oncology2020;22(12Suppl2):iv1-iv96.JonesC,KarajannisMA,JonesDTW,etal.Pediatrichigh-gradeglioma:biologicallyandclinicallyinneedofnewthinking.NeuroOncol2017;19:153-161.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.INTRO2OF2pontineglioma(DIPG)dandnotissuePrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.pontineglioma(DIPG)dandnotissuemasdexRADIOLOGICPRESENTATIONaCLINICALIMPRESSIONbSURGERYcegliomasfegliomasfIOomNCCNdelinesrCentralvoustemncersdults BrainMRIa,eEXCEPTdiffusemablewithgoalof?Oligodendroglioma,IDH-mutant?Oligodendroglioma,IDH-mutantand1p/19q-codeleted,WHOgrade3?Astrocytoma,IDH-mutant,WHOgrade3orgrade4yinputfortmentradelresectionortissuediagnosisnddebulking BrainMRIa,eifsiblemassttsibleacticbiopsyacticbiopsyeredopsytiontwithdiffuseintrinsictwithdiffuseintrinsicavailableforhistologicconfirmationoraSeePrinciplesofBrainTumorImaging(PEDCNS-A).DecisionnottobiopsybSeePrinciplesofBrainTumorPathology(PEDCNS-B).cThegoalsofsurgeryaretoobtainapathologicdiagnosisandmoleculargeneticcharacterization,alleviatesymptomsrelatedtoincreasedintracranialpressureortumormasseffect,increasesurvival,anddecreasecorticosteroiddoserequirements.SeePrinciplesofSurgery(PEDCNS-C).dEncouragebiopsyifatypicalfeaturesonMRIarepresent,ifpatientis<3yearsofage,orifstandardofcareatinstitution.ePostoperativefollow-upisideallybetween24–48hours.fDiagnosesincludediffusehemisphericglioma,H3G34-mutant;pediatricdiffusehigh-gradeglioma,H3wild-typesandIDHwild-type;andinfant-typehemisphericglioma,inadditiontootherhigh-gradeglialentities.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.PGLIO-1Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.masdexPATHOLOGYbAGEADJUVANTTREATMENTFOLLOW-UPahhgrademidlineglioma,H3K27-alteredorpontinelocationarsarsClinicaltrial(preferred)rdrdbrainRTgmozolomideTMZantTMZ±lomustinerdrdbrainRTgthetumorhStandardthetumorh±concurrentTMZ+adjuvanttargetedtherapybasedonthemolecularcompositionofClinicaltrial(preferred)orneedforradiationneedforradiationhAdjuvanttargetedtherapyositionofthetumorositionofthetumorh?2–6weeksafterRT?thenevery2–3monthsfor1year?thenevery3–6monthsindefinitelyaSeePrinciplesofBrainTumorImaging(PEDCNS-A).bSeePrinciplesofBrainTumorPathology(PEDCNS-B).fDiagnosesincludediffusehemisphericglioma,H3G34-mutant;pediatricdiffusehigh-gradeglioma,H3wild-typesandIDHwild-type;andinfant-typehemisphericglioma,inadditiontootherhigh-gradeglialentities.gSeePrinciplesofRadiationTherapyManagement(PEDCNS-D).hPrinciplesofSystemicTherapy(PEDCNSSee-E).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PGLIO-2PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.masdexPATHOLOGYbLOCATIONADJUVANTTREATMENTFOLLOW-UPamaPediatricdiffusehigh-gradeglioma,H3wild-typeandilableiagnosisbyimagingfeaturestypicalilableiagnosisbyimagingfeaturestypicalforDIPGrdbrainRTgrdbrainRTgorrdbrainRTgrrentTMZantTMZmustinerialrdbrainRTg?2–6weeksafterRT?thenevery2–3monthsfor1year?thenevery3–6monthsindefinitelyaSeePrinciplesofBrainTumorImaging(PEDCNS-A).bSeePrinciplesofBrainTumorPathology(PEDCNS-B).gSeePrinciplesofRadiationTherapyManagement(PEDCNS-D).Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PGLIO-3drogliomaPrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.drogliomamasdexPATHOLOGYbRECURRENCETREATMENTRecurrentandprogressivediseasegliomasiEXCEPTfordiffusegliomasiEXCEPTIDH-mutantand1p/19qcodeletedorastrocytomaIDH-mutantResectableResectionj,kBrainorresectionnotrecommended/electedDiffuseormultipleClinicaltrial(preferred)orSurgeryrChemotherapyrand/orTargetedtherapybasedontheumorhmmolecularcompositionumorhmrrand/orPalliative/bestsupportivecareifpoorperformancestatussupportivecareSeeNCCNGuidelinesforPalliativeCarebSeePrinciplesofBrainTumorPathology(PEDCNS-B).gSeePrinciplesofRadiationTherapyManagement(PEDCNS-D).hPrinciplesofSystemicTherapy(PEDCNSSee-E).iDiagnosesincludediffusehemisphericglioma,H3G34-mutant;pediatricdiffusehigh-gradeglioma,H3wild-typesandIDHwild-type;andinfant-typehemisphericglioma;diffusemidlineglioma,H3K27-altered,inadditiontootherhigh-gradeglialentities.jSeePrinciplesofSurgeryPEDCNS-C.kConsiderenrollmentinphase0orpreoperativeclinicaltrialsbeforeresection.lRe-resectionatthetimeofrecurrencemayimproveoutcomes.Asinadultpatientswithdiffusehigh-gradeglioma,tumorinvolvementinspecificcriticalbrainareasandpoorKPSscoremaybeassociatedwithunfavorablere-resectionoutcomes.mForhightumormutationalburden(TMB)orpersonalorfamilyhistoryofcMMRD,considercheckpointblockade;RAFandMEKinhibitionfortumorswithBRAFV600Emutation,andTRKinhibitorsfortumorswithNTRKgenefusionarerecommended.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PGLIO-4PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.usSystemCancersdexDSPINETUMORIMAGINGaConventionalMRIisrecommendedfortumordiagnosissurgicalguidanceandtherapeuticmonitoring.ItmaybecomplementedbyuessuchasMRperfusionimagingMRspectroscopyandPETtoenhancediagnosticcapabilitydifferentiateationnecrosisfromactiveneoplasmandguidebiopsyImagingisalwaysrecommendedtoinvestigatetheetiologyofemergentsignsandsymptoms.Belowisalistofimagingmodalitiesavailableandusedinneuro-oncologytomaketreatmentdecisions.MRI1-4oftheBrainand/orSpine(entireneuralaxis)(withandwithoutIVcontrast)?Benefits:excellentsofttissuecontrastanddepictionofneoplasmsthroughacombinationofstandard,universallyavailablepulsesequences;typicallyinfiltrativegrowthpattern;highergradecomponentscommonlyenhanceanddemonstraterestricteddiffusion;noionizingradiation?Limitations:relativelylongexaminations;sensitivetopatientmotionsoyoungerchildrengenerallyrequiredeepsedation/anesthesia;metalfromsurgeryandimplantscauseartifact;someimplantsareunsafeinMRIenvironment?BasicMRIsequencesofthebrainshouldincludeT1-weightedimagesbeforecontrast,T1-weightedimagesintwoplanesaftercontrast(oneofwhichwouldideallybeacquiredasa3Dsequence),T2-weighted,T2-FLAIR,anddiffusion-weightedimaging(DWI)andgradientechoorsusceptibility-weighted(blood-sensitive)imaging.pTheseshouldbeutilizedforpreliminarydiagnosticevaluationandimmediatepostoperativefollow-up(ideallywithin24–48hourspost-op,ifclinicallyfeasible)toevaluatediseaseburden(measurableandnon-measurabledisease)oninitialexamandextentofresectiononimmediatepostoperativescan.p2Dacquisitionsshouldbe≤4-mmslices;3Dacquisitionsshouldbenearlyisotropic.pPost-contrast3Dsequencecanbeobtainedaseither3DT1-weightedgradientechoorturbospinecho(TSE)acquisitionsforplanarreconstructionsand/orvolumetricanalysisoftumors.?GroupIIgadolinium-basedcontrastagents(GBCAs)arerecommendedforusegiventhepotentialofhighergadoliniumretentionwithlinearGBCAs.?BasicMRIimagingofthespineshouldincludepost-contrastsagittalandaxialT1-weightedimagesoftheentireneuralaxis.AdditionalsequencessuchasheavilyT2-weightedimagesand/orDWImaybehelpful.pTheseshouldbeutilizedtoevaluateforleptomeningealspreadofneoplasm.pSagittalslicesshouldbe3mmandaxialslicesmaybe3-to4-mmslices.pPreoperativespineimagingshouldbeperformedatthetimeofbrainimagingsincemanychildrenrequiresedationtotoleratetheexam.pPostoperativespineMRIsshouldbedelayedtooccuratleast10daysaftersurgeryifevaluatingforleptomeningealspreadofneoplasmtoavoidconfusionwithbloodbyproducts.?Follow-upstudiesofthebrainandspineshouldbeperformedatintervalsdefinedbythetreatmentalgorithms.Morefrequentimagingmaybenecessaryifindicatedbythetreatingphysicianintheeventofclinicaldeteriorationorevolvingimagingfindingsconcerningforrecurrentorresidualdisease.pLongitudinalfollow-upstudiesmaybecomplementedbyMRperfusionorMRspectroscopytoassessresponsetotherapyortoevaluateforprogression,pseudoprogression,orradiationnecrosisifthosetechniquesareavailable.aSomeimagingmodalitiesortechniquesmaynotbeavailableatallinstitutions.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementofanypatientwithcancerisinaclinicaltrial.Participationinclinicaltrialsisespeciallyencouraged.Version1.2023,07/12/22?2022NationalComprehensiveCancerNetwork(NCCN),Allrightsreserved.NCCNGuidelinesandthisillustrationmaynotbereproducedinanyformwithouttheexpresswrittenpermissionofNCCN.PEDCNS-AOF3PrintedbyMinTangon7/14/20229:31:46AM.Forpersonaluseonly.Notapprovedfordistribution.Copyright?2022NationalComprehensiveCancerNetwork,Inc.,AllRightsReserved.usSystemCancersdexDSPINETUMORIMAGINGaCToftheBrain(withcontrastorwithandwithoutcontrast):?Canbeusedforrapidassessmentintheacutesettingandfortheevaluationofacuteintracranialhemorrhage,ventriculomegaly,andshunt-relatedissues.?ShouldbeusedinthosepatientsinwhomanMRIiscontraindicatedbecauseofunsafeimplantsorforeignbodies.?Benefits:shorteracquisition;generallynosedationisneeded;idealinacuteorimmediatepostoperativesetting;sensitivetoacutebloodandcalcium?Limitations:ionizingradiation;limitedsofttissuecontrast;metalcausesartifactMRPerfusion5-7:Measurescerebralbloodvolumeand/orcerebralbloodflowinneoplasms;choiceofvarioustechniques(dynamicsusceptibilitycontrast-enhanced[DSC]vs.dynamiccontrast-enhanced[DCE]vs.arterialspinlabeling[ASL]perfusion)willdependuponuseravailabilityandpreference?Maybehelpfulforgradingneoplasms,assessingresponsetotherapy,identifyingmalignantdegenerationandpseudoprogression,distinguishingradiationnecrosisfromrecurrentneoplasm,andchoosingbiopsysite?Limitations:reliabilitydegradedbyadjacentmetal,bloodbyproducts,air,andbone/softtissueinterface;othergenerallimitationsofMRIareaslistedabovepv7,8:Assessmetabolitesofneoplasms(choiceofsinglevoxelvs.multivoxelspectroscopywilldependonuserpreference?Maybehelpfulforgradingneoplasms,assessingresponsetotherapy,identifyingmalignantdegenerationandpseudoprogression,distinguishingradiationnecrosisfromrecurrentneoplasm,andchoosingbiopsysite?Limitations:complexacquisition;longacquisitions;nonstandardacquisitionandpost-processing;reliabilitydegradedbyadjacentmetal,bloodbyproducts,andbone/softtissue/airinterfacesBrainPETStudies:Assessbraintissuemetabolismwithradiopharmaceutical?Maybeusefulindifferentiatingbetweenneoplasmandradiationnecrosis,tumorgrading,oridentifyingmoreaggressivefocusforbiopsy?Limitations:spatialresolution;availabilityofradioisotopes;additionalradiationexposureSupplementalImagingforPreoperativePlanning:?IsotropicvolumetricMRItoaccuratelylocalizetheneoplasmsbycoregisteringthedatawithintraoperativeguidancesoftware;oftencomplementedwithisotropicCTstudiestoimprovelocalization?FunctionalMRIstudiescanbeusedtodepictspatialrelationshipsbetweeneloquentcortex(eg,regionsofthebrainprimarilyresponsibleforspeech,vision,andmotorandsensoryfunction)andtheneoplasmstoserveasaroadmapandpromotesaferesections?Diffusiontensorimaging(DTI)mayalsobeusedtolocalizemajorwhitemattertractsunderlyingtheeloquentcortexthatcouldalsocompromisevitalfunctionsifinjuredduringsurgeryaSomeimagingmodalitiesortechniquesmaynotbeavailableatallinstitutions.Note:Allrecommendationsarecategory2Aunlessotherwiseindicated.ClinicalTrials:NCCNbelievesthatthebestmanagementof