Malignant gliomas (MG) include glioblastomas (GBM) and anaplastic astrocytomas (AA), anaplastic oligoastrocytomas (AOA), and anaplastic oligodendrogliomas (AO). AOA) and anaplastic oligodendrogliomas (AO). The annual incidence rate of GBM is 3.19/100,000 people. Statistics from the Central Brain Tumor Registry of the United States (CBTRUS) for the period 2004-2007 indicate that GBM accounts for 53.7% of all gliomas and AA accounts for 6.7%. Despite maximum surgical resection and postoperative radiotherapy, the clinical prognosis of MG is not promising, with a median survival of 3.3 months for GBM (11.3-14.6 months) and a 5-year relative survival rate of 4.75% for GBM, 27.36% for AA, and 49.40% for AO. 49.40%. Therefore, the treatment of MG, especially how to control the recurrence of MG and improve the quality of life of patients, is still a long way to go. As far as the clinical treatment of MG is concerned, surgical resection is still the first choice. It is recommended to use microscopic neurosurgery technique to make an anatomical resection along the white matter fiber bundle of the tumor edge with the cerebral sulcus as the boundary, so as to obtain the maximum tumor resection with the minimum tissue and neurological function damage. For primary MG, surgical resection can significantly improve survival and prognosis compared to biopsy only. The advantage of surgical resection is not only to clarify the pathology and effectively guide the subsequent radiotherapy, but also to remove the intracranial tumor, reduce the intracranial pressure, and prevent the increase of intracranial pressure caused by the tumor growth or the edema of brain tissue caused by radiotherapy. In the case of recurrent MG, secondary surgery with subtotal tumor removal prolongs patient survival, and nearly half of these patients have increased postoperative Karnofsky performance status (KPS) compared to preoperative. However, some studies have shown that patients who underwent secondary surgery only had significantly lower survival rates compared to those who received concurrent radiotherapy/chemotherapy after secondary surgery, and suggested that secondary surgery must be combined with a combination of radiotherapy and chemotherapy to improve patient prognosis. In this regard, we believe that secondary surgery should be actively considered for recurrent single lesion MG that does not involve important structures such as the brainstem and thalamus, but for single lesion MG with multiple lesions or involvement of important structures, the patient should undergo moderate surgical treatment followed by other treatments. The assessment of prognosis of patients undergoing secondary surgery has been mostly based on KPS score, extent of tumor resection, time interval between surgeries and patient’s age, which are more complicated and less relevant. For recurrent GBM, tumor involvement in the speech and motor areas or the peripheral areas of the middle cerebral artery M1 and M2; tumor volume ≥ 50 cm3; and KPS ≤ 80 all suggest a shortened survival after secondary surgery. One point was scored for each of the above three indexes, and patients were divided into three groups: good (0 points), moderate (1-2 points), and poor (3 points), corresponding to a median postoperative survival of 10.8, 4.5, and 1.0 months, respectively. With the widespread use of new technologies such as intraoperative navigation, functional MRI, and intraoperative MRI, how to achieve as much tumor removal as possible while preserving the patient’s neurological function during surgery has become the current clinical goal of MG surgery. Conventional navigation suffers from intraoperative brain displacement caused by release of cerebrospinal fluid, dehydration, hyperventilation and other factors, making it difficult to achieve precise positioning in real time. The use of intraoperative MRI can achieve real-time intraoperative localization, which plays an important role in guiding the operator to locate residual tumors and functional structures. The use of intraoperative MRI can improve the surgical resection rate, quality of life, and survival of GBM compared with traditional surgical approaches. The combination of functional MRI with intraoperative MRI navigation will further improve the accuracy of surgery and facilitate the preservation of important functional structures such as speech areas, motor-sensory areas, and conduction tracts, etc. Sun et al. reported the integration of diffusion tensor imaging into the operating microscope for navigation and intraoperative MRI to remove gliomas involving the optic radiation, with a mean tumor residual rate of 5.3% (36 cases) and a mean tumor residual rate of 5.3% (36 cases) between the first intraoperative MRI and the last intraoperative MRI. The average tumor residual rate was 5.3% (36 cases), and the percentage of tumors resected with the first intraoperative MRI and the last intraoperative MRI was 88.3% and 95.7%, respectively, which significantly improved the extent of tumor resection. In addition, intraoperative fluorescence-guided resection (FGR) is also a current direction of interest. Fluorescence-guided resection using 5-aminolevulinic acid (5-ALA) can increase the rate of total tumor resection from 36% to 65%, and the rate of progression-free survival at 6 months after surgery from 21.1% to 41%. It is believed that with the promotion of these new technologies, the surgical treatment results of MG, especially the postoperative KPS scores of patients, will be further improved. Radiotherapy The therapeutic effect of whole brain radiotherapy for MG has been widely recognized. However, since the central nervous system cannot repair the damage caused by radiotherapy to some extent, radiotherapy for recurrent MG is still controversial. However, it is now mostly believed that secondary radiotherapy can be administered after an interval of at least 6 months. In recent years, the development of stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) has also led to a significant decrease in radiotherapy complications. After SRS in patients with recurrent MG, the overall survival time of GBM patients was 23 months and the progression-free period was 4.6 months, with a significant improvement in prognosis, but the overall survival time of patients with WHO grade III tumors was 37.5 months and the progression-free period was 8.6 months, with no significant improvement in prognosis. It is worth noting that SRS is mostly used for small residual or recurrent tumors, and if the tumor is too large, the increase in irradiation volume will certainly lead to excessive exposure of normal tissues to high doses of radiation, thus increasing the chance of radiotherapy complications. The median survival of patients treated with FSRT for recurrent GBM is 9 months, with a 1-year progression-free survival rate of 22% and an overall survival time of 27 months. In addition to the common external irradiation, intra-tumor brachytherapy radiotherapy is also gaining attention from clinicians. Internal irradiation with the isotope iodine-125 placed within the recurrent GBM tumor bed can result in actual patient survival of about 47 weeks, which can significantly prolong patient survival even for patients who cannot undergo tumor resection. Chemotherapy Temozolomide (TMZ) remains the first-line chemotherapeutic agent for MG, and the standard dosing regimen is simultaneous chemotherapy with radiotherapy and oral TMZ 75mg/m2 . Four weeks after the completion of radiotherapy, adjuvant TMZ treatment will be continued at 150mg/m2 for 5 days, 28 days as a course of treatment, and if well tolerated, the dose will be increased to 200mg/m2 in subsequent courses of chemotherapy, and 6 courses of adjuvant TMZ chemotherapy are recommended. Compared with radiotherapy alone, radiotherapy combined with TMZ treatment increased the two-year survival rate from 11.2% to 27.3% and the five-year survival rate from 1.9% to 9.8% in patients with MG. For recurrent gliomas, the response rate to standard chemotherapy regimens is currently proven to be only 30%. Due to the increasing importance of the DNA repair enzyme O6-methylguanine methyltransferase (MGMT) in TMZ chemoresistance, many new dosing regimens have emerged to induce MGMT deficiency in tumors by prolonging the duration of dosing. Wick et al. proposed a new alternate weekly dosing regimen of 150 mg/m2/day administered every four weeks on days 1-7 and 15-21, which showed a 6-month progression-free survival (PFS) of 43.8% of GBM patients and a 1-year survival rate of 23% without severe lymphopenia or opportunistic bacterial infections. In addition, there are other regimens such as 21 days of dosing within a 28-day cycle at 75-100 mg/m2 per day or 50 mg/m2 per day continuous dosing, the efficacy of which remains to be further clinically validated. In case of TMZ treatment failure, other kinds of chemotherapeutic drugs can also be considered as remedial treatment, such as the nitrosoureas lomustine, nimostine, teniposide, vincristine and cisplatin, etc. The use of these drugs can prolong the survival of patients to some extent. In addition to systemic drugs, local use of chemotherapeutic drugs in tumor lesions is also worthy of attention. Compared with systemic drugs, local administration can bypass the blood-brain barrier and can avoid the side effects caused by systemic drugs. Studies have shown that for primary GBM, topical carmustine implanted with the membrane agent Gliadel Wafer prolongs survival without detecting serious drug side effects, but there is no valid evidence of prolonged progression-free survival and improved quality of life. In recurrent GBM, carmustine implantation did not significantly prolong survival. No clinical reports of its use in China have been seen. For chemotherapeutic drugs, a barrier that remains insurmountable is chemoresistance, in particular multidrug resistance (MDR), which deserves further attention. Clinically speaking, MDR can be divided into primary resistance (present at the beginning of treatment) and secondary resistance (present after treatment), where secondary resistance may be related to genetic mutations and the screening effect of drugs. With the development of molecular pathology, various genes such as MGMT, apoptosis-related proteins, and transporter proteins have been identified to be clearly related to secondary drug resistance in glioma. mGMT, a DNA repair enzyme, achieves tolerance to alkylating agents by removing alkyl groups from the guanine O6 site. upregulation of MGMT expression can significantly enhance the tolerance of tumor cells to alkylating agents such as TMZ and BCNU. The use of O6-benzylguanine (O6-BG), a selective inhibitor of MGMT, can significantly inhibit MGMT activity and enhance the effect of chemotherapeutic drugs. In contrast, MGMT promoter methylation in patients with malignant glioma suggests that patients are more sensitive to TMZ and BCNU chemotherapy and have a relatively improved prognosis. Bcl-2 and epidermal growth factor receptor (EGFR), as apoptosis-associated proteins, can inhibit the apoptotic process in vivo, leading to cellular drug resistance. P-glycoprotein (P-gp) and multidrug resistance-associated protein (MRP) are both transporter proteins, which can achieve drug resistance through substrate transport. These genes are up-regulated in MG, and their elevated expression also indicates chemoresistance and poor prognosis. In addition to the above therapeutic approaches, research on tumor angiogenesis, tumor stem cells, viral transfection, immunotherapy and other modalities is ongoing, and some of them have entered the clinical research stage. Vascular endothelial growth factor (VEGF) can promote angiogenesis and plays an important role in the sustained growth of malignant tumors. Bevacizumab, a monoclonal antibody to VEGF, can inhibit the activity of VEGF. Studies have confirmed that bevacizumab alone or in combination with irinotecan for the treatment of recurrent glioma has a treatment efficiency of 20-60% and a progression-free survival of up to 25-50% of patients at 6 months. In addition, photodynamic therapy (PDT) has also been tried for the adjuvant treatment of glioma. The principle is that tumor cells selectively absorb the photosensitizer and then irradiation with light of appropriate wavelengths activates the photosensitizer, resulting in tumor cell death. Photodynamic therapy using 5-ALA-induced protoporphyrin IX as a photosensitizer for recurrence-limited MG has a median survival of up to 15 months. A single-center randomized controlled clinical study also confirmed that fluorescent navigation supplemented with postoperative photodynamic therapy extended the mean survival of GBM patients from 24.6 weeks to 52.8 weeks. The use of these new drugs and technologies opens up new directions in the treatment of MG, but remains to be tested in large-scale clinical use. In conclusion, for the treatment of MG, surgical total excision of the tumor as far as possible, supplemented by radiotherapy plus concurrent and subsequent TMZ chemotherapy is still recommended. Other kinds of treatment modalities can still be considered after treatment failure. For different patients, individualized treatment plans should be specified according to their tumor site, size, molecular pathology and other various factors to achieve the best tumor control outcome. For the determination of MG prognosis, the proven prognostic factors are 1p/19q co-deletion, MGMT promoter methylation and IDH-1/2 mutation, and the presence of these prognostic factors all suggest that the tumor is sensitive to radiotherapy response and the patient has a prolonged progression-free survival.