Role of Radiation Therapy and Radiosurgery in the Management of Craniopharyngiomas John H. Suh, MD a, * , Nalin Gupta, MD, PhD b a Brain Tumor Institute, Department of Radiation Oncology, T28, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA b Division of Pediatric Neurosurgery, Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA Craniopharyngiomas are histologically benign neuroepithelial tumors that arise from the hypo- physeal duct or Rathke’s pouch. They comprise 5% to 10% of pediatric brain tumors and 1% to 4% of adult brain tumors and have a bimodal distribution with peak rates at childhood (5–14 years) and older adulthood (50–74 years) [1]. Although these tumors are slow growing, well circumscribed, and encapsu- lated, the frequent involvement of such structures as the pituitary stalk, hypothalamus, adjacent vas- culature, and optic apparatus complicate their management. A large number of treatment modal- ities are used, including gross total resection (GTR), limited surgery followed by radiation ther- apy, fractionated radiation approaches, intracavi- tary irradiation, and stereotactic radiosurgery. This article reviews the goals and complications of surgery and the results with conventional and modern radiation approaches. Surgical goals The overall goals of surgery are diagnosis, decompression, and prevention of recurrence [2]. Hydrocephalus and endocrine abnormalities are associated with high perioperative morbidity and must be treated first. Hydrocephalus can be treated acutely with an external ventricular drain or more permanently with a ventriculoperitoneal shunt be- fore definitive surgery. Patients with craniophar- yngiomas who present with acute visual deterioration or symptoms of elevated intracranial pressure from tumor-associated mass effect also re- quire urgent surgical decompression. In general, for smaller tumors in which complete resection is pos- sible without injury to critical structures, a select group, surgery remains the treatment of choice. For most tumors, there are two main views regarding the overall treatment strategy. Some think that GTR offers the best chance for long- term survival by avoiding the additional morbidity of repeated surgical procedures and external beam radiotherapy. Others think that radical resection leads to unacceptable morbidity and recommend an approach focused on subtotal resection (STR) and adjunctive therapy. The two approaches have not been compared directly in a clinical trial. Based on a survey from the 1990s of American pediatric neurosurgeons, aggressive surgery with the objec- tive of GTR was the preferred treatment [3]. Although complete tumor resection is associa- ted with higher cure rates than STR, the increased procedure-related morbidity and mortality have raised the issue of whether GTR should be the sur- gical goal for all patients [4–10]. Complications of surgery The surgical resection of craniopharyngiomas is associated with significant risks to endocrine func- tion and vision. The most common postoperative complication is diabetes insipidus, which occurs in 59% to 93% of patients after surgery [6,9,11]. Fahl- busch and colleagues [6] noted that normal preop- erative anterior pituitary function was maintained in more than 50% of patients after surgery and that the incidence of hypogonadism increased * Corresponding author. E-mail address: suhj@ccf.org (J.H. Suh). 1042-3680/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nec.2006.02.001 neurosurgery.theclinics.com Neurosurg Clin N Am 17 (2006) 143–148