Pediatric craniopharyngioma is a rare sellar-region epithelial tumor that, in 
spite of its typically benign pathology, has the potential to be clinically 
devastating, and presents a host of formidable management challenges for the 
skull base surgeon. Strategies in craniopharyngioma care have been the cause of 
considerable controversy, with respect to both philosophical and technical 
issues. Key questions remain unresolved, and include optimizing 
extent-of-resection goals; the ideal radiation modality and its role as an 
alternative, adjuvant, or salvage treatment; appropriate indications for 
expanded endoscopic endonasal surgery as an alternative to transcranial 
microsurgery; risks and benefits of skull base techniques in a pediatric 
population; benefits of and indications for intracavitary therapies; and the 
preferred management of common treatment complications. Correspondingly, we 
sought to review the preceding basic science and clinical outcomes literature on 
pediatric craniopharyngioma, so as to synthesize overarching recommendations, 
highlight major points of evidence and their conflicts, and assemble a general 
algorithm for skull base surgeons to use in tailoring treatment plans to the 
individual patient, tumor, and clinical course. In general terms, we concluded 
that safe, maximal, hypothalamic-sparing resection provides very good tumor 
control while minimizing severe deficits. Endoscopic endonasal, 
intraventricular, and transcranial skull base technique all have clear roles in 
the armamentarium, alongside standard craniotomies; these roles frequently 
overlap, and may be further optimized by using the approaches in adaptive 
combinations. Where aggressive subtotal resection is achieved, patients should 
be closely followed, with radiation initiated at the time of progression or 
recurrence-ideally via proton beam therapy, although three-dimensional conformal 
radiotherapy, intensity-modulated radiotherapy, and stereotactic radiosurgery 
are very appropriate in a range of circumstances, governed by access, patient 
age, disease architecture, and character of the recurrence. Perhaps most 
importantly, outcomes appear to be optimized by consolidated, multidisciplinary 
care. As such, we recommend treatment in highly experienced centers wherever 
possible, and emphasize the importance of longitudinal follow-up-particularly 
given the high incidence of recurrences and complications in a benign disease 
that effects a young patient population at risk of severe morbidity from 
hypothalamic or pituitary injury in childhood.