Historical Trends in the Management of Craniopharyngioma: Results from the Multicenter Rapid Registry

Background: The modern surgical management of craniopharyngioma remains unclear with significant institutional heterogeneity and evidence from small single-center studies. Over the last 20 years, there has been considerable advancement in endoscopic endonasal surgical technique, radiation technology, and our understanding of molecular biology of craniopharyngioma opening horizons to medial therapeutic options, such as BRAF inhibitors. We aimed to evaluate trends in surgical outcomes and management via a multicenter study. Objective: We performed a study of the 2000-2024 Registry of Adenomas of the Pituitary and Related Disorders (RAPID) consortium data on craniopharyngiomas across 14 academic high-volume institutions. Methods: Trends in extent of resection, surgical approach, stalk management, use of radiation treatment, reconstruction techniques and complications were evaluated as continuous variables using a bivariate Spearman’s rank correlation for time. Results: A total of 469 patients (mean age 46 years) were evaluated. From 2000 to 2024, 78% of craniopharyngioma resections were performed using a transsphenoidal approach, 22% were done using a transcranial approach, 62.5% involved stalk preservation, 48% gross total resection (GTR), 41% subtotal resection (STR), and 11% STR + adjuvant radiation treatment (RT). There were no significant trends over time in extent of resection, use of transsphenoidal approach, or stalk preservation (p>0.05). There was a significant increase in the use of the nasoseptal flap (p=0.0001) and radiation treatment encompassing both adjuvant and salvage RT (p=0.01). The average tumor recurrence rate, which included all groups, showed a significant decrease over time (p=0.01). Overall recurrence rates, from 2000 to 2024, were 25% in STR, 12% in GTR, and 6% in STR + Adjuvant RT. More specifically, when analyzing trends in recurrence over time, there was a significant decrease in recurrence rate in GTR (p = 0.002, n = 201) and STR (p = 0.05, n = 173); however, the decrease in STR + Adjuvant RT recurrence rate (p > 0.05, n = 47) did not reach significance indicating that the recurrence rate in this group was relatively stable over the 24 year period. Mean follow up time was 2.7 years for GTR alone, 3.0 years for STR alone, and 2.9 years for STR + Adjuvant RT. Furthermore, a multivariable, time-to-event adjusted model controlling for surgery date and extent of resection demonstrated that radiation treatment had the largest impact on the decreased tumor recurrence rate. In addition to the decrease in recurrence rate over time, significant decreases in AVP-deficiency (p=0.002) and adrenal insufficiency (p=0.03) were also seen. Conclusion: From 2000 to 2024, the increase in usage of RT contributed significantly to the decreased tumor recurrence rate in craniopharyngioma patients who received adjuvant RT after STR. Trends of decreased recurrence rates in GTR and STR alone, decreased permanent AVP-deficiency, and decreased adrenal insufficiency likely reflect improvements in surgical techniques over time. These results demonstrate the national changes in craniopharyngioma management. Notably, the current standards of surgical and radiation management may soon be redefined with the emergence of targeted therapies such as BRAF inhibitors, which could transform the current treatment paradigm. Publication History Article published online: 27 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany