How late is soon enough?

Optic pathway gliomas really test the limits of risk / benefit therapeutic decision-making. On the one hand, these tumors rarely threaten lives, while local treatments threaten vision and/or cognitive development. On the other hand, vision will eventually be compromised if left untreated. Here is a retrospective look at visual outcomes of 38 children treated for sporadic (read: without neurofibromatosis) optic pathway glioma at Texas Children’s Hospital. Eleven patients (29%) received proton radiation as either first- (n=6) or second‐line (n=5) therapy with the rest receiving at least two lines of chemotherapy. Three received radiation at ages 6, 7, and 8 years old with the remaining at 10 years or older. Chemo, on the other hand, was initiated at a median age of only 3.5 years. The primary endpoint of blindness-free survival was 100% versus 60% at 8 years with versus without radiation as first- or second-line therapy. The point here isn’t that radiation is always the best option—the side effect profile per age obviously has to be considered—but rather that radiation offers excellent vision preservation and should therefore at least be considered for older children with declining vision. | Hanania, Cancer 2021