Treatment Sequencing and Regimen Selection in PLGG

In this segment, Dr. Chintagumpala and Dr. Abdelbaki discuss how to sequence therapies and select regimens across the chronic course of pediatric low-grade glioma (PLGG).

Clinicians now carry "several cards in your pocket," but each decision must weigh excellent long-term survival against the cumulative morbidity of successive treatments. Key triggers for initiating or restarting therapy include a decline of 0.2 logMAR or more in visual acuity from baseline (with repeat examination in young children to confirm), radiographic progression of 25%–30% from the post-treatment baseline over time, worsening hypothalamic-endocrine function, or new or progressive neurologic deficits such as motor weakness from a thalamic lesion.

Families increasingly request MEK inhibitors over chemotherapy after reading about them on social media, drawn by oral administration and fewer clinic visits. The standard remains carboplatin and vincristine, though the field is actively comparing MEK inhibitors to chemotherapy. Practical factors such as distance from the treatment center, access to a port, and the child's ability to swallow pills heavily influence the choice among intravenous chemotherapy, daily or twice-daily oral agents such as selumetinib, once-weekly options such as trametinib or tovorafenib, and vinblastine. The initial regimen choice shapes subsequent options, making strategic first-line selection essential.

In the next episode, "Institutional Perspectives on Treatment Thresholds in PLGG," the panel explores whether specific radiographic or clinical cutoffs should trigger therapy initiation.