The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer.

BACKGROUND: Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT. METHODS: This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy. DISCUSSION: Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy. TRIAL REGISTRATION: The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Squamous cell carcinoma of the oral tongue: histopathological parameters associated with outcome.

The purpose of this study was to investigate the applicability of the histological risk assessment model proposed by Brandwein-Gensler et al. in a cohort of oral tongue squamous cell carcinoma (OTSCC) patients treated with definitive surgery. We also examined the impact of additional histopathological features on disease acceleration. The cases of 49 OTSCC patients attending our institution between 1995 and 2009, who underwent definitive surgical resection followed by adjunct chemoradiotherapy when indicated, were reviewed retrospectively. Surgical resection specimens and complete clinical and demographic data were available for these patients; follow-up was at least 6 months. In this cohort we only identified a correlation between gender and the histopathological risk model score (P<0.001). With regard to clinical and demographic data, histopathological parameters, and disease status at last follow-up, we identified significant correlations between disease status and (1) grade of differentiation (P=0.0086), and (2) keratin score (P=0.026). We found no significant correlations between the histopathological risk assessment model and disease progression or outcomes, with the exception of gender (P<0.0001). Grade of differentiation, keratin score, and the lymphocytic host response significantly impacted disease acceleration. For OTSCC, it appears that clinical characteristics of the tumour as well as histopathological markers play an important role in the outcome. Efforts towards identifying predictive markers should be continued, especially by sub-site of the oral cavity.

Repair of tracheal defect with Goretex graft during resection of carcinoma of the esophagus.

Repair options for tracheal defects secondary to tumor or trauma have been unsatisfactory for emergent cases. We report a case in which the tracheobronchial tree was entered during resection of carcinoma of the esophagus and emergently repaired with a Goretex graft. The patient did well for 22 months after esophagectomy, at which time the graft was found to be infected and was removed. The patient continues to remain free of tumor 4 years after initial resection.