Brazil-TNT: A Randomized Phase 2 Trial of Neoadjuvant Chemoradiation Followed by FOLFIRINOX Versus Chemoradiation for Stage II/III Rectal Cancer.

BACKGROUND: Neoadjuvant radiation and oxaliplatin-based systemic therapy (total neoadjuvant therapy-TNT) have been shown to increase response and organ-preservation rates in localized rectal cancer. However, trials have been heterogeneous regarding treatment protocols and few have used a watch-and-wait (WW) approach for complete responders. This trial evaluates if conventional long-term chemoradiation followed by consolidation of FOLFIRINOX increases complete response rates and the number of patients managed by WW. METHODS: This was a pragmatic randomized phase II trial conducted in 2 Cancer Centers in Brazil that included patients with T3+ or N+ rectal adenocarcinoma. After completing a long-course 54 Gy chemoradiation with capecitabine patients were randomized 1:1 to 4 cycles of mFOLFIRINOX (Oxaliplatin 85, irinotecan 150, 5-FU 2400)-TNT-arm-or to the control arm, that did not include further neoadjuvant treatment. All patients were re-staged with dedicated pelvic magnetic resonance imaging and sigmoidoscopy 12 weeks after the end of radiation. Patients with a clinical complete response were followed using a WW protocol. The primary endpoint was complete response: clinical complete response (cCR) or pathological response (pCR). RESULTS: Between April 2021 and June 2023, 55 patients were randomized to TNT and 53 to the control arm. Tumors were 74% stage 3, median distance from the anal verge was 6 cm, 63% had an at-risk circumferential margin, and 33% an involved sphincter. The rates of cCR + pCR were (31%) for TNT versus (17%) for controls (odds ratio 2.19, CI 95% 0.8-6.22 P = .091) and rates of WW were 16% and 9% (P = ns). Median follow-up was 8.1 months and recurrence rates were 16% versus 21% for TNT and controls (P = ns). CONCLUSIONS: TNT with consolidation FOLFIRINOX is feasible and has high response rates, consistent with the current literature for TNT. This trial was supported by a grant from the Brazilian Government (PROADI-SUS - NUP 25000.164382/2020-81).

Interobserver Agreement and Positivity of PI-RADS Version 2 Among Radiologists with Different Levels of Experience.

RATIONALE AND OBJECTIVES: To evaluate interobserver agreement of Prostate Imaging Reporting and Data System (PI-RADS) v2 category among radiologists with different levels of experience. The secondary objective was to evaluate the positivity for significant cancer among each category (splitting category 4 into two) and among different lesion sizes. MATERIALS AND METHODS: Institutional review board and ethics comitee approved retrospective study. Eight radiologists with different levels of experienced in prostatic magnetic resonance imaging-two more experienced, four with intermediate experience, and two abdominal radiology fellows-interpreted 160 lesions. Reference standard was fusion-targeted biopsy. Percentage agreement, k coefficients, and analysis concordance were used. RESULTS: Coefficient of concordance according to categories was 0.71 considering both zones, 0.72 for peripheral zone (PZ) and 0.44 for peripheral zone (TZ). Agreement for PI-RADS score of 3 or greater was 0.48 in PZ and 0.57 in TZ. Tumor positivity rates were 54.3% and 66.0% for PI-RADS 3 + 1 and 4 for PZ, respectively; and 25.0 and 49.2% for PI-RADS 3 + 1 and 4 for TZ, respectively (p < 0.001 in both analysis). Lesions <10, 10-14, and ≥15 mm had 55.3%, 74.6%, and 93.5% of positivity rates for cancer in PZ (p = 0.002 and <0.001) and 26.7%, 56.5%, and 59.6% in TZ, respectively (p = 0.245 and 0.632). Sensitivities, specificities, and accuracies of magnetic resonance imaging for prostate cancer using PI-RADS v2 were 76%, 72%, and 74% for PZ; and 76%, 69%, and 71% for TZ, respectively. CONCLUSION: This study shows that PI-RADS v2 has overall good interobserver agreement among radiologists with different levels of experience. PI-RADS category 3 + 1 showed lower positivity rates for significant cancer compared to category 4. Lastly, lesions 10-14 mm has similar positivity rates compared to ≥15 mm for TZ lesions.

Corkscrew esophagus.

Corkscrew esophagus (also referred as rosary bead esophagus) is a classic finding of diffuse esophageal spasm (DES) in barium studies reflecting abnormal contractions, leading to compartmentalization and curling of the esophagus, ultimately giving an appearance similar to a corkscrew or rosary beads. We review the pathophysiology of this finding, correlating it to corkscrew and rosary images that originated this classic description.

Incidentally detected tuberculous prostatitis with microabscess

ABSTRACT Tuberculous prostatitis is a rare and often overlooked entity that may mimic prostatic adenocarcinoma on imaging exams, especially multiparametric magnetic resonance imaging (MRI) of the prostate. Detection of a prostatic abscess is a clue to the correct diagnosis.