Real-Life Management of Patients Aged 80 Years Old and Over With Multiple Myeloma: Results of the EMMY Cohort.

INTRODUCTION: Multiple myeloma patients aged 80 years and older are a population more prone to comorbidities and frailty. We aim to describe the real-life management and outcomes of this population. EMMY is a descriptive large-scale study. PATIENTS: Between 2017 and 2021 we included 4383 patients of which 894 (20.3%) were aged ≥ 80 years. Four cohorts of patients aged ≥ 80 years were analysed: line 1 (L1), line 2 (L2), line 3 (L3) or line 4+ (L4+). RESULTS: The proportion of patients ≥ 80 years old was 20.8% in L1, 21.3% in L2, 20.9% in L3 and 17.8% in L4+. L1 patients received more treatment including a proteasome inhibitor (PI) (42.9%), L2 patients received mainly an immunomodulator (IMID) (65.9%) or an anti-CD38 (31.5%). For L3, IMID was used in 71.4% than an anti-CD38 (33.5%). L4+ patients received a PI (40.6%), IMID (33.2%) or an anti-CD38 (29.1%). Regarding efficacy, the median progression-free survival was 18.4 months in L1, 15.1 months in L2, 10.4 months in L3 and 6.5 months in L4+. The median overall survival was 49 months in L1, 31.3 months in L2, 21.4 months in L3 and 13.6 months in L4+. CONCLUSION: EMMY cohort confirmed that patients ≥ 80 years of age represent an important proportion of MM patients, in the de novo or relapse setting. This study is an important step in improving our comprehension and management of treatment in elderly patients.

Plasma cell-directed therapies induce profound clinical and durable responses in patients with severe or relapsed/refractory scleromyxedema.

BACKGROUND: Scleromyxedema (SM) is a rare skin disorder related to monoclonal gammopathy. High dose intravenous immunoglobulins (HDIVIg) are usually used as a frontline therapy with initial efficacy. However, some patients evolve with relapse, refractory state or severe extra-cutaneous complications such as dermato-neuro syndrome (DNS) or cardiac involvement. The objective of the study is to evaluate the use of anti-plasma cell treatment in these patients in order to obtain a deep and durable dermatological and haematological response. METHODS: We report here eight patients treated with HDIVIg together with anti-plasma cell therapy including: lenalidomide and dexamethasone (n = 5); bortezomib, cyclophosphamide and dexamethasone (n = 1); daratumumab, lenalidomide and dexamethasone (n = 2). RESULTS: Combination of HDIVIg with a treatment targeting the monoclonal component led to a high level of haematological remission and drastically improved skin response with an acceptable safety profile in all patients. Moreover, HDIVIg was reduced and stopped in 4 of the 7 patients who achieved complete remission. CONCLUSIONS: The association of lenalidomide and dexamethasone with HDIVIg could improve the treatment of relapsed or severe SM.

Impact of renal impairment on dihydropyrimidine dehydrogenase (DPD) phenotyping.

BACKGROUND: The chemotherapeutic agent 5-fluorouracil (5-FU) is catabolized by dihydropyrimidine dehydrogenase (DPD), the deficiency of which may lead to severe toxicity or death. Since 2019, DPD deficiency testing, based on uracilemia, is mandatory in France and recommended in Europe before initiating fluoropyrimidine-based regimens. However, it has been recently shown that renal impairment may impact uracil concentration and thus DPD phenotyping. PATIENTS AND METHODS: The impact of renal function on uracilemia and DPD phenotype was studied on 3039 samples obtained from three French centers. We also explored the influence of dialysis and measured glomerular filtration rate (mGFR) on both parameters. Finally, using patients as their own controls, we assessed as to what extent modifications in renal function impacted uracilemia and DPD phenotyping. RESULTS: We observed that uracilemia and DPD-deficient phenotypes increased concomitantly to the severity of renal impairment based on the estimated GFR, independently and more critically than hepatic function. This observation was confirmed with the mGFR. The risk of being classified 'DPD deficient' based on uracilemia was statistically higher in patients with renal impairment or dialyzed if uracilemia was measured before dialysis but not after. Indeed, the rate of DPD deficiency decreased from 86.4% before dialysis to 13.7% after. Moreover, for patients with transient renal impairment, the rate of DPD deficiency dropped dramatically from 83.3% to 16.7% when patients restored their renal function, especially in patients with an uracilemia close to 16 ng/ml. CONCLUSIONS: DPD deficiency testing using uracilemia could be misleading in patients with renal impairment. When possible, uracilemia should be reassessed in case of transient renal impairment. For patients under dialysis, testing of DPD deficiency should be carried out on samples taken after dialysis. Hence, 5-FU therapeutic drug monitoring would be particularly helpful to guide dose adjustments in patients with elevated uracil and renal impairment.

Real-time quantum error correction beyond break-even.

The ambition of harnessing the quantum for computation is at odds with the fundamental phenomenon of decoherence. The purpose of quantum error correction (QEC) is to counteract the natural tendency of a complex system to decohere. This cooperative process, which requires participation of multiple quantum and classical components, creates a special type of dissipation that removes the entropy caused by the errors faster than the rate at which these errors corrupt the stored quantum information. Previous experimental attempts to engineer such a process1-7 faced the generation of an excessive number of errors that overwhelmed the error-correcting capability of the process itself. Whether it is practically possible to utilize QEC for extending quantum coherence thus remains an open question. Here we answer it by demonstrating a fully stabilized and error-corrected logical qubit whose quantum coherence is substantially longer than that of all the imperfect quantum components involved in the QEC process, beating the best of them with a coherence gain of G = 2.27 ± 0.07. We achieve this performance by combining innovations in several domains including the fabrication of superconducting quantum circuits and model-free reinforcement learning.

ASSESSMENT OF OVERRANGING AS A FUNCTION OF PITCH, COLLIMATION AND ROTATION TIME FOR THREE OF THE MOST RECENT AND WIDESPREAD CT SCANS IN FRANCE.

PURPOSE: to assess overranging (OR) as a function of pitch, collimation and rotation time for three commonly used CT models in France. METHODS: OR was measured using XR-SP2 Gafchromic films (Ashland, USA) and computed from exposure data for three widely used CT models in France. The impact of collimation, pitch and rotation time on OR was analyzed while comparing the three CT models. RESULTS: for a typical head protocol, measured OR was found to be equal to 1.64 cm for CT scan A, 0.5 cm for CT scan B and 3.44 cm for CT scan C. OR values were respectively of 4.47, 3.24 and 7.81 cm for the typical chest protocol and the 3 CT models. OR was lowest at pitch values <1 for CT scan A, while it linearly increased with pitch for CT scan B and was lowest for high pitch values for CT scan C. Additionally, OR increase with collimation (24 mm to 38.4 mm) was most pronounced for CT scan B (factor of 2.2 for low pitch (0.5) and 2.8 for high pitch (1.2)) while it increased linearly regardless of the pitch for CT scans A and C. Rotation time also proved to slightly affect OR mainly for CT scan B (up to 2.2 mm). CONCLUSION: the present study shows that overranging remains an issue in modern CT scanners with large disparities across the vendors.

Time from first seen in specialist care to surgery does not influence survival outcome in patients with upfront resected pancreatic adenocarcinoma.

BACKGROUND: This study evaluated the impact of time to surgery (TTS) on overall survival (OS), disease free survival (DFS) and postoperative complication rate in patients with upfront resected pancreatic adenocarcinoma (PA). METHODS: We retrospectively included patients who underwent upfront surgery for PA between January 1, 2004 and December 31, 2014 from four French centers. TTS was defined as the number of days between the date of the first consultation in specialist care and the date of surgery. DFS for a 14-day TTS was the primary endpoint. We also analyzed survival depending on different delay cut-offs (7, 14, 28, 60 and 75 days). RESULTS: A total of 168 patients were included. 59 patients (35%) underwent an upfront surgery within 14 days. Patients in the higher delay group (> 14 days) had significantly more vein resections and endoscopic biliary drainage. Adjusted OS (p = 0.44), DFS (p = 0.99), fistulas (p = 0.41), hemorrhage (p = 0.59) and severe post-operative complications (p = 0.82) were not different according to TTS (> 14 days). Other delay cut-offs had no impact on OS or DFS. DISCUSSION: TTS seems to have no impact on OS, DFS and 90-day postoperative morbidity.

Outcomes of active surveillance of EU-TIRADS 5 thyroid nodules.

OBJECTIVE: Active surveillance of cytologically proven microcarcinomas has been shown as a safe procedure. However, fine needle aspiration biopsy (FNAB) is not recommended by European Thyroid Association (ETA) and American Thyroid Association (ATA) guidelines for highly suspicious nodules ≤ 10 mm. The aim of the study was to assess the outcomes of active surveillance of EU-TIRADS 5 nodules ≤ 10 mm not initially submitted to FNAB. PATIENTS AND METHODS: 80 patients with at least one EU-TIRADS 5 nodule ≤ 10 mm and no suspicious lymph nodes, accepting active surveillance, were included. RESULTS: Mean baseline diameter and volume were 5.4 mm (±2.0) and 64.4 mm3 (±33.5), respectively. After a median follow-up of 36.1 months, a volumetric increase ≥ 50% occurred in 28 patients (35.0%) and a suspicious lymph node in 3 patients (3.8%). Twenty-four patients underwent an FNAB (30.0%) after at least a 1 year follow-up of which 45.8% were malignant, 8.3% benign, 33.3% undetermined and 8.3% nondiagnostic. Sixteen patients (20.0%) underwent conversion surgery after a median follow-up of 57.2 months, confirming the diagnosis of papillary carcinoma in 15/16 cases (not described in 1 histology report), all in remission at 6-12 months postoperative follow-up. CONCLUSION: Applying ETA and ATA guidelines to avoid FNA of EU-TIRADS 5 sub-centimeter nodules and proceeding to active surveillance of such nodules in selected patients is a safe procedure. Thus, US-FNAB could be postponed until the nodule shows signs of progression or a suspicious lymph node appears, with no added risk for the patient.

Microwave Quantum Link between Superconducting Circuits Housed in Spatially Separated Cryogenic Systems.

Superconducting circuits are a strong contender for realizing quantum computing systems and are also successfully used to study quantum optics and hybrid quantum systems. However, their cryogenic operation temperatures and the current lack of coherence-preserving microwave-to-optical conversion solutions have hindered the realization of superconducting quantum networks spanning different cryogenic systems or larger distances. Here, we report the successful operation of a cryogenic waveguide coherently linking transmon qubits located in two dilution refrigerators separated by a physical distance of five meters. We transfer qubit states and generate entanglement on demand with average transfer and target state fidelities of 85.8% and 79.5%, respectively, between the two nodes of this elementary network. Cryogenic microwave links provide an opportunity to scale up systems for quantum computing and create local area superconducting quantum communication networks over length scales of at least tens of meters.

Systemic high-dose intravenous methotrexate in patients with central nervous system metastatic breast cancer.

BACKGROUND: Infusion of high-dose intravenous methotrexate (MTX) has been demonstrating to penetrate the blood-brain barrier. The aim of this present study was to assess the efficacy and safety of high dose MTX in patients with central nervous system (CNS) metastases of breast cancer. METHODS: Twenty-two patients with CNS metastases treated by MTX (3 g/m2) between April 2004 and October 2009 were enrolled. Clinical response rate, time to progression (TTP), overall survival (OS), and safety were assessed. RESULTS: In terms of brain metastases, 2 patients (9%) achieved a partial response, 10 patients (45%) had disease stabilization, and 10 patients (45%) had disease progression. In others metastatic sites, 7 patients (39%) achieved a disease stabilization, and 11 patients (61%) had disease progression. TTP and OS were 2.1 (95%CI 1.4-2.9) and 6.3 (95%CI 1.8-10) months, respectively. CONCLUSION: High-dose MTX demonstrated a moderate activity at 3 g/m2. Nonetheless, the favorable toxicity profile should suggest the possibility to increase the dosage and further study are planned.

Fast and Unconditional All-Microwave Reset of a Superconducting Qubit.

Active qubit reset is a key operation in many quantum algorithms, and particularly in quantum error correction. Here, we experimentally demonstrate a reset scheme for a three-level transmon artificial atom coupled to a large bandwidth resonator. The reset protocol uses a microwave-induced interaction between the |f,0⟩ and |g,1⟩ states of the coupled transmon-resonator system, with |g⟩ and |f⟩ denoting the ground and second excited states of the transmon, and |0⟩ and |1⟩ the photon Fock states of the resonator. We characterize the reset process and demonstrate reinitialization of the transmon-resonator system to its ground state in less than 500 ns and with 0.2% residual excitation. Our protocol is of practical interest as it has no additional architectural requirements beyond those needed for fast and efficient single-shot readout of transmons, and does not require feedback.

Deterministic quantum state transfer and remote entanglement using microwave photons.

Sharing information coherently between nodes of a quantum network is fundamental to distributed quantum information processing. In this scheme, the computation is divided into subroutines and performed on several smaller quantum registers that are connected by classical and quantum channels 1 . A direct quantum channel, which connects nodes deterministically rather than probabilistically, achieves larger entanglement rates between nodes and is advantageous for distributed fault-tolerant quantum computation 2 . Here we implement deterministic state-transfer and entanglement protocols between two superconducting qubits fabricated on separate chips. Superconducting circuits 3 constitute a universal quantum node 4 that is capable of sending, receiving, storing and processing quantum information5-8. Our implementation is based on an all-microwave cavity-assisted Raman process 9 , which entangles or transfers the qubit state of a transmon-type artificial atom 10 with a time-symmetric itinerant single photon. We transfer qubit states by absorbing these itinerant photons at the receiving node, with a probability of 98.1 ± 0.1 per cent, achieving a transfer-process fidelity of 80.02 ± 0.07 per cent for a protocol duration of only 180 nanoseconds. We also prepare remote entanglement on demand with a fidelity as high as 78.9 ± 0.1 per cent at a rate of 50 kilohertz. Our results are in excellent agreement with numerical simulations based on a master-equation description of the system. This deterministic protocol has the potential to be used for quantum computing distributed across different nodes of a cryogenic network.

TIRADS score is of limited clinical value for risk stratification of indeterminate cytological results.

CONTEXT: Thyroid nodules with cytological indeterminate results represent a daily and recurrent issue for patient management. OBJECTIVE: The primary aim of our study was to determine if TIRADS (Thyroid Imaging Reporting and Data System) could be used to stratify the malignancy risk of these nodules and to help in their clinical management. Secondary objective was to estimate if this risk stratification would change after reclassification of encapsulated non-invasive follicular variant of papillary carcinomas (FVPTC) as non-invasive follicular thyroid neoplasm (NIFTP). PATIENTS AND METHODS: Single-center retrospective study of a cohort of 602 patients who were referred for ultrasound-guided fine-needle aspiration from January 2010 to December 2016 with an indeterminate cytological result and in whom histological results after surgery were available. TIRADS score was prospectively determined for all patients included. Nodules that had been classified as FVPTC were submitted to a rereading of histological report and reclassified as NIFTP when judged relevant. A table of malignancy risk crossing Bethesda and TIRADS results was built before and after this reclassification. RESULTS: The study included 602 cytologically indeterminate nodules. TIRADS score was positively correlated with the malignancy rate (P < 0.0001). Risk stratification with TIRADS was significant only in Bethesda V nodules (P = 0.0004). However, the risk of malignancy in this Bethesda V category was always above 45%, whatever the TIRADS score. CONCLUSION: For a clinician facing an indeterminate cytological result for a thyroid nodule, return to TIRADS score is of limited value in most conditions to rule in or rule out malignancy and to guide subsequent management of patients.

[Thrombosis during thrombopoietin receptor agonist treatment for immune thrombocytopenia. A French multicentric observational study]. / Thromboses sous agonistes du récepteur de la thrombopoïétine au cours du purpura thrombopénique immunologique. Étude rétrospective multicentrique en France.

INTRODUCTION: Thrombopoietin-receptor agonists (TPO-RA) are marketed for immune thrombocytopenia (ITP). They have been associated to thrombosis occurrence in randomized controlled trials. However, the characteristics of these thromboses in the real-life practice as well as their management are poorly known. The objectives of this study were to determine the risk factors, circumstances and management of thrombosis occurring during exposure to TPO-RA in ITP. METHODS: We carried out a multicentre retrospective study in France. Moreover, all cases reported to the French pharmacovigilance system were also analyzed. RESULTS: Overall, 41 thrombosis (13 arterial) in 36 ITP patients (14 males and 22 females, mean age: 59 years) were recorded between January 2009 and October 2015. Twenty patients were treated with romiplostim, 15 with eltrombopag and 1 was treated by both medications. Thirty-three (92%) of the patients had another risk factor for thrombosis. Ten (28%) had an history of thrombosis and 13 (36%) received immunoglobulin in the month preceding the thrombotic event. Three had antiphospholipid antibodies; congenital low-risk thrombophilia was found in 4 cases; 18 patients (50%) were splenectomized. Median platelet count at the time of thrombosis was 172G/l (1-1049G/l). In 22 patients (56%), a good prognosis was associated with the thrombosis and was not linked with TPO-RA withdrawal. Bleeding events occurred in 14% of the patients treated with antiplatelet or anticoagulant drug, including 5% serious events (1 death of intracranial haemorrhage, 1 death of haemorrhagic shock). CONCLUSIONS: The thrombotic risk may be carefully assessed before starting TPO-RA in ITP patients. The impact of antiphospholipid antibodies and of congenital thrombophilia remains to be defined. Thrombosis evolution seems independent of TPO-RA management. Bleeding manifestations seem rare. Poor prognosis was mainly due to ischemic sequelae.

Current anti-myeloma therapies in renal manifestations of monoclonal light chain-associated Fanconi syndrome: a retrospective series of 49 patients.

We retrospectively reviewed 49 patients with light chain (LC) Fanconi syndrome (FS). Patients presented with chronic kidney disease (median estimated glomerular filtration rate (eGFR) of 33 ml/min/1.73 m2) and tubular proteinuria. All patients tested had elevated fractional excretion of phosphate, uric acid, generalized aminoaciduria and/or normoglycemic glycosuria. Thirty-eight patients had monoclonal gammopathy of renal significance and eleven patients had an overt hematological malignancy. The monoclonal LC isotype was kappa in 46/49 cases. Kidney biopsy in 39 patients showed various proximal tubular lesions and characteristic LC intracytoplasmic crystalline inclusions in 24 patients. Forty-two patients received chemotherapy. Patients with plasma cell proliferation (n=38) received bortezomib-based regimens (n=11), immunomodulatory agents (n=7) or alkylating agents (n=6). High-dose melphalan (HDM) followed by autologous stem cell transplantation was performed in 14 patients. Hematological response was obtained in 90% of evaluable patients, assessed on serum free light chains (FLC). GFR remained stable as long as hematological response was maintained and declined when serum FLC level rebounded. Improvement in proximal tubule function occurred in 13 patients. In patients with LC-associated FS, chemotherapy using HDM and/or new generation anti-myeloma agents can stabilize renal function and improve proximal tubule function. Serum FLC should be used to assess the hematological response, related to renal outcome.

Safe and prolonged survival with long-term exposure to pomalidomide in relapsed/refractory myeloma.

BACKGROUND: The IFM2009-02 trial studied pomalidomide (4 mg daily, 21/28 versus 28/28) and dexamethasone in very advanced relapsed or refractory multiple myeloma (RRMM). We observed that 40% of patients had a prolonged progression-free survival (PFS) and subsequently overall survival (OS). We sought to analyze the characteristics of these patients and study the effect of long exposure to pomalidomide. DESIGN: We separated the studied population into two groups: 3 months to 1 year (<1 year) and more than 1 year (≥1 year) of treatment with pomalidomide and dexamethasone based on clinical judgment and historical control studies. We then analyzed the characteristics of patients according to duration of treatment. RESULTS: The overall response rate (ORR) for the <1-year group was 43%, the median PFS 4.6 months [95% confidence interval (95% CI) 3.8-6.4] with only 6% at 12 months, and the median OS was 15 months (11.7-20.3) and 40% at 18 months. For the ≥1-year group, the response rate and survival were strikingly different, ORR at 83%, median PFS 20.7 months (14.7-35.4), median OS not reached, and 91% at 18 months. CONCLUSION: Pomalidomide and dexamethasone favored prolonged and safe exposure to treatment in 40% of heavily treated and end-stage RRMM, a paradigm shift in the natural history of RRMM characterized with a succession of shorter disease-free intervals and ultimately shorter survival. Although an optimization of pomalidomide-dexamethasone regimen is warranted in advanced RRMM, we claim that pomalidomide has proven once more to change the natural history of myeloma in this series, which should be confirmed in a larger study.

CD14+ CD16+ monocytes rather than CD14+ CD51/61+ monocytes are a potential cytological marker of circulating osteoclast precursors in multiple myeloma. A preliminary study.

INTRODUCTION: Osteolytic bone destruction is a major clinical problem in multiple myeloma patients. Osteoclasts can differentiate in vitro from bone marrow-resident monocyte progenitors, such as common monocyte progenitors, as well as circulating monocytes. Various types of monocytes, including osteoclast precursors, appear to circulate systemically. METHODS: We investigated the possibility of demonstrating, by in vitro differentiation and flow cytometry, a circulating osteoclast precursor population in multiple myeloma (MM) patients by studying the distribution of CD14(+/++) CD11b(+) CD51/61(+) and CD14(+/++) CD16(+/-) populations. RESULTS: Under short-term in vitro osteoclastic differentiation conditions, almost all CD14 monocytes acquired CD51/61 and CD16 expression. Flow cytometry studies failed to demonstrate a statistically significant increase in circulating CD14(+/++) CD11b(+) CD51/61(+) populations in 20 MM patients with osteolytic lesions. However, the minor circulating CD14(+/++) CD16(+) fraction was significantly increased in MM patients compared with healthy volunteers (109.3 ± 63.1/mm(3) vs. 65.3 ± 34.9/mm(3) ; P = 0.005), but with no correlation with markers of tumour burden. The CD14(+/++) CD16(+) to CD14(+/++) CD16(-) ratio was higher in MM patients. CONCLUSION: The circulating CD14(+/++) CD11b(+) CD51/61(+) fraction was not correlated with bone lesions in MM patients. However, CD14(+/++) CD16(+) monocytes may be a candidate marker. A larger study must be conducted to confirm these promising results for the diagnosis and follow-up of MM patients.