Daratumumab Resistant Natural Killer/T-Cell Lymphoma Exhibit an Addiction to the Exosome Biogenesis Pathway for Survival
Authors: Mustafa Nurulhuda , Azaman Muhamad Irfan , Chng Wee-Joo 
Published: November 2021

Abstract
A phase 2 clinical trial has demonstrated that daratumumab monotherapy was safe and well tolerated in relapsed/refractory Natural Killer/T-Cell Lymphoma (NKTL). However, no patients achieved complete response, and duration of response was short. Similarly, in Multiple Myeloma (MM), while daratumumab based combinations are approved for front line treatment, responses are heterogeneous and development of treatment resistance inevitable. Therefore, elucidation of mechanisms which can overcome daratumumab resistance is essential for the optimization of therapeutic response in patients.
To this end, 2 pairs of isogenic daratumumab resistant and sensitive models of NKTL were developed in vitro via sequential exposure of cell lines to increasing concentrations of daratumumab in the presence of complement serum. A 3rd model was also studied in vivo whereby long-term administration of daratumumab in mice identified a sub-group of tumors which stopped responding to treatment and began to rapidly enlarge ('Resistant') as compared to others which remained similar to or smaller ('Sensitive') than the tumour volume at the initiation of treatment. RNA sequencing was performed on these models and genes commonly upregulated or downregulated analyzed.
Differential gene expression analysis highlighted an enrichment for the upregulation of genes involved in exosome biogenesis and secretion in both cell line and mouse-derived daratumumab resistant NKTL models. An additional daratumumab resistant model was developed in an MM cell line to further validate these findings and extend the study in an MM model. Immunoblotting of the 3 pairs of isogenic sensitive and resistant cell line models demonstrate that there is indeed an upregulation of proteins regulating exosomal biogenesis and secretion; Alix, TSG101 and Rab27b in the daratumumab resistant phenotype. This is associated with a concomitant increase in secreted exosomes levels in the tumour microenvironment. The size and quantification of extracellular vesicles (EV) secreted in the media were studied by nanoparticle tracking analysis. Extracellular vesicles ranged in the size of 70-150nM corroborating with the size of exosomes and nanoparticle quantification revealed a higher concentration of exosomes present in the tumour microenvironment of resistant cells as compared to sensitive cells. Subsequently, exosomes were purified via ultracentrifugation and protein expression analysis confirmed elevation of exosome markers CD63 and CD81.
To study the role of exosomal-mediated mechanisms in the survival of daratumumab resistant cells, we treated isogenic models with neticonazole and ketoconazole (azoles) which have been identified as selective inhibitors of exosomal biogenesis in a drug repurposing study for advanced cancers. Interestingly, azole treatment demonstrated a selective and more effective suppression of tumour cell viability in daratumumab resistant than sensitive cell lines. Immunoblot analysis showed that azole treatment at identical concentrations resulted in a more extensive downregulation of Alix, Rab27b and CD81 protein expression in resistant than sensitive cells. Additionally, depletion of Alix and Rab27b protein expression via siRNA knockdown induced cell death confirming that daratumumab-resistant cell lines are dependent on exosomal-mediated pathways for survival.
Current research is focused mainly on intrinsic or immune cell-mediated mechanisms of daratumumab resistance, but little is known regarding the effect of extrinsic components in the tumour microenvironment. We demonstrate that daratumumab resistant models exhibit a distinct upregulation of proteins mediating exosome biogenesis resulting in enhanced exosome secretion. Daratumumab resistant cells are targeted more efficaciously with exosome biogenesis inhibitors than sensitive counterparts thereby suggesting an addiction to exosome-mediated mechanisms of survival. This is further supported by gene silencing studies. In future, we aim to perform miRNA profiling of exosomes purified from the tumour microenvironment of isogenic daratumumab-resistant and sensitive cell line models as well as from bone marrow plasma of daratumumab treated patients. miRNA which are enriched in the exosomes of resistant phenotypes will be characterized, unique biomarkers of response identified and in depth mechanisms of resistance studied.

Disclosures
No relevant conflicts of interest to declare.