Daratumumab Impairs Myeloma Cell Adhesion Mediated Drug Resistance through CD38 Internalization
Authors: Ghose Jayeeta , Terrazas Cesar , Viola Domenico , Caserta Enrico , Krishnan Amrita , Hofmeister Craig C , Satoskar Abhay , Pichiorri Flavia 
Published: October 2019

Abstract
Introduction: Daratumumab (HuMax-CD38, Dara) is an immunoglobulin G1 kappa (IgG1k) human monoclonal antibody that binds a CD38 epitope that has been recently approved by the Food and Drugs Administration as a single agent for the treatment of Multiple Myeloma (MM). Multiple myeloma (MM) is a plasma cell disorder affecting approximately 83,000 US citizens with 30,330 new cases per year in the US. The discovery of intra-clonal heterogeneity strengthens the scientific rationale of using novel therapy combinations to overcome mechanisms of resistance.
While CD38 participates in NAD+ hydrolysis generating adenosine and influences intracellular calcium homeostasis through cADPR and NAADP synthesis, CD38 facilitates bone marrow (BM) homing of plasma cells through interaction with CD31 which is highly expressed in MM BM stromal cells (BMSCs) and macrophages (BM-M). Since adhesion of MM cells to stromal cells induces cell adhesion mediated drug resistance (CAM-DR), in this work, tested whether CD38 internalization after Daratumumab treatment impairs stromal cell adhesion, sensitizing MM cells to other drugs including proteasome inhibitors.
Methods:Flow cytometry analysis and single cell flow analysis was done to measure the extent of surface CD38 internalization into MM cells (MM cell lines and primary cells) in vitro and ex-vivo. Adhesion assays were performed using MM cell lines treated with Daratumumab and co-cultured with BMSCs and BM-M. Apoptotic assays including cell proliferation and Annexin-V/PI staining were done to assess proteasome inhibitor induced apoptosis (bortezomib, BTZ) of MM cells pretreated with Daratumumab in the presence or absence of BM stroma. Chou-Talalay synergy analysis was used to assess the ability of Daratumumab to synergize with BTZ.
Results:Single cell flow analysis revealed surface CD38 internalization into MM cell lines (MM1.S, H929, L363, RPMI-8226) and in primary myeloma cells upon incubation with increasing doses of Daratumumab. Our data show that MM cell lines and primary CD138+ MM plasma cells (MM-PCs) revealed loss of adhesion in a dose and time dependent fashion in co-culture experiments with BMSc. Moreover our data indicate that both BMSCs and BM-M protect MM cells to BTZ treatments. In order to investigate whether loss of adhesion of MM cells deprives them of protection, MM cell lines and primary cells were treated with Daratumumab and co-cultured with BM stroma and then treated with BTZ. Interestingly, it was observed that although stromal cells could protect MM cells from induced apoptosis, it failed to do so when MM cells were pretreated with Daratumumab. A more than two-fold increase in MM cell apoptosis was observed with Daratumumab-BTZ combination compared to the single agent treatments. This indicates that Daratumumab potentiates BTZ killing of MM cells.
Conclusion:Daratumumab in combination with both proteasome inhibitors and immune modulators (IMiDs) are synergistic as evidenced by the results of CASTOR and POLLUX trials respectively, but the mechanisms of killing and resistance will likely be different. The main anti-MM effect of Daratumumab has so far been attributed to its antibody-dependent cellular cytotoxicity, complement dependent cellular cytotoxicity, antibody-dependent cellular phagocytosis activities and in promoting T cell expansion in relapsed/refractary MM patients enrolled in Daratumumab monotherapy trials. Our data indicate that Daratumumab potentiates the BTZ killing of MM cells via CD38 internalization, providing rationale to further explore CD38 targeting using other drugs or cell therapies.

Disclosures
Hofmeister: Celgene: Research Funding; Karyopharm Therapeutics: Research Funding; Arno Therapeutics, Inc.: Research Funding; Incyte, Corp: Membership on an entity's Board of Directors or advisory committees; Signal Genetics, Inc.: Membership on an entity's Board of Directors or advisory committees; Janssen: Pharmaceutical Companies of Johnson & Johnson: Research Funding; Takeda Pharmaceutical Company: Research Funding; Teva: Membership on an entity's Board of Directors or advisory committees.