Background
The introduction of novel agents has improved outcomes of multiple myeloma (MM) patients. Nevertheless, the impact of
therapy is different according to the underlying biology of the disease and patient may become resistant. Recently, next
generation sequencing techniques (whole genome sequencing-WGS, whole exome sequencing-WES and RNA sequencing-
RNA-seq) together with immunophenotype revealed clonal evolution and determinants of response/refractoriness.
Hypothesis
Daratumumab monotherapy is highly effective in heavily pretreated relapsed or refractory MM patients and improved overall
response rate compared with single-agent pomalidomide, carfilzomib and lenalidomide. Therefore, we hypothesized that the
effects mediated by T-cell activation and other effector cells may promote deeper and longer responses. Yet, response are not
satisfactory in most cases and patients eventually relapse. Moreover, several findings suggest that PD1-PDL1 blockade alone is
insufficient to induce clinically meaningful anti-myeloma immunity. Consequently, the incorporation of strategies to expand
myeloma-specific T cells and repair the effector cells repertoire could be critical to enhance their efficacy.
Aims
1)To define cell intrinsic mechanisms of sensitivity vs resistance to antiCD38 and antiPD1-PDL1 therapies through genomic,
transcriptomic and immunophenotypic analyses.
2)To define cell extrinsic mechanisms through the evaluation of B-T cells interplay and the role of microenvironment in
response to immunotherapy.
3)To perform an integrative approach by correlation with clinical data to identify biomarkers of response.
Experimental Design
- Evaluation of cell-intrinsic mechanisms: WGS and WES will be performed on CD138+ plasma cells to evaluate their genomic
profile. RNA-seq on CD138+ cells will evaluate transcriptomic profile. Flow cytometry analysis will examine the expression of
specific plasma cells targets prior to treatment, at response and at relapse, and the EuroFlow-IMF MM minimal residual disease
panel will be applied.
- Evaluation of cell-extrinsic mechanisms: through Flow Cytometry we will evaluate T-cells population and B-T cells interplay
and the role of suppressive immune populations like myeloid-derived suppressor cells (MDSCs). RNA-seq will identify the
frequencies of the various helper and effector lymphocyte populations, and correlate them with response to treatment or lack
thereof. Finally, we will measure a broad spectrum of cytokines secreted by MM and other cells within the BM
microenvironment.
Expected Results
We expect to classify genomic alterations as follows:
- early lesions before starting immune therapies: these findings will provide potential predictor of response.
- acquired lesions during immunotherapies: these results will shed light on which combination of novel agents will limit
mechanisms of resistance.
We expect to identify an extensive and heterogeneous pattern of genomic lesions including mutations, rearrangements and copy
number changes which could alter the interaction between myeloma cells and immune system.
Impact On Cancer
This project will foster our drive towards "individualized therapy" in myeloma. MM is highly heterogeneous and the "one size
fits all" strategy can no longer be adopted. As already shown in other cancers, such as melanoma with BRAF and MEK
inhibitors, a "precision medicine" approach is an urgent medical need. The achievement of this goal will be highly beneficial
both to patients in terms of outcome and quality of life, and to health-care systems in terms of better allocation of resources.