Anti CD38 monoclonal antibodies for multiple myeloma treatment

The numerous facets of 1q21+ in multiple myeloma: Pathogenesis, clinicopathological features, prognosis and clinical progress (Review)

Multiple myeloma (MM) is a malignant neoplasm characterized by the clonal proliferation of abnormal plasma cells (PCs) in the bone marrow and recurrent cytogenetic abnormalities. The incidence of MM worldwide is on the rise. 1q21+ has been found in ~30-40% of newly diagnosed MM (NDMM) patients.1q21+ is associated with the pathophysiological mechanisms of disease progression and drug resistance in MM. In the present review, the pathogenesis and clinicopathological features of MM patients with 1q21+ were studied, the key data of 1q21+ on the prognosis of MM patients were summarized, and the clinical treatment significance of MM patients with 1q21+ was clarified, in order to provide reference for clinicians to develop treatment strategies targeting 1q21+.

Multiple Myeloma

Multiple myeloma (MM) is a cancer that arises from plasma cells in bone marrow. Approximately 35,730 Americans received a new diagnosis and MM will claim the lives of an estimated 12,590 people in 2023. Complications of the disease process include anemia, leukopenia, thrombocytopenia, renal failure, severe pain, bone loss, and hypercalcemia. Patients with MM have a high risk for pathological fractures. For most forms of MM there are effective treatments that may result in long-term remission using multi-drug regimens. Although the medications approved in the United States to treat MM generally produce good outcomes, they have serious, and potentially life-threatening adverse effects. In addition, patients with specific genetic variations are at high risk for relapse. Communication with the oncology team and early intervention in the event of adverse effects of medications, complications of the disease process, or evidence of relapse are important to obtain the best possible outcome. Patients are easily overwhelmed with a three- to four-drug treatment regimen with some drugs given intravenously and/or subcutaneously at the clinic, and others taken orally at home on specific days of each 28-day cycle. Home care nursing is needed to assess for tolerance, adverse effects, and to address patient concerns. Medication management and teaching are very important in guiding patients to safely manage a schedule that changes daily. In addition, the high risk of pathological fractures and serious injury if the patient should fall supports the need for physical and occupational therapy fall prevention and safety education and exercise programs to help avert decline in functional status and combat cancer-related fatigue.

Targeted therapy for multiple myeloma: an overview on CD138-based strategies

Multiple myeloma (MM) is an incurable hematological disease characterized by the uncontrolled growth of plasma cells primarily in the bone marrow. Although its treatment consists of the administration of combined therapy regimens mainly based on immunomodulators and proteosome inhibitors, MM remains incurable, and most patients suffer from relapsed/refractory disease with poor prognosis and survival. The robust results achieved by immunotherapy targeting MM-associated antigens CD38 and CD319 (also known as SLAMF7) have drawn attention to the development of new immune-based strategies and different innovative compounds in the treatment of MM, including new monoclonal antibodies, antibody-drug conjugates, recombinant proteins, synthetic peptides, and adaptive cellular therapies. In this context, Syndecan1 (CD138 or SDC1), a transmembrane heparan sulfate proteoglycan that is upregulated in malignant plasma cells, has gained increasing attention in the panorama of MM target antigens, since its key role in MM tumorigenesis, progression and aggressiveness has been largely reported. Here, our aim is to provide an overview of the most important aspects of MM disease and to investigate the molecular functions of CD138 in physiologic and malignant cell states. In addition, we will shed light on the CD138-based therapeutic approaches currently being tested in preclinical and/or clinical phases in MM and discuss their properties, mechanisms of action and clinical applications.

Efficacy and Safety of Anti-CD38 Monoclonal Antibodies in Patients with Relapsed or Refractory Multiple Myeloma: A Meta-Analysis of Randomized Clinical Trials

The benefit of associating anti-CD38 monoclonal antibodies to proteasome inhibitor (PI)/immunomodulatory agent (IA) and dexamethasone in the treatment of patients with relapsed or refractory multiple myeloma (MM) remains unclear. PubMed, Embase, and Cochrane Library databases were searched for randomized controlled trials that investigated the addition of anti-CD38 monoclonal antibodies to a therapy composed of PI/IA and dexamethasone versus PI/IA and dexamethasone alone for treating relapsed or refractory MM. Hazard ratios (HRs) or risk ratios (RRs) were computed for binary endpoints, with 95% confidence intervals (CIs). Six studies comprising 2191 patients were included. Anti-CD38 monoclonal antibody significantly improved progression-free survival (HR 0.52; 95% CI 0.43-0.61; p < 0.001) and overall survival (HR 0.72; 95% CI 0.63-0.83; p < 0.001). There was a significant increase in hematological adverse events, such as neutropenia (RR 1.41; 95% CI 1.26-1.58; p < 0.01) and thrombocytopenia (RR 1.14; 95% CI 1.02-1.27; p = 0.02), in the group treated with anti-CD38 monoclonal antibody. Also, there was a significant increase in non-hematological adverse events, such as dyspnea (RR 1.72; 95% CI 1.38-2.13; p < 0.01) and pneumonia (RR 1.34; 95% CI 1.13-1.59; p < 0.01), in the group treated with anti-CD38 monoclonal antibody. In conclusion, the incorporation of an anti-CD38 monoclonal antibody demonstrated a promising prospect for reshaping the established MM treatment paradigms.

Membranous nephropathy treatment standard

Membranous nephropathy (MN) is characterized by deposition of immune complexes leading to thickening of glomerular basement membranes. Over time, the understanding of MN has evolved, with the identification of specific autoantibodies against novel podocyte antigens and the unraveling of intricate pathogenic pathways. Although the anti-CD20 monoclonal antibody rituximab is favored as part of the initial therapy in MN, a subgroup of MN patients may be resistant to rituximab necessitating the use of alternative agents such as cytotoxic therapies. In addition, newer agents such as novel anti-CD20 monoclonal antibodies, therapies targeting the CD38-positive plasma cells and anti-complement therapy are being studied in patients who are resistant to traditional treatment strategies. This manuscript furnishes a review of the novel developments in the pathophysiology of MN including the identification of target antigens and current treatment standards for MN, concentrating on evidenced-based interventions designed to attain remission and to prevent disease progression.

Therapeutic tactics for targeting B lymphocytes in autoimmunity and cancer

B lymphocytes have become a very popular therapeutic target in a number of autoimmune indications due to their newly appreciated roles, and approachability, in these diseases. Many of the therapies now applied in autoimmunity were initially developed to deplete malignant B cells. These strategies have also been found to benefit patients suffering from such autoimmune diseases as multiple sclerosis, type I diabetes, systemic lupus erythematosus, and rheumatoid arthritis, to name a few. These observations have supported the expansion of research addressing the mechanistic contributions of B cells in these diseases, as well as blossoming of therapeutics that target them. This review seeks to summarize cutting-edge modalities for targeting B cells, including monoclonal antibodies, bispecific antibodies, antibody-drug conjugates, chimeric antigen receptor-T cells, and small molecule inhibitors. Efforts to refine B-cell targeted therapy to eliminate only pathogenic autoreactive cells will be addressed as well as the potential for future B-cell-based cellular therapeutics. Finally, we also address approaches that seek to silence B-cell function without depletion.

Safety of daratumumab in the real-world: a pharmacovigilance study based on FAERS database

BACKGROUND

Daratumumab is widely used in multiple myeloma (MM) and light chain amyloidosis (AL amyloidosis). The purpose of this study was to identify adverse event (AE) signals for daratumumab through the FDA Adverse Event Reporting System (FAERS) database to assess its safety in a large sample of people.

METHODS

Based on data from the FAERS database, three disproportionality analysis methods were used to mine AE signals for daratumumab, including reporting odd ratio (ROR), proportional reporting ratio (PRR), and bayesian configuration promotion neural network (BCPNN).

RESULTS

A total of 9220 AE reports with daratumumab as the primary suspect drug were collected, containing 23,946 AEs. Within these reports, 252 preferred terms (PT) levels, 73 high level term (HLT) levels and 11 system organ class (SOC) levels of AE signals were detected, along with some new AEs. Most AEs occurred within the first month after drug administration.

CONCLUSION

Our findings were consistent with the results of established studies that daratumumab has a good safety profile. The newly identified AEs are of concern and prospective clinical studies are needed to confirm whether they are causally related to daratumumab. This study provided an early warning for the safe use of daratumumab and also provided guidance for further safety studies.

Nicotinamide-Expanded Allogeneic Natural Killer Cells with CD38 Deletion, Expressing an Enhanced CD38 Chimeric Antigen Receptor, Target Multiple Myeloma Cells

Natural killer (NK) cells are a vital component of cancer immune surveillance. They provide a rapid and potent immune response, including direct cytotoxicity and mobilization of the immune system, without the need for antigen processing and presentation. NK cells may also be better tolerated than T cell therapy approaches and are susceptible to various gene manipulations. Therefore, NK cells have become the focus of extensive translational research. Gamida Cell's nicotinamide (NAM) platform for cultured NK cells provides an opportunity to enhance the therapeutic potential of NK cells. CD38 is an ectoenzyme ubiquitously expressed on the surface of various hematologic cells, including multiple myeloma (MM). It has been selected as a lead target for numerous monoclonal therapeutic antibodies against MM. Monoclonal antibodies target CD38, resulting in the lysis of MM plasma cells through various antibody-mediated mechanisms such as antibody-dependent cellular cytotoxicity (ADCC), complement-dependent cytotoxicity, and antibody-dependent cellular phagocytosis, significantly improving the outcomes of patients with relapsed or refractory MM. However, this therapeutic strategy has inherent limitations, such as the anti-CD38-induced depletion of CD38-expressing NK cells, thus hindering ADCC. We have developed genetically engineered NK cells tailored to treat MM, in which CD38 was knocked-out using CRISPR-Cas9 technology and an enhanced chimeric antigen receptor (CAR) targeting CD38 was introduced using mRNA electroporation. This combined genetic approach allows for an improved cytotoxic activity directed against CD38-expressing MM cells without self-inflicted NK-cell-mediated fratricide. Preliminary results show near-complete abolition of fratricide with a 24-fold reduction in self-lysis from 19% in mock-transfected and untreated NK cells to 0.8% of self-lysis in CD38 knock-out CAR NK cells. Furthermore, we have observed significant enhancements in CD38-mediated activity in vitro, resulting in increased lysis of MM target cell lines. CD38 knock-out CAR NK cells also demonstrated significantly higher levels of NK activation markers in co-cultures with both untreated and αCD38-treated MM cell lines. These NAM-cultured NK cells with the combined genetic approach of CD38 knockout and addition of CD38 CAR represent a promising immunotherapeutic tool to target MM.

Development, methodological evaluation and application of a cell-based TRF assay for analysis of ADCC activity

Interaction of an antibody with its FcγR plays an important role in effector functions such as antibody-dependent cell-mediated cytotoxicity (ADCC). Nowadays altered ADCC activity of an antibody can be achieved by utilizing an effective glyco-engineering strategy, which often involves changes of sugar moieties in Fc part of the antibody, thereby affecting its receptor binding with effector cells. We aimed to construct a cell-based time-resolved fluorescence (TRF) assay for the evaluation of ADCC activity triggered by the antibody drug Trastuzumab (anti-HER2) and T-DM1. The assay was initiated by incubating 2,2':6',2 "-Terpyridine-6,6"-dicarboxylic acid (TDA)-labeled target SK-BR3 cells with the testing antibodies and engineered NK-92 effector cells. After incubation, the target cells were lysed to detect TDA released into the supernatant. Together with added Eu, the TDA in the supernatant formed a stable chelate of EuTDA with high-intensity fluorescence. The ADCC activity was then determined by measuring the fluorescence of EuTDA. Consequently, the method demonstrated good accuracy, precision, linearity, and specificity over methodological assessment and compared well with the Luciferase release assay in terms of the agreement of the achieved results. Using the developed assay, we evaluated the ADCC activity of two glyco-engineered anti-HER-2 antibody-drug conjugates (ADCs) and the results showed that antibody Fc glycosylation modifications influenced antibody ADCC activity to varying degrees. In conclusion, the present assay is able to accurately assess the ADCC activity induced by Trastuzumab (anti-HER2) and T-DM1, and a similar methodology can be applied to other therapeutic antibodies during drug development to help screen for antibodies with desirable ADCC activity.

Efficacy of isatuximab in combination with steroids for the treatment of relapsed/refractory multiple myeloma patients exhibiting only biochemical progression-A single center retrospective study

OBJECTIVES

Isatuximab is approved for treatment of relapsed/refractory multiple myeloma (RRMM) with dexamethasone and carfilzomib or pomalidomide. Patients receiving these three-drug regimens have exhibited more Grade ≥ 3 adverse events (AEs) compared to the two-drug class combination of isatuximab and steroids alone. Thus, this single-center retrospective study investigated the efficacy of isatuximab with dexamethasone and methylprednisolone (ISAdm) for RRMM patients showing only biochemical progression (BP) of their disease.

METHODS

Twenty-four RRMM patients exhibiting only BP were administered isatuximab at 10 mg/kg with dexamethasone once weekly for cycle 1 of a 28-day cycle, followed by every other week for each cycle thereafter. Starting in cycle 2, oral methylprednisolone was added every other day stopping 48 h before and starting 48 h after each dexamethasone infusion.

RESULTS

Overall response rate and clinical benefit rate were 63% and 79%, respectively. Progression free survival was 12.9 months. There were only 5 AEs of Grade ≥ 3 which included lymphocytopenia (13%), leukopenia (4%), and neutropenia (4%). No Grade ≥ 3 AE related to respiratory infection, anemia, or thrombocytopenia were reported.

CONCLUSION

This study shows that the two-drug class combination of ISAdm is an effective and well tolerated treatment option for RRMM patients exhibiting only BP.

CD38-targeted and erythrocyte membrane camouflaged nanodrug delivery system for photothermal and chemotherapy in multiple myeloma

Multiple myeloma (MM) is a malignant and incurable disease. Chemotherapy is currently the primary treatment option for MM. However, chemotherapeutic drugs can interrupt treatment because of serious side effects. Therefore, development of novel therapeutics for MM is essential. In this study, we designed and constructed an innovative nanoparticle-based drug delivery system, P-R@Ni3P-BTZ, and investigated its feasibility, effectiveness, and safety both in vitro and in vivo. P-R@Ni3P-BTZ is a nanocomposite that consists of two parts: (1) the drug carrier (Ni3P), which integrates photothermal therapy (PTT) with chemotherapy by loading bortezomib (BTZ); and (2) the shell (P-R), a CD38 targeting peptide P-modified red blood cell membrane nanovesicles. In vitro and in vivo, it was proven that P-R@Ni3P-BTZ exhibits remarkable antitumor effects by actively targeting CD38 + MM cells. P-R@Ni3P-BTZ significantly induces the accumulation of intracellular reactive oxygen species (ROS) and increases the apoptosis of MM cells, which underlies the primary mechanism of its antitumor effects. In addition, P-R@Ni3P exhibits good biocompatibility and biosafety, both in vitro and in vivo. Overall, P-R@Ni3P-BTZ is a specific and efficient MM therapeutic method.

Comprehensive analysis of thirteen-gene panel with prognosis value in Multiple Myeloma

BACKGROUND

Although there are many treatments for Multiple myeloma (MM), patients with MM still unable to escape the recurrence and aggravation of the disease.

OBJECTIVE

We constructed a risk model based on genes closely associated with MM prognosis to predict its prognostic value.

METHODS

Gene function enrichment and signal pathway enrichment analysis, Least Absolute Shrinkage and Selection Operator (LASSO) regression analysis, univariate and multivariate Cox regression analysis, Kaplan-Meier (KM) survival analysis and Receiver Operating Characteristic (ROC) analysis were used to identify the prognostic gene signature for MM. Finally, the prognostic gene signature was validated using the Gene Expression Omnibus (GEO) database.

RESULTS

Thirteen prognostic genes were screened by univariate Cox analysis and LASSO regression analysis. Multivariate Cox analysis revealed risk score to be an independent prognostic factor for patients with MM [Hazard Ratio (HR) = 2.564, 95% Confidence Interval (CI) = 2.223-2.958, P< 0.001]. The risk score had a high level of predictive value according to ROC analysis, with an area under the curve (AUC) of 0.744.

CONCLUSIONS

The potential prognostic signature of thirteen genes were assessed and a risk model was constructed that significantly correlated with prognosis in MM patients.

Current Status of Novel Agents for the Treatment of B Cell Malignancies: What's Coming Next?

Resistance to death is one of the hallmarks of human B cell malignancies and often contributes to the lack of a lasting response to today's commonly used treatments. Drug discovery approaches designed to activate the death machinery have generated a large number of inhibitors of anti-apoptotic proteins from the B-cell lymphoma/leukemia 2 family and the B-cell receptor (BCR) signaling pathway. Orally administered small-molecule inhibitors of Bcl-2 protein and BCR partners (e.g., Bruton's tyrosine kinase and phosphatidylinositol-3 kinase) have already been included (as monotherapies or combination therapies) in the standard of care for selected B cell malignancies. Agonistic monoclonal antibodies and their derivatives (antibody-drug conjugates, antibody-radioisotope conjugates, bispecific T cell engagers, and chimeric antigen receptor-modified T cells) targeting tumor-associated antigens (TAAs, such as CD19, CD20, CD22, and CD38) are indicated for treatment (as monotherapies or combination therapies) of patients with B cell tumors. However, given that some patients are either refractory to current therapies or relapse after treatment, novel therapeutic strategies are needed. Here, we review current strategies for managing B cell malignancies, with a focus on the ongoing clinical development of more effective, selective drugs targeting these molecules, as well as other TAAs and signaling proteins. The observed impact of metabolic reprogramming on B cell pathophysiology highlights the promise of targeting metabolic checkpoints in the treatment of these disorders.

"Friends and foes" of multiple myeloma measurable/minimal residual disease evaluation by next generation flow

Next Generation Flow (NGF) represents a gold standard for the evaluation of Minimal Residual Disease (MRD) in Multiple Myeloma (MM) patients at any stage of treatment. Although the assessment of MRD is still not universally employed in clinical practice, numerous studies have demonstrated the strength of MRD as a reliable predictor of long-term outcome, and its potential to supersede the prognostic value of CR. The possibility to acquire millions of events, in combination with the use of standard reagents and a good expertise in the analysis of rare populations, led to high chance of success and a sensitivity of 10-6 that is superimposable to the one of Next Generation Sequencing molecular techniques. Some minor bias, correlated to the protocols applied, to the quality of samples and to the high heterogeneity of plasma cells phenotype, may be overcome using standard protocols and having at disposition personnel expertise for MRD analysis. With the use of NGF we can today enter a new phase of the quantification of residual disease, switching from the definition of "minimal" residual disease to "measurable" residual disease. This review takes account of the principle "friends and foes" of Myeloma "Measurable" Residual Disease evaluation by NGF, to give insights into the potentiality of this technique. The optimization of the quality of BM samples and the analytic expertise that permits to discriminate properly the rare pathologic clones, are the keys for obtaining results with a high clinical value that could be of great impact and relevance in the future.

Daratumumab Interferes with Allogeneic Crossmatch Impacting Immunological Assessment in Solid Organ Transplantation

We report the first case of Daratumumab interference of allogeneic crossmatch tests repeatedly causing aberrant false-positive results, which inadvertently delayed transplant for a waitlisted renal patient with multiple myeloma. Daratumumab is an IgG1κ human monoclonal antibody commonly used to treat multiple myeloma, characterized by cancerous plasma cells and often leads to renal failure requiring kidney transplant, by depleting CD38-expressing plasma cells. In this case study, the patient had end-stage renal disease secondary to multiple myeloma and was continuously receiving Daratumumab infusions. The patient did not have any detectable antibodies to human leukocyte antigens but repeatedly had unexpected positive crossmatch by the flow cytometry-based method with 26 of the 27 potential deceased organ donors, implying donor-recipient immunological incompatibility. However, further review and analysis suggested that the positive crossmatches were likely false-positive as a result of interference from Daratumumab binding to donor cell surface CD38 as opposed to the presence of donor-specific antibodies. The observed intensity of the false-positive crossmatches was also highly variable, potentially due to donor- and/or cell-dependent expression of CD38. The variability of CD38 expression was, therefore, for the first time, characterized on the T and B cells isolated from various tissues and peripheral blood of 78 individuals. Overall, T cells were found to have a lower CD38 expression profile than the B cells, and no significant difference was observed between deceased and living individuals. Finally, we show that a simple cell treatment by dithiothreitol can effectively mitigate Daratumumab interference thus preserving the utility of pre-transplant crossmatch in multiple myeloma patients awaiting kidney transplant.