Chimeric antigen receptor T-cell (CART) and T-cell engager (TCE) therapies targeting B-cell maturation antigen (BCMA) are transforming the treatment landscape for relapsed multiple myeloma (MM). However, despite impressive initial response rates, most patients eventually relapse. To investigate this unmet medical need, we applied whole-genome sequencing (WGS) to MM cells from cohorts of 102 relapsed patients treated with anti-BCMA CART and TCE therapies. Several genomic alterations were associated with clinical outcomes, particularly primary refractoriness, including high genomic complexity and mutations in genes regulating plasma cell identity, which predicted resistance to therapy. Single-cell RNA sequencing further revealed that MM cells from refractory patients exhibited high proliferation signatures and reduced expression of TNFRSF17 (encoding BCMA), while were less enriched for plasma cell-associated transcriptional programs, a phenomenon we term "plasma cell identity escape." This profile was strongly associated with immune dysregulation of CD8 T cells including increased activation and exhaustion. This evolution of MM toward a more proliferative and lineage-divergent state, refractory to the anti-BCMA T-cell redirecting therapies, was functionally validated in preclinical MM mouse models. Collectively, our results comprehensively define the cellular and molecular mechanisms underlying primary resistance to anti-BCMA therapies.

Arnie Charbonneau Cancer Institute University of Calgary Calgary Canada

Dana Farber Cancer Institute Boston USA

Department of Haemato oncology University Hospital Ostrava and Faculty of Medicine University of Ostrava Ostrava Czech Republic

Department of Hematology Center for Applied Medical Research Cancer Center Clinica Universidad de Navarra IDISNA CIBERONC University of Navarra Pamplona Spain

Executive Director Translational Development Bristol Myers Squibb Summit NJ 07901

Mayo Clinic Scottsdale AZ USA

Moffitt Cancer Center Tampa FL USA

Myeloma Service Memorial Sloan Kettering Cancer Center New York NY USA

Myeloma Service Sylvester Comprehensive Cancer Center University of Miami Miami FL USA

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