Inhibition of RARα2 or Its Downstream Signaling Pathways Decreases Drug Resistance in Myeloma

We have previously reported that the 30% of newly diagnosed myeloma (MM) patients expressing RARα2, had a significantly inferior outcome. RARα2 expression was also significantly increased in rapidly relapsing myelomas compared to paired baseline samples, indicating the existence at diagnosis of a RARα2 subclone, which is drug-resistant. We further demonstrated that RARα2 expression was significantly higher in MM cell line-derived and primary MM stem cells (MMSC) than in CD138+ bulk MM cells. In this study, we further explore the role of RARα2 in myeloma drug resistance.

RARα2 related drug resistance was evaluated by clonogenic formation assays, using 20,000 MM cells from the RARα2 high-expressing ARK and KMS11 MM cell lines, treated with all-trans retinoic acid (ATRA) (1nM, 10nM), Wnt inhibitor CAY10404 (1 nM, 10nM), Hedgehog inhibitor cyclopamine (1nM, 10nM), bortezomib (1nM, 10nM), as well as doxorubicin (50nM, 100nM), etoposide (50nM, 100nM), and verapamil (50nM). To determine whether inhibition of RARa2 decreased drug resistance, 1.0 × 10⁶ KMS11 cells, made resistant to bortezomib, were transfected with RARα2 shRNA and injected subcutaneously into 20 NOD/SCID mice. The 5TGM1 myeloma mice were used to determine whether targeting RARa2 or its signaling pathways could eliminate MMSC.

After serial replating for 6 weeks, MMSCs (CD138- fraction) exhibited greater clonogenic expansion than the control CD138+ fraction, while ATRA, an inhibitor of RARα2, induced potent clonogenic inhibition on MMSC. We also showed in vitro that over-expression of RARα2 in low-expressing MM cell lines, ARP1 and OCI-MY5 resulted in increased clonogenic potential and drug-resistance. In a xenograft myeloma mouse model, knockdown of RARα2 in the KSM11bortezomib-resistant cells decreased resistance to bortezomib. We further identified that RARα2 induced drug resistance by activating the drug efflux pump gene ABCC3 through Wnt and Hedgehog signaling. Inhibition of Wnt (CAY10404) signaling or the ABC transporter by verapamil overcame the drug-resistance in ARP1 and OCI-MY5 cells caused by RARα2 over-expression. Finally, targeting RARa2 or its pathways using ATRA, CAY10404 and cyclopamine significantly reduced the tumor burden as determined by idiotype IgG2 protein levels and increased survival compared to untreated controls (P < 0.05) in the 5TGM1 mice after injection of 5TGM1 MMSC.

Over-expression of RARa2 induces drug resistance by activating the drug efflux pump gene ABCC3 through activation of the Wnt and Hedgehog pathways, while inhibition of RARα2 decreases drug resistance. We also provide a possible strategy to eliminate MMSC by targeting RARa2 and/or its downstream targets, such as the Wnt and Hedgehog pathways.

No relevant conflicts of interest to declare.