针对B细胞淋巴瘤（如MCL）的靶向治疗策略是有效的，但获得性耐药仍然是一个反复出现的问题。在本文中，我们对接受针对CD20、BCL2和BTK靶向治疗（即OAsIs试验）的MCL患者进行了综合纵向基因组和单细胞RNA测序分析。我们揭示了在体中出现了对OAsIs联合治疗具有选择性优势的亚克隆，同时证明了耐药细胞的特点是BCR独立的NFkB1靶基因过表达，特别是由于CARD11突变所导致。功能研究表明，CARD11增强功能不仅导致了BCR的独立性，而且直接增加了抗凋亡基因BCL2A1的转录水平，从而导致了对venetoclax和OAsIs联合治疗的耐药性。基于OAsIs耐药亚克隆的转录谱，我们设计了一个包含16个基因的耐药标识，该标识也预测了接受传统化疗的MCL患者，揭示了一种共同的逃逸机制。在可药物靶向的CARD11依赖型NFkB1信号传导中，我们评估了其必需合作伴侣MALT1的选择性抑制。我们证明，MALT1蛋白酶抑制导致了OAsIs耐药相关基因的减少，包括BCL2A1。因此，MALT1抑制与BCL2抑制联合可以诱导细胞体外和体内的协同细胞死亡，不受CARD11突变状态的影响。综上所述，我们的研究发现了靶向治疗的耐药机制，并提供了一种新的策略来克服侵袭性B细胞淋巴瘤的耐药性。版权所有 © 2023年美国血液学会。

Strategy combining targeted therapies is effective in B-cell lymphomas such as mantle cell lymphoma (MCL), but acquired resistances remain a recurrent issue. Herein, we performed integrative longitudinal genomic and single-cell RNA-seq analyses of MCL patients treated with targeted therapies against CD20, BCL2 and BTK (i.e., OAsIs trial). We revealed the emergence of subclones with a selective advantage against OAsIs combination in vivo and showed that resistant cells were characterized by BCR-independent overexpression of NFkB1 target genes, especially due to CARD11 mutations. Functional studies demonstrated that CARD11 gain of function not only resulted in BCR independence, but also directly increase the transcription of the antiapoptotic BCL2A1, leading to venetoclax and OAsIs combination resistance. Based on the transcriptional profile of OAsIs-resistant subclones, we designed a 16-gene resistance signature that was also predictive for MCL patients treated with conventional chemotherapy, underlying a common escape mechanism. Among druggable strategies to inhibit CARD11-dependent NFkB1 transduction, we evaluated the selective inhibition of its essential partner MALT1. We demonstrated that MALT1 protease inhibition led to the reduction of genes involved in OAsIs resistance, including BCL2A1. Consequently, MALT1 inhibition induced synergistic cell death in combination with BCL2 inhibition, irrespective of CARD11 mutational status, both in vitro and in vivo. Taken together our study identified mechanisms of resistance to targeted therapies and provided a novel strategy to overcome resistance in aggressive B-cell lymphoma.Copyright © 2023 American Society of Hematology.