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"Other resistance mechanisms include overexpression of complement inhibitory protein as CD55 and CD59; bone marrow stromal cells (BMSC)-mediated suppression of ADCC by upregulating protein survivin in MM cells (cell adhesion-mediated immune resistance, CAM-IR); Fc-gamma-receptor polymorphisms, affecting ADCC and ADCP; reduction of NK cells, the most important mediators of daratumumab-mediated ADCC; production of neutralizing antibodies. xref Several studies are evaluating strategies that may overcome resistance to CD38 mAbs, such as adding pembrolizumab, a humanized PD-1 mAb, to daratumumab xref or combining daratumumab with azacitidine. xref Moreover, recent data support the possibility of treating patients refractory to daratumumab with isatuximab, due to MM cells “re-sensitization” after withdrawal daratumumab. xref However, the multicenter retrospective MAMMOTH study xref demonstrated that patients who become refractory to CD38 and those “penta-refractory” (refractory to CD38 mAb, two PIs and two IMiDs) had median OS of 8.6 and 5.6 months, respectively, so this poor outcome requires development and introduction in clinical practice of innovative therapeutic options."