Shelter in place: Live CLL cells inside the bone marrow fibroblasts and its implication in drug resistance

Introduction: Cell-in-cell (CIC) describes a century old observation where an intact cell can be seen inside another whole cell. It has been associated with human cancers, especially hematopoietic malignancies. However, most observations have been published as case reports. In the absence of systematic studies of case cohorts, understanding of the pathological significance of live CIC remains challenging. Methods: In this investigation, we studied primary CLL samples using an ex vivo co-culture model system which mimics the CLL tumor microenvironment (TME). In these TME models, CLL cells were cocultured with bone marrow fibroblasts (BMF) in the presence of B-cell growth factors. The tumor cells survive for weeks, become larger, downregulate surface CXCR4 and upregulate Ki67 expression. Phenotypically, tumor cells proliferate and divide into daughter cells. Collectively, these features recapitulate the behavior of lymph node-resident CLL cells. In this study, cells were observed and analyzed with confocal microscopy and 3D reconstruction. Results: We observed that CLL cells were actively internalized by BMF in 41 CLL cases studied. The internalized CLL cells were alive and mobile within the BMF’s cytoplasm. Moreover, the tumor cells were seen leaving their BMF host and re-entering into other BMFs. The number of internalized CLL cells were quantified and correlated with patients’ clinical and pathological parameters. No correlations were found between cell internalization and widely used CLL prognostic indicators, including cytogenetic features and IGHV mutational status. However, we have found that treated patients had higher level of CIC than those not treated. We hypothesized that live CIC may contribute to drug resistance and internalization may be an important mechanism for tumor cells to evade harmful drug insult and survive as residual disease. To test the hypothesis, we exposed CLL cells in the TME models to BTK inhibitors including ibrutinib and pirtobrutinib. Our results showed that the drug exposure drove CLL cells into BMF. Additionally, we observed that increased CIC was associated with higher cellular proliferation capacity. Importantly, chemokine CXCL12-CXCR4 axis played a critical role in this process. Specifically, CXCL12 ligand promoted cell internalization, while a CXCR4 antagonist partially prevented CIC from occurring. The research was funded by: NCI Keywords: Chronic Lymphocytic Leukemia (CLL), Microenvironment, Molecular Targeted Therapies No conflicts of interests pertinent to the abstract.