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Simple Summary  Acute myeloid leukemia is a blood disease whose long-term treatment is not satisfactory due to frequent (>50%) relapse despite complete initial remission. By adopting protumoral properties, macrophages in the leukemia cell microenvironment may promote resistance to treatment leading to relapse. Our goal was to assess whether macrophages in contact with leukemia cells have an impact on blast survival and sensitivity to chemotherapy. We observed that leukemia cells can educate macrophages to support their survival and proliferation and reduce their sensitivity to therapy, as long as the CSF1 receptor remains active and they are in close contact. By inhibiting the activity of the CSF1 receptor, in the presence of GM-CSF, we could modify the macrophage phenotype and increase blast apoptosis and sensitivity to treatment. Our results indicate that leukemia therapies should not only target blasts but also their microenvironment and specifically macrophages and their receptor for CSF1.    Abstract  Relapse is a major issue in acute myeloid leukemia (AML) and while the contribution of gene mutations in developing drug resistance is well established, little is known on the role of macrophages (MΦs) in an AML cell microenvironment. We examined whether myeloblasts could educate MΦs to adopt a protumoral orientation supporting myeloblast survival and resistance to therapy. Flow cytometry analyses demonstrated that M2-like CD163 +  MΦs are abundantly present, at diagnosis, in the bone marrow of AML patients. We showed that myeloblasts, or their conditioned medium, polarize monocytes to M2-like CD163 +  MΦs, induce the secretion of many protumoral factors, and promote myeloblast survival and proliferation as long as close intercellular contacts are maintained. Importantly, pharmacologic inhibition of the CSF1 receptor (CSF1R), in the presence of GM-CSF, reprogrammed MΦ polarization to an M1-like orientation, induced the secretion of soluble factors with antitumoral activities, reduced protumoral agonists, and promoted the apoptosis of myeloblasts interacting with MΦs. Furthermore, myeloblasts, which became resistant to venetoclax or midostaurin during their interplay with protumoral CD163 +  MΦs, regained sensitivity to these targeted therapies following CSF1R inhibition in the presence of GM-CSF. These data reveal a crucial role of CD163 +  MΦ interactions with myeloblasts that promote myeloblast survival and identify CSF1R inhibition as a novel target for AML therapy.

CSF1R Inhibition Combined with GM-CSF Reprograms Macrophages and Disrupts Protumoral Interplays with AML Cells