Block, clear, and boost: a novel therapeutic framework for targeting intercellular mitochondrial transfer in Cancer immunotherapy

Intercellular mitochondrial transfer (IMT) is emerging as a critical regulator of the tumor microenvironment, reshaping bioenergetics, signaling, and therapeutic responsiveness across the tumor-immune interface. Mitochondrial material can be exchanged within the tumor microenvironment (TME) through multiple routes, including tunneling nanotubes (TNTs), extracellular vesicles (EVs), gap junction-associated exchange, and cell-cell fusion. The outcome of this exchange depends strongly on the quality of the transferred mitochondrial material: delivery of metabolically competent mitochondria may restore oxidative phosphorylation and effector function in T cells, whereas transfer of damaged mitochondrial cargo may amplify oxidative stress and promote terminal dysfunction. Mitochondrial quality-control mechanisms, including the PINK1-Parkin pathway and USP30-regulated deubiquitination, may critically influence how recipient cells process transferred mitochondrial material. Beyond adaptive immunity, IMT has also been implicated in innate immune compartments, including macrophages, natural killer cells, and dendritic cells. More broadly, cancer cells can acquire mitochondrial support from non-malignant partners, including neurons, adipose-derived stem cells, and endothelial cells, thereby enhancing metabolic flexibility, drug resistance, and metastatic potential in selected contexts. Based on these mechanisms, this review proposes "Block, Clear, and Boost" as a hypothesis-generating framework for organizing future studies of IMT modulation in cancer immunotherapy. The three conceptual arms refer to blocking harmful transfer, clearing damaged mitochondrial cargo, and boosting immune cells through metabolic augmentation or engineered mitochondrial donation. Importantly, this framework has not been clinically validated, and its therapeutic relevance remains to be tested in route-specific, cell-type-specific, and prospectively designed studies. To support future translational development, we discuss candidate biomarkers for patient stratification, including host mtDNA haplogroups, somatic tumor signatures (e.g., Mitochondrial Pathway Signature, MitoPS), and circulating IMT proxies. Finally, we outline challenges and future directions for evaluating IMT modulation alongside existing immunotherapies, including immune checkpoint inhibitors (ICIs) and adoptive cell therapies (ACTs).