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Targeting Autophagy for Cancer Treatment and Tumor Chemosensitization

Identifieur interne : 000902 ( Pmc/Corpus ); précédent : 000901; suivant : 000903

Targeting Autophagy for Cancer Treatment and Tumor Chemosensitization

Auteurs : Marta Pérez-Hernández ; Alain Arias ; David Martínez-García ; Ricardo Pérez-Tomás ; Roberto Quesada ; Vanessa Soto-Cerrato

Source :

RBID : PMC:6826429

Abstract

Autophagy is a tightly regulated catabolic process that facilitates nutrient recycling from damaged organelles and other cellular components through lysosomal degradation. Deregulation of this process has been associated with the development of several pathophysiological processes, such as cancer and neurodegenerative diseases. In cancer, autophagy has opposing roles, being either cytoprotective or cytotoxic. Thus, deciphering the role of autophagy in each tumor context is crucial. Moreover, autophagy has been shown to contribute to chemoresistance in some patients. In this regard, autophagy modulation has recently emerged as a promising therapeutic strategy for the treatment and chemosensitization of tumors, and has already demonstrated positive clinical results in patients. In this review, the dual role of autophagy during carcinogenesis is discussed and current therapeutic strategies aimed at targeting autophagy for the treatment of cancer, both under preclinical and clinical development, are presented. The use of autophagy modulators in combination therapies, in order to overcome drug resistance during cancer treatment, is also discussed as well as the potential challenges and limitations for the use of these novel therapeutic strategies in the clinic.


Url:
DOI: 10.3390/cancers11101599
PubMed: 31635099
PubMed Central: 6826429

Links to Exploration step

PMC:6826429

Le document en format XML

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<name sortKey="Quesada, Roberto" sort="Quesada, Roberto" uniqKey="Quesada R" first="Roberto" last="Quesada">Roberto Quesada</name>
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<nlm:aff id="af5-cancers-11-01599">Department of Chemistry, Universidad de Burgos, 09001 Burgos, Spain;
<email>rquesada@ubu.es</email>
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<name sortKey="Soto Cerrato, Vanessa" sort="Soto Cerrato, Vanessa" uniqKey="Soto Cerrato V" first="Vanessa" last="Soto-Cerrato">Vanessa Soto-Cerrato</name>
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<nlm:aff id="af1-cancers-11-01599">Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences, Universitat de Barcelona, 08905 Barcelona, Spain;
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<p>Autophagy is a tightly regulated catabolic process that facilitates nutrient recycling from damaged organelles and other cellular components through lysosomal degradation. Deregulation of this process has been associated with the development of several pathophysiological processes, such as cancer and neurodegenerative diseases. In cancer, autophagy has opposing roles, being either cytoprotective or cytotoxic. Thus, deciphering the role of autophagy in each tumor context is crucial. Moreover, autophagy has been shown to contribute to chemoresistance in some patients. In this regard, autophagy modulation has recently emerged as a promising therapeutic strategy for the treatment and chemosensitization of tumors, and has already demonstrated positive clinical results in patients. In this review, the dual role of autophagy during carcinogenesis is discussed and current therapeutic strategies aimed at targeting autophagy for the treatment of cancer, both under preclinical and clinical development, are presented. The use of autophagy modulators in combination therapies, in order to overcome drug resistance during cancer treatment, is also discussed as well as the potential challenges and limitations for the use of these novel therapeutic strategies in the clinic.</p>
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</TEI>
<pmc article-type="review-article">
<pmc-dir>properties open_access</pmc-dir>
<front>
<journal-meta>
<journal-id journal-id-type="nlm-ta">Cancers (Basel)</journal-id>
<journal-id journal-id-type="iso-abbrev">Cancers (Basel)</journal-id>
<journal-id journal-id-type="publisher-id">cancers</journal-id>
<journal-title-group>
<journal-title>Cancers</journal-title>
</journal-title-group>
<issn pub-type="epub">2072-6694</issn>
<publisher>
<publisher-name>MDPI</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="pmid">31635099</article-id>
<article-id pub-id-type="pmc">6826429</article-id>
<article-id pub-id-type="doi">10.3390/cancers11101599</article-id>
<article-id pub-id-type="publisher-id">cancers-11-01599</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Review</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Targeting Autophagy for Cancer Treatment and Tumor Chemosensitization</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0003-1331-5493</contrib-id>
<name>
<surname>Pérez-Hernández</surname>
<given-names>Marta</given-names>
</name>
<xref ref-type="aff" rid="af1-cancers-11-01599">1</xref>
<xref ref-type="aff" rid="af2-cancers-11-01599">2</xref>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0002-1107-9426</contrib-id>
<name>
<surname>Arias</surname>
<given-names>Alain</given-names>
</name>
<xref ref-type="aff" rid="af1-cancers-11-01599">1</xref>
<xref ref-type="aff" rid="af3-cancers-11-01599">3</xref>
<xref ref-type="aff" rid="af4-cancers-11-01599">4</xref>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0001-7731-2107</contrib-id>
<name>
<surname>Martínez-García</surname>
<given-names>David</given-names>
</name>
<xref ref-type="aff" rid="af1-cancers-11-01599">1</xref>
<xref ref-type="aff" rid="af2-cancers-11-01599">2</xref>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0003-3226-1240</contrib-id>
<name>
<surname>Pérez-Tomás</surname>
<given-names>Ricardo</given-names>
</name>
<xref ref-type="aff" rid="af1-cancers-11-01599">1</xref>
<xref ref-type="aff" rid="af2-cancers-11-01599">2</xref>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0003-2764-7157</contrib-id>
<name>
<surname>Quesada</surname>
<given-names>Roberto</given-names>
</name>
<xref ref-type="aff" rid="af5-cancers-11-01599">5</xref>
</contrib>
<contrib contrib-type="author">
<contrib-id contrib-id-type="orcid" authenticated="true">https://orcid.org/0000-0001-5835-3595</contrib-id>
<name>
<surname>Soto-Cerrato</surname>
<given-names>Vanessa</given-names>
</name>
<xref ref-type="aff" rid="af1-cancers-11-01599">1</xref>
<xref ref-type="aff" rid="af2-cancers-11-01599">2</xref>
<xref rid="c1-cancers-11-01599" ref-type="corresp">*</xref>
</contrib>
</contrib-group>
<aff id="af1-cancers-11-01599">
<label>1</label>
Department of Pathology and Experimental Therapeutics, Faculty of Medicine and Health Sciences, Universitat de Barcelona, 08905 Barcelona, Spain;
<email>martaperezh@ub.edu</email>
(M.P.-H.);
<email>alain.arias@ufrontera.cl</email>
(A.A.);
<email>david.martinez@ub.edu</email>
(D.M.-G.);
<email>rperez@ub.edu</email>
(R.P.-T.)</aff>
<aff id="af2-cancers-11-01599">
<label>2</label>
Oncobell Program, Institut d’Investigació Biomèdica de Bellvitge (IDIBELL), L’Hospitalet de Llobregat, 08908 Barcelona, Spain</aff>
<aff id="af3-cancers-11-01599">
<label>3</label>
Department of Integral Adult Dentistry, Research Centre for Dental Sciences (CICO), Universidad de La Frontera, Temuco 4811230, Chile</aff>
<aff id="af4-cancers-11-01599">
<label>4</label>
Research Group of Health Sciences, Faculty of Health Sciences, Universidad Adventista de Chile, Chillán 3780000, Chile</aff>
<aff id="af5-cancers-11-01599">
<label>5</label>
Department of Chemistry, Universidad de Burgos, 09001 Burgos, Spain;
<email>rquesada@ubu.es</email>
</aff>
<author-notes>
<corresp id="c1-cancers-11-01599">
<label>*</label>
Correspondence:
<email>vsoto@ub.edu</email>
; Tel.: +34-93-4031140</corresp>
</author-notes>
<pub-date pub-type="epub">
<day>19</day>
<month>10</month>
<year>2019</year>
</pub-date>
<pub-date pub-type="collection">
<month>10</month>
<year>2019</year>
</pub-date>
<volume>11</volume>
<issue>10</issue>
<elocation-id>1599</elocation-id>
<history>
<date date-type="received">
<day>27</day>
<month>9</month>
<year>2019</year>
</date>
<date date-type="accepted">
<day>16</day>
<month>10</month>
<year>2019</year>
</date>
</history>
<permissions>
<copyright-statement>© 2019 by the authors.</copyright-statement>
<copyright-year>2019</copyright-year>
<license license-type="open-access">
<license-p>Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>
).</license-p>
</license>
</permissions>
<abstract>
<p>Autophagy is a tightly regulated catabolic process that facilitates nutrient recycling from damaged organelles and other cellular components through lysosomal degradation. Deregulation of this process has been associated with the development of several pathophysiological processes, such as cancer and neurodegenerative diseases. In cancer, autophagy has opposing roles, being either cytoprotective or cytotoxic. Thus, deciphering the role of autophagy in each tumor context is crucial. Moreover, autophagy has been shown to contribute to chemoresistance in some patients. In this regard, autophagy modulation has recently emerged as a promising therapeutic strategy for the treatment and chemosensitization of tumors, and has already demonstrated positive clinical results in patients. In this review, the dual role of autophagy during carcinogenesis is discussed and current therapeutic strategies aimed at targeting autophagy for the treatment of cancer, both under preclinical and clinical development, are presented. The use of autophagy modulators in combination therapies, in order to overcome drug resistance during cancer treatment, is also discussed as well as the potential challenges and limitations for the use of these novel therapeutic strategies in the clinic.</p>
</abstract>
<kwd-group>
<kwd>autophagy</kwd>
<kwd>anticancer therapy</kwd>
<kwd>autophagy inhibitors</kwd>
<kwd>autophagic cell death</kwd>
<kwd>chemoresistance</kwd>
<kwd>chemosensitization</kwd>
</kwd-group>
</article-meta>
</front>
<body>
<sec sec-type="intro" id="sec1-cancers-11-01599">
<title>1. Introduction</title>
<p>Cellular homeostasis is crucial for cell survival and refers to all processes involved in the maintenance of an internal steady state at the level of the cell. Autophagy is one of the main catabolic mechanisms that contributes to cellular homeostasis, through the degradation and recycling of cytoplasmic components and organelles in the lysosomes [
<xref rid="B1-cancers-11-01599" ref-type="bibr">1</xref>
,
<xref rid="B2-cancers-11-01599" ref-type="bibr">2</xref>
]. This process confers the ability to adapt to environmental stresses, preventing cellular damage, and promoting cell survival, even in starving conditions, thus having a main physiologic cytoprotective role. It is a process tightly regulated and its dysfunction has been related to several pathologies, such as neurodegeneration, cancer, or aging [
<xref rid="B3-cancers-11-01599" ref-type="bibr">3</xref>
]. Hence, autophagy modulation is emerging as a promising new therapeutic strategy to treat these malignancies [
<xref rid="B4-cancers-11-01599" ref-type="bibr">4</xref>
]. Indeed, more than 120 clinical trials related to the process of autophagy were initiated to date. The majority of those target autophagy for cancer treatment, already showing promising results, for instance, using chloroquine or hydroxychloroquine as single agents or in combination therapies [
<xref rid="B5-cancers-11-01599" ref-type="bibr">5</xref>
,
<xref rid="B6-cancers-11-01599" ref-type="bibr">6</xref>
]. Nevertheless, the role of autophagy in cancer is somewhat controversial. Cytotoxic or cytoprotective roles have been reported depending on the cellular context [
<xref rid="B7-cancers-11-01599" ref-type="bibr">7</xref>
]. Therefore, the deep understanding of autophagy regulation and the identification of its role in each cellular context is crucial for the selection of an appropriate therapeutic intervention involving autophagy modulation in cancer.</p>
<p>In this review, the molecular mechanisms that regulate autophagy and the dual role of autophagy in cancer are presented and discussed. Moreover, current strategies targeting autophagy for cancer treatment are summarized, highlighting combination therapies involving autophagy modulators that can sensitize cancer cells to conventional therapies, thus being able to overcome chemoresistance.</p>
</sec>
<sec id="sec2-cancers-11-01599">
<title>2. Autophagy Process and Regulation</title>
<p>The term autophagy encompasses diverse cellular processes that are characterized by lysosomal degradation of cytoplasmic material. Three different types of autophagy have been described: Microautophagy, chaperone mediated autophagy (CMA), and macroautophagy [
<xref rid="B8-cancers-11-01599" ref-type="bibr">8</xref>
]. Microautophagy consists of direct engulfment, via lysosomal membrane invagination, of cytoplasmic material that has to be degraded [
<xref rid="B9-cancers-11-01599" ref-type="bibr">9</xref>
]. In mammals, this process also occurs in late endosomes, which is known as endosomal microautophagy [
<xref rid="B10-cancers-11-01599" ref-type="bibr">10</xref>
]. CMA involves the targeting of specific proteins by chaperones and their delivery to lysosomes for their subsequent degradation [
<xref rid="B11-cancers-11-01599" ref-type="bibr">11</xref>
]. Finally, macroautophagy is a highly conserved process involving the formation of autophagosomes, double membrane vesicles that engulf cytoplasmic components and fuse with the lysosomes for their content degradation [
<xref rid="B2-cancers-11-01599" ref-type="bibr">2</xref>
]. A specific type of macroautophagy is called mitophagy, which consists of the selective degradation of damaged mitochondria by autophagy, promoting their turnover, and preventing the accumulation of dysfunctional mitochondria [
<xref rid="B12-cancers-11-01599" ref-type="bibr">12</xref>
].</p>
<p>Macroautophagy (here on called autophagy) has multiple steps, including the initiation, nucleation, elongation, maturation, and vesicle content degradation (
<xref ref-type="fig" rid="cancers-11-01599-f001">Figure 1</xref>
). This process is tightly regulated at the molecular level by a family of proteins called autophagy-related proteins (ATGs) [
<xref rid="B13-cancers-11-01599" ref-type="bibr">13</xref>
]. The initiation step can be triggered through diverse stresses, such as growth factors or nutrient deprivation, hypoxia, oxidative stress, and protein aggregation, among others [
<xref rid="B4-cancers-11-01599" ref-type="bibr">4</xref>
]. Under starvation, low levels of glucose, amino acids, or growth factors provoke the activation of Unc-51-like kinase 1 (ULK1) complex (consisting of ULK1, ATG13, RB1-inducible coiled-coil protein 1 (FIP200) and ATG101)) through the inhibition of the mammalian target of rapamycin complex 1 (mTORC1) [
<xref rid="B14-cancers-11-01599" ref-type="bibr">14</xref>
,
<xref rid="B15-cancers-11-01599" ref-type="bibr">15</xref>
]. Similarly, low levels of ATP activate AMP-activated protein kinase (AMPK), inducing mTORC1 inhibition and subsequent ULK1 activation [
<xref rid="B16-cancers-11-01599" ref-type="bibr">16</xref>
]. Once ULK1 complex is activated (initiation step), it induces the phosphorylation and activation of the catalytic subunit of vacuolar protein sorting 34 (VPS34), a class III phosphatidylinositol 3-kinase (PI3KC3) that forms a complex with VPS15, Beclin-1, and ATG14. During the vesicle nucleation step, Beclin-1 acts as a scaffold for the rest of the components and VPS34 converts phosphatidylinositol (PI) to PI-3-phosphate (PI3P) giving rise to the phagophore, the initial portion of double membrane that will enclose the cytoplasmic material. This process takes place in the endoplasmic reticulum by the anchoring of the PI3KC3 complex through ATG14 protein to a region called omegasome [
<xref rid="B17-cancers-11-01599" ref-type="bibr">17</xref>
]. After phagophore formation, ATG7 and ATG10 mediate ATG12 conjugation to ATG5, which form a complex with ATG16L1 that attaches to to the autophagosome membrane during vesicle elongation. At the same time, microtubule-associated protein light chain 3 (LC3, also named ATG8) is cleaved by the protease ATG4 to form LC3-I, then it is activated by ATG7 and finally ATG3, at the vesicle membrane, promoting the conjugation of LC3-I (or γ-aminobutiric acid receptor-associated proteins (GABARAPs)) with membrane-resident phosphatidylethanolamine (PE) to form LC3-II that will permit cargo recognition and vesicle elongation and fusion [
<xref rid="B18-cancers-11-01599" ref-type="bibr">18</xref>
,
<xref rid="B19-cancers-11-01599" ref-type="bibr">19</xref>
]. Apart from the endoplasmic reticulum, other compartments also act as membrane donors, such as Golgi, recycling endosomes, mitochondria, or plasma membrane [
<xref rid="B20-cancers-11-01599" ref-type="bibr">20</xref>
,
<xref rid="B21-cancers-11-01599" ref-type="bibr">21</xref>
]. After vesicle expansion and sealing, the autophagosome maturates and fuses with the lysosome, resulting in an autophagolysosome. Several soluble N-ethylmaleimide-sensitive factor activating protein receptor (SNARE) proteins, such as syntaxin 17 (STX17) and synaptosomal-associated protein 29 (SNAP29) or the lysosome-associated membrane protein 2 (LAMP2) participate in the fusion of autophagosomes with lysosomes [
<xref rid="B22-cancers-11-01599" ref-type="bibr">22</xref>
,
<xref rid="B23-cancers-11-01599" ref-type="bibr">23</xref>
]. Finally, acidic hydrolases coming from the lysosome degrade the autophagic cargo and the resulting products, such as amino acids or fatty acids, are finally recycled to the cytosol.</p>
</sec>
<sec id="sec3-cancers-11-01599">
<title>3. Dual Role of Autophagy in Cancer</title>
<p>Autophagy has opposing roles in cancer, preventing tumor initiation in healthy tissues, but favoring cancer progression once the tumor is formed [
<xref rid="B4-cancers-11-01599" ref-type="bibr">4</xref>
]. Before the onset of carcinogenesis, the cytoprotective role of autophagy has been described to mainly act as a tumor suppressor mechanism, mitigating metabolic stress and genome instability that may cause tumor initiation [
<xref rid="B24-cancers-11-01599" ref-type="bibr">24</xref>
,
<xref rid="B25-cancers-11-01599" ref-type="bibr">25</xref>
]. Indeed, loss of function of ATGs, such as Beclin-1, has been associated with increased risk of cancer [
<xref rid="B26-cancers-11-01599" ref-type="bibr">26</xref>
,
<xref rid="B27-cancers-11-01599" ref-type="bibr">27</xref>
]. For instance, the suppression of ATG proteins in mice has been shown to provoke multiple benign tumors in liver [
<xref rid="B28-cancers-11-01599" ref-type="bibr">28</xref>
]. However, once the primary tumor is formed, the role of autophagy in cancer cells varies, being cytotoxic or cytoprotective depending on the cellular context [
<xref rid="B7-cancers-11-01599" ref-type="bibr">7</xref>
]. Therefore, it is crucial to understand the dual role of autophagy in cancer cells for the selection of a successful therapeutic strategy targeting autophagy.</p>
<p>On one hand, some tumors can undergo autophagic cell death (ACD) upon the induction of autophagy by some anticancer drugs, acting as a cytotoxic process [
<xref rid="B29-cancers-11-01599" ref-type="bibr">29</xref>
,
<xref rid="B30-cancers-11-01599" ref-type="bibr">30</xref>
]. ACD frequently occurs in cancer cells lacking functional apoptotic machinery, such as p53-deficient cancer cells [
<xref rid="B31-cancers-11-01599" ref-type="bibr">31</xref>
]. Hence, autophagy induction may be an appropriate therapeutic strategy for this type of tumors. Likewise, autophagy activation has also been described as beneficial when combined with therapies that induce immunogenic cell death, since cells dying from autophagy release certain molecules, damage-associated molecular pattern molecules (DAMPs), which recruit immune effectors enhancing the therapeutic response [
<xref rid="B8-cancers-11-01599" ref-type="bibr">8</xref>
,
<xref rid="B32-cancers-11-01599" ref-type="bibr">32</xref>
,
<xref rid="B33-cancers-11-01599" ref-type="bibr">33</xref>
].</p>
<p>On the other hand, some tumors trigger autophagy as a response to mitigate the cellular stress induced by an anticancer drug. In this case, inhibition of autophagy sensitizes cancer cells to therapy, enhancing the cytotoxic effects induced by chemotherapeutic agents [
<xref rid="B34-cancers-11-01599" ref-type="bibr">34</xref>
,
<xref rid="B35-cancers-11-01599" ref-type="bibr">35</xref>
,
<xref rid="B36-cancers-11-01599" ref-type="bibr">36</xref>
,
<xref rid="B37-cancers-11-01599" ref-type="bibr">37</xref>
]. Indeed, autophagy has been described as a pro-survival mechanism present in most advanced tumors, facilitating tumor adaptation to different stresses, such as hypoxia or nutrient deprivation, thus mediating tumor progression [
<xref rid="B38-cancers-11-01599" ref-type="bibr">38</xref>
,
<xref rid="B39-cancers-11-01599" ref-type="bibr">39</xref>
]. Accordingly, many types of advanced cancers show higher basal autophagic activity than normal tissues, and some have been described as “autophagy-dependent” tumors, such as pancreatic cancer or activated Ras tumors [
<xref rid="B40-cancers-11-01599" ref-type="bibr">40</xref>
,
<xref rid="B41-cancers-11-01599" ref-type="bibr">41</xref>
]. This basal autophagy also facilitates cancer cell adaptation to therapy-induced stresses, provoking therapy resistance in these tumors, which is one of the major challenges in the clinic. Moreover, autophagy has also been related to the survival of dormant cancer cells and metastatic tumor recurrence [
<xref rid="B42-cancers-11-01599" ref-type="bibr">42</xref>
]. Hence, the inhibition of autophagy may be an appropriate therapeutic strategy to treat these tumors.</p>
</sec>
<sec id="sec4-cancers-11-01599">
<title>4. Therapeutic Strategies Targeting Autophagy</title>
<p>Modulation of autophagy has emerged as a promising therapeutic option for cancer treatment. Due to the dual role of autophagy in cancer cells, activators as well as inhibitors have been described as feasible chemotherapeutic agents.</p>
<p>In this section, we compiled different therapeutic interventions targeting autophagy, either for its stimulation or for its inhibition (
<xref ref-type="fig" rid="cancers-11-01599-f001">Figure 1</xref>
).</p>
<sec id="sec4dot1-cancers-11-01599">
<title>4.1. Autophagy Stimulation for Cancer Treatment</title>
<p>Induction of ACD has become an interesting alternative to overcome resistance to apoptosis and to exploit a caspase independent cell death for cancer treatment. In the following sections, compounds for which the mechanism of action is based on stimulating autophagy are described (
<xref rid="cancers-11-01599-t001" ref-type="table">Table 1</xref>
). </p>
<sec id="sec4dot1dot1-cancers-11-01599">
<title>4.1.1. mTOR Inhibitors</title>
<p>The mTOR is a protein kinase that participates in multiple cellular processes such as cell growth, survival, metabolism, and immunity. Thus, mTOR regulates several cellular mechanisms including cell cycle, apoptosis, and autophagy [
<xref rid="B74-cancers-11-01599" ref-type="bibr">74</xref>
], inhibiting the initiation of the latter process [
<xref rid="B75-cancers-11-01599" ref-type="bibr">75</xref>
]. Rapamycin (sirolimus), a secondary metabolite isolated from
<italic>Streptomyces hygroscopicus,</italic>
showed potent antifungal, antitumor, and immunosuppressive properties [
<xref rid="B76-cancers-11-01599" ref-type="bibr">76</xref>
,
<xref rid="B77-cancers-11-01599" ref-type="bibr">77</xref>
]. Rapamycin and its semi-synthetic analogues, known as rapalogs, are allosteric selective inhibitors of mTORC1 affecting downstream targets, including the activation of autophagy [
<xref rid="B78-cancers-11-01599" ref-type="bibr">78</xref>
,
<xref rid="B79-cancers-11-01599" ref-type="bibr">79</xref>
]. However, their efficacy inhibiting tumor growth is limited due to lack of inhibition of mTORC2 and other compensatory signaling pathways that promote cell survival [
<xref rid="B80-cancers-11-01599" ref-type="bibr">80</xref>
].</p>
<p>Rapamycin has shown to inhibit proliferation and induce ACD in murine sarcoma [
<xref rid="B43-cancers-11-01599" ref-type="bibr">43</xref>
], neuroblastoma [
<xref rid="B44-cancers-11-01599" ref-type="bibr">44</xref>
], lung cancer [
<xref rid="B45-cancers-11-01599" ref-type="bibr">45</xref>
], and osteosarcoma [
<xref rid="B46-cancers-11-01599" ref-type="bibr">46</xref>
]. Conversely, the rapalog temsirolimus or cell cycle inhibitor-779 (CCI779), has shown to inhibit tumor growth in vitro in adenoid cystic carcinoma [
<xref rid="B47-cancers-11-01599" ref-type="bibr">47</xref>
] but has also shown to stimulate autophagy as a pro-survival mechanism in renal-cell carcinoma [
<xref rid="B48-cancers-11-01599" ref-type="bibr">48</xref>
]. Additionally, everolimus (or RAD001), a derivative rapalog developed for oral administration, has shown to induce cell cycle arrest through autophagy-mediated degradation of cyclin D1 in breast cancer cells [
<xref rid="B49-cancers-11-01599" ref-type="bibr">49</xref>
], but promotes autophagy in aromatase inhibitor-resistant breast cancer cells as a mechanism of resistance [
<xref rid="B50-cancers-11-01599" ref-type="bibr">50</xref>
].</p>
<p>Other types of mTOR inhibitors are compounds that compete with ATP, impeding phosphorylation of its target proteins, resulting in a more efficient inhibition of mTOR [
<xref rid="B81-cancers-11-01599" ref-type="bibr">81</xref>
]. Among them, AZD8055 inhibits both mTOR complexes and has shown to inhibit tumor growth [
<xref rid="B51-cancers-11-01599" ref-type="bibr">51</xref>
] and induce ACD in hepatocellular carcinoma cell lines [
<xref rid="B52-cancers-11-01599" ref-type="bibr">52</xref>
], but it is also capable of limiting tumor growth through induction of apoptosis and cell cycle arrest [
<xref rid="B82-cancers-11-01599" ref-type="bibr">82</xref>
]. Taken together these findings suggest that mTOR inhibitors may act through different mechanisms to induce cell death in a tumor context dependent manner, which makes them suitable for combined therapies to overcome cancer cell resistance [
<xref rid="B83-cancers-11-01599" ref-type="bibr">83</xref>
]. </p>
</sec>
<sec id="sec4dot1dot2-cancers-11-01599">
<title>4.1.2. BH3 Mimetics</title>
<p>BH3 (Bcl-2 homology 3) mimetics are a group of small molecules that mimic interactions of BH3-only proteins [
<xref rid="B84-cancers-11-01599" ref-type="bibr">84</xref>
], which are a sub-group of pro-apoptotic proteins in the Bcl-2 family [
<xref rid="B85-cancers-11-01599" ref-type="bibr">85</xref>
]. In general, BH3 mimetics may stimulate autophagy by liberating Beclin-1 from Bcl2 and Bcl-X
<sub>L</sub>
inhibition [
<xref rid="B85-cancers-11-01599" ref-type="bibr">85</xref>
,
<xref rid="B86-cancers-11-01599" ref-type="bibr">86</xref>
].</p>
<p>Gossypol is a BH3 mimetic isolated from cotton that has a high affinity for Bcl-2, Bcl-X
<sub>L</sub>
, Mcl-1, and Bcl-w [
<xref rid="B85-cancers-11-01599" ref-type="bibr">85</xref>
]. Its orally available enantiomeric form (-)-gossypol (AT-101) has shown to induce ACD in malignant glioma [
<xref rid="B56-cancers-11-01599" ref-type="bibr">56</xref>
], but the induced autophagy has also been accompanied by apoptosis in head and neck squamous cell carcinoma [
<xref rid="B53-cancers-11-01599" ref-type="bibr">53</xref>
], malignant mesothelioma [
<xref rid="B54-cancers-11-01599" ref-type="bibr">54</xref>
], and colon cancer cells [
<xref rid="B55-cancers-11-01599" ref-type="bibr">55</xref>
]. Obatoclax (GX15-070) is another BH3 mimetic that has shown autophagic-mediated necroptosis in oral squamous cell carcinoma [
<xref rid="B57-cancers-11-01599" ref-type="bibr">57</xref>
], rhabdomyosarcoma cells [
<xref rid="B58-cancers-11-01599" ref-type="bibr">58</xref>
], and acute lymphoblastic leukemia cells [
<xref rid="B59-cancers-11-01599" ref-type="bibr">59</xref>
]. Moreover, obatoclax induced autophagy in adenoid cystic carcinoma [
<xref rid="B87-cancers-11-01599" ref-type="bibr">87</xref>
] and Beclin-1 independent autophagy inhibition in colorectal cancer cells [
<xref rid="B88-cancers-11-01599" ref-type="bibr">88</xref>
]. Finally, ABT-737 has shown effectivity in vitro for hepatocellular carcinoma cells in a Beclin-1-dependent autophagy manner [
<xref rid="B60-cancers-11-01599" ref-type="bibr">60</xref>
].</p>
</sec>
<sec id="sec4dot1dot3-cancers-11-01599">
<title>4.1.3. Cannabinoids</title>
<p>Cannabinoids are a group of more than 60 lipophilic ligands for specific cell-surface cannabinoid receptors (CB
<sub>1 y 2</sub>
) present in the plant cannabis sativa, with Δ
<sup>9</sup>
-Tetrahydrocannabinol (THC) being the main psychoactive compound [
<xref rid="B89-cancers-11-01599" ref-type="bibr">89</xref>
]. Cannabinoids have shown potent anticancer effects related to autophagy, but they have also shown cytoprotective effects depending on cell type and cannabinoid used [
<xref rid="B90-cancers-11-01599" ref-type="bibr">90</xref>
]. THC has shown to activate non-canonical autophagy-mediated apoptosis in melanoma cells [
<xref rid="B61-cancers-11-01599" ref-type="bibr">61</xref>
] and induce ACD in glioma cells through mTORC1 inhibition and autolysosome permeabilization with the consequent release of cathepsins and posterior induction of apoptosis [
<xref rid="B62-cancers-11-01599" ref-type="bibr">62</xref>
,
<xref rid="B63-cancers-11-01599" ref-type="bibr">63</xref>
]. JWH-015 is a synthetic cannabinoid CB
<sub>2</sub>
receptor-selective agonist that has shown to inhibit tumor growth through an autophagy-dependent mechanism in hepatocellular carcinoma cells and in vivo models through inhibition of Akt/mTORC1-pathway via AMPK activation [
<xref rid="B64-cancers-11-01599" ref-type="bibr">64</xref>
].</p>
</sec>
<sec id="sec4dot1dot4-cancers-11-01599">
<title>4.1.4. Histone Deacetylase Inhibitors (HDACIs)</title>
<p>The HDAC family includes four classes (I-IV) of transcriptional repressors that alter the structure of chromatin (via deacetylation) [
<xref rid="B91-cancers-11-01599" ref-type="bibr">91</xref>
] and have been studied as anticancer compounds based on their potential to regulate gene expression [
<xref rid="B92-cancers-11-01599" ref-type="bibr">92</xref>
]. Although apoptosis has been referred to as the main route for HDACIs-induced cancer cell death, autophagy stimulation has also been implicated, being the inactivation of PI3K/Akt/mTOR signaling the most described pathway [
<xref rid="B93-cancers-11-01599" ref-type="bibr">93</xref>
].</p>
<p>Suberoylanilide hydroxamic acid (SAHA, Vorinostat) (a pan HDAC inhibitor) was the first HDACI approved by the FDA for the treatment of cutaneous T-cell lymphoma [
<xref rid="B94-cancers-11-01599" ref-type="bibr">94</xref>
] that has shown to inhibit tumor growth through autophagy stimulation via activation of Cathepsin B in breast cancer cells in vitro [
<xref rid="B65-cancers-11-01599" ref-type="bibr">65</xref>
]. Finally, MHY2256 (a synthetic class III HDAC inhibitor) has shown to induce ACD, cell cycle arrest and apoptosis in endometrial cancer cells in both in vitro and in vivo [
<xref rid="B66-cancers-11-01599" ref-type="bibr">66</xref>
].</p>
</sec>
<sec id="sec4dot1dot5-cancers-11-01599">
<title>4.1.5. Natural Products</title>
<p>Some natural compounds have shown promising anticancer activities based on autophagy stimulation. Betulinic acid is a pentacyclic triterpenoid derived from widespread plants that has shown to induce ACD in multiple myeloma cells with high levels of Bcl-2 expression. This derivative acts as an attenuator for mitochondrial-mediated apoptosis, promoting ACD by inducing Beclin-1 phosphorylation [
<xref rid="B67-cancers-11-01599" ref-type="bibr">67</xref>
]. Resveratrol, a polyphenol compound widely found in plants, has been shown to inhibit cell proliferation in breast cancer stem-like cells via suppressing the Wnt/b-catenin signaling pathway [
<xref rid="B68-cancers-11-01599" ref-type="bibr">68</xref>
]. This pathway, which regulates critical genes in tissue development and homeostasis, is aberrantly activated in many cancers and its inhibition has been reported to be related with autophagy processes [
<xref rid="B68-cancers-11-01599" ref-type="bibr">68</xref>
,
<xref rid="B95-cancers-11-01599" ref-type="bibr">95</xref>
]. δ-Tocotrienol is one of the four isomers that comprises vitamin E that has shown cytotoxic effects against prostate cancer cells in vitro through autophagy activation via ER stress [
<xref rid="B69-cancers-11-01599" ref-type="bibr">69</xref>
]. Curcumin is a major constituent of
<italic>Curcuma longa</italic>
(turmeric) that induces autophagy, which has been shown to elicit a dual role protecting or leading to cell death depending on the duration of the treatment and concentration used [
<xref rid="B70-cancers-11-01599" ref-type="bibr">70</xref>
]. </p>
</sec>
<sec id="sec4dot1dot6-cancers-11-01599">
<title>4.1.6. Others</title>
<p>Other compounds have been reported to induce ACD in cancer. For example, lapatinib is a small molecule tyrosine kinase inhibitor, targeting epidermal growth factor receptors that is capable of inducing ACD in hepatocellular carcinoma [
<xref rid="B71-cancers-11-01599" ref-type="bibr">71</xref>
] and in acute leukemia cell lines [
<xref rid="B72-cancers-11-01599" ref-type="bibr">72</xref>
]. APO866 is an inhibitor of nicotinamide adenine dinucleotide (NAD) biosynthesis that has shown anticancer activity through induction of ACD in cells from hematological malignancies [
<xref rid="B73-cancers-11-01599" ref-type="bibr">73</xref>
].</p>
</sec>
</sec>
<sec id="sec4dot2-cancers-11-01599">
<title>4.2. Autophagy Inhibition for Cancer Treatment</title>
<p>In several tumors, autophagy has a protective role; therefore, its inhibition could be an interesting approach for tumor treatment. There are several autophagy inhibitors that block the process of autophagy at different steps, which we detail below (
<xref rid="cancers-11-01599-t002" ref-type="table">Table 2</xref>
).</p>
<sec id="sec4dot2dot1-cancers-11-01599">
<title>4.2.1. ULK Inhibitors</title>
<p>ULKs are a family of serine/threonine protein kinases that form complexes with multiple regulator units. The role of ULK1 is essential for the initiation of autophagy [
<xref rid="B15-cancers-11-01599" ref-type="bibr">15</xref>
,
<xref rid="B160-cancers-11-01599" ref-type="bibr">160</xref>
,
<xref rid="B161-cancers-11-01599" ref-type="bibr">161</xref>
], however the role of ULK2 in autophagy seems to be cell type dependent [
<xref rid="B162-cancers-11-01599" ref-type="bibr">162</xref>
]. Due to the homology between ULK1 and ULK2 [
<xref rid="B163-cancers-11-01599" ref-type="bibr">163</xref>
], inhibitors of ULK1 also inhibit ULK2 [
<xref rid="B163-cancers-11-01599" ref-type="bibr">163</xref>
]. ULK1 has been shown to be upregulated in several cancers, which correlated with poor prognosis and treatment resistance [
<xref rid="B99-cancers-11-01599" ref-type="bibr">99</xref>
,
<xref rid="B164-cancers-11-01599" ref-type="bibr">164</xref>
,
<xref rid="B165-cancers-11-01599" ref-type="bibr">165</xref>
,
<xref rid="B166-cancers-11-01599" ref-type="bibr">166</xref>
]. Inhibition of ULK1 has been shown to induce a decrease in tumor growth and induction of apoptosis [
<xref rid="B100-cancers-11-01599" ref-type="bibr">100</xref>
,
<xref rid="B101-cancers-11-01599" ref-type="bibr">101</xref>
]. This has led to the search for compounds that inhibit this kinase activity finding some molecules that compete with the ATP-binding site, such as compound 6 [
<xref rid="B96-cancers-11-01599" ref-type="bibr">96</xref>
], MRT68921, and MRT67307 [
<xref rid="B97-cancers-11-01599" ref-type="bibr">97</xref>
,
<xref rid="B98-cancers-11-01599" ref-type="bibr">98</xref>
]. Besides them, SBI-0206965 is the most studied [
<xref rid="B102-cancers-11-01599" ref-type="bibr">102</xref>
], which inhibits autophagy and induces apoptosis in neuroblastoma cell lines [
<xref rid="B100-cancers-11-01599" ref-type="bibr">100</xref>
], non-small cell lung cancer (NSCLC) cells [
<xref rid="B101-cancers-11-01599" ref-type="bibr">101</xref>
,
<xref rid="B102-cancers-11-01599" ref-type="bibr">102</xref>
], and in clear cell renal carcinoma cells [
<xref rid="B99-cancers-11-01599" ref-type="bibr">99</xref>
]. Moreover, it has also been reported to be a direct inhibitor of AMPK, which is a serine/threonine kinase that activates the ULK complex, among other roles [
<xref rid="B167-cancers-11-01599" ref-type="bibr">167</xref>
]. Recently more ULK inhibitors, such as ULK100 and ULK101, have been described [
<xref rid="B103-cancers-11-01599" ref-type="bibr">103</xref>
], which supports that the idea that blocking ULK1 may be a good strategy for cancer therapy. </p>
</sec>
<sec id="sec4dot2dot2-cancers-11-01599">
<title>4.2.2. Pan PI3K Inhibitors</title>
<p>The family of phosphoinositide 3-kinases (PI3Ks) is divided into three classes with different substrate preferences, which define their functions. The role of class II on autophagy is unclear. However, class I activates mTORC1 through the PI3K/Akt pathway and consequently inhibits autophagy, while class III (VPS34) activates autophagy [
<xref rid="B168-cancers-11-01599" ref-type="bibr">168</xref>
]. PI3K pathways have been associated with cancer due to their participation in tumorigenic processes such as cell proliferation, survival, migration, and angiogenesis. Therefore, they are a good target for therapy development [
<xref rid="B169-cancers-11-01599" ref-type="bibr">169</xref>
]. Most of the studied PI3K inhibitors are not selective for a specific class of PI3K, hence, they affect different cellular processes, not only autophagy, and consequently their effect cannot be only attributed to inhibition of autophagy. However, due to their therapeutic relevance, we describe briefly some of them below.</p>
<p>3-Methyladenine (3MA) was one of the first inhibitors of autophagy described [
<xref rid="B104-cancers-11-01599" ref-type="bibr">104</xref>
]. It exerts a dual effect on autophagy. Under starving conditions it suppresses autophagy through PI3KC3 inhibition. However, in the presence of nutrients it promotes autophagy by inhibition of PI3KC1 [
<xref rid="B105-cancers-11-01599" ref-type="bibr">105</xref>
]. Additionally, it has been reported that it reduces the expression of drug efflux transporters, overcoming taxol and doxorubicin resistance [
<xref rid="B106-cancers-11-01599" ref-type="bibr">106</xref>
]. 3MA is effective at high concentrations, although presents solubility problems. In order to overcome this limitation some derivatives have been synthetized [
<xref rid="B107-cancers-11-01599" ref-type="bibr">107</xref>
]. Wortmannin is a fungal metabolite that binds irreversibly to the catalytic site of PI3Ks [
<xref rid="B108-cancers-11-01599" ref-type="bibr">108</xref>
,
<xref rid="B109-cancers-11-01599" ref-type="bibr">109</xref>
]. LY294002 is a synthetic small molecule [
<xref rid="B110-cancers-11-01599" ref-type="bibr">110</xref>
] with poor solubility and short half-life. A conjugate analog of LY294002, named SF1126, was designed to accumulate in integrin expressing tissues, improving LY294002 solubility and pharmacokinetic, favoring its accumulation in the tumor site and showing antitumor and antiangiogenic properties in mouse models [
<xref rid="B111-cancers-11-01599" ref-type="bibr">111</xref>
,
<xref rid="B112-cancers-11-01599" ref-type="bibr">112</xref>
]. Other non-selective Pan PI3K inhibitors are PI103 [
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
], KU55933, Gö6976 [
<xref rid="B114-cancers-11-01599" ref-type="bibr">114</xref>
], and GSK1059615 [
<xref rid="B115-cancers-11-01599" ref-type="bibr">115</xref>
,
<xref rid="B116-cancers-11-01599" ref-type="bibr">116</xref>
,
<xref rid="B170-cancers-11-01599" ref-type="bibr">170</xref>
].</p>
</sec>
<sec id="sec4dot2dot3-cancers-11-01599">
<title>4.2.3. VPS34 (PI3KC3) Complex Inhibitors</title>
<p>VPS34 is a PI3KC3 that transforms PI to PI3P. VPS34 forms a complex with several subunits needed for its activation, such as VPS15 (also known as p150), ATG14, and Beclin-1. Autophagy can be blocked by inhibition of VPS34 activity; SAR405 is one compound of the (2S)-tetrahydropyrimido-pyrimidinones series with kinase inhibitor activity by strong competition for ATP site. However, it is highly selective for PI3KC3, compared to class I and II, and more than 200 protein kinases and 15 lipid kinases. SAR405 inhibits autophagy induced either by starvation or mTOR inhibition [
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
]. VPS34-IN1 is a bipyrimidinamine that inhibits PI3KC3 selectively, compared with more than 300 protein kinases analyzed [
<xref rid="B117-cancers-11-01599" ref-type="bibr">117</xref>
]. Additionally, PIK-III, a bisaminopyrimidine, binds to a hydrophobic pocket unique in VPS34 that cannot be found in other related kinases [
<xref rid="B118-cancers-11-01599" ref-type="bibr">118</xref>
]. Compound 31 is a small molecule selective against protein and other lipid kinases [
<xref rid="B119-cancers-11-01599" ref-type="bibr">119</xref>
]. All these four inhibitors are selective for PI3KC3, but it should be noted that VPS34 can form different complexes with other subunits that lead to a different localization and function, participating also in vesicle trafficking [
<xref rid="B171-cancers-11-01599" ref-type="bibr">171</xref>
]. Thus, inhibitors of VPS34 can also have an effect on endosomal trafficking, as the case of SAR405 that prevents the activity of both VPS34 complexes [
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
]. Therefore, it may also affect cellular secretion [
<xref rid="B172-cancers-11-01599" ref-type="bibr">172</xref>
].</p>
<p>On the other hand, autophagy can be also inhibited blocking PI3KC3 complex formation; Spautin-1 indirectly inhibits the activity of VPS34 by proteosomal degradation of proteins that form VPS34 complexes through reduction of Beclin-1 deubiquitination mediated by USP10 and USP13 [
<xref rid="B120-cancers-11-01599" ref-type="bibr">120</xref>
]. </p>
</sec>
<sec id="sec4dot2dot4-cancers-11-01599">
<title>4.2.4. ATG inhibitors</title>
<p>Membrane PI3P produced by VPS34 leads to the recruitment of PI3P-binding ATG proteins and additional factors, resulting in the formation of complexes that participate in the elongation of the phagophore. Inhibition of autophagy can be achieved by impeding the formation of these complexes.</p>
<p>ATG7 participates in the formation of the complex ATG12-ATG5 and the conjugation of PE to LC3 and GABARAP. Recently, some inhibitors of ATG7 (WO2018/089786) have been designed and it has extended the use of micro RNAs that target ATG7 gene such as miR-154 that inhibits blade cancer progression [
<xref rid="B121-cancers-11-01599" ref-type="bibr">121</xref>
].</p>
<p>On the other hand, ATG4B cleaves LC3, activating it for its conjugation with PE [
<xref rid="B173-cancers-11-01599" ref-type="bibr">173</xref>
] necessary for the expansion of the autophagosome and its recognition. Additionally, it participates in LC3-PE deconjugation, which is important for LC3 recycling and for the fusion of the autophagosome with the lysosome [
<xref rid="B174-cancers-11-01599" ref-type="bibr">174</xref>
]. Therefore, ATG4B could be a good target to inhibit autophagy more selectively, thus, a large number of ATG4B possible inhibitors have been screened in the last years [
<xref rid="B175-cancers-11-01599" ref-type="bibr">175</xref>
]. NSC185058 is a small compound that docked at the active site of ATG4B inhibiting not only autophagy but also the volume of the autophagosomes, which is accompanied by suppression of tumor growth in an osteosarcoma subcutaneous mouse model [
<xref rid="B122-cancers-11-01599" ref-type="bibr">122</xref>
]. Tioconazole is an antifungal drug that binds to the active site of ATG4 blocking autophagy flux reducing cell viability and sensitizing tumor cells to doxorubicin in a xenograft mouse model [
<xref rid="B123-cancers-11-01599" ref-type="bibr">123</xref>
]. Other ATG4B inhibitors that suppress autophagy in cell lines and in vivo inhibiting cell proliferation are UAMC-2526, a derivative of benzotropolones stable in plasma [
<xref rid="B124-cancers-11-01599" ref-type="bibr">124</xref>
], and LV-320, a styrylquinoline [
<xref rid="B125-cancers-11-01599" ref-type="bibr">125</xref>
].</p>
<p>It should be noticed that the roles of ATG4B in cancer are not well understood and some of the ATG4 inhibitors showed only inhibition in LC3-PE delipidation, but not in the autophagosome formation such as S130 [
<xref rid="B126-cancers-11-01599" ref-type="bibr">126</xref>
] and FMK-9a [
<xref rid="B127-cancers-11-01599" ref-type="bibr">127</xref>
,
<xref rid="B128-cancers-11-01599" ref-type="bibr">128</xref>
,
<xref rid="B129-cancers-11-01599" ref-type="bibr">129</xref>
]. Additionally, some studies are focused on the evaluation of different markers that may predict the effectiveness of those inhibitors [
<xref rid="B176-cancers-11-01599" ref-type="bibr">176</xref>
]. For instance, ATG4B inhibition is effective only in Her-2 positive cells and not in those negative [
<xref rid="B177-cancers-11-01599" ref-type="bibr">177</xref>
].</p>
</sec>
<sec id="sec4dot2dot5-cancers-11-01599">
<title>4.2.5. Autophagosome Formation Inhibition</title>
<p>Verteporfin is a benzoporphyrin derivative used in the clinic in photodynamic therapy. Interestingly, it prevents autophagosome formation induced by glucose and serum deprivation, but not by mTOR inhibition [
<xref rid="B130-cancers-11-01599" ref-type="bibr">130</xref>
]. One possible mechanism of action of verteporfin is the blockade of p62 oligomerization, a protein necessary for the sequestration of ubiquitinated targets into autophagosomes [
<xref rid="B178-cancers-11-01599" ref-type="bibr">178</xref>
,
<xref rid="B179-cancers-11-01599" ref-type="bibr">179</xref>
]. Additional to autophagy inhibition, verteporfin reduces [
<xref rid="B131-cancers-11-01599" ref-type="bibr">131</xref>
,
<xref rid="B133-cancers-11-01599" ref-type="bibr">133</xref>
] transcriptional co-activators that regulate the Hippo pathway, implicated in cell growth and stem cell function [
<xref rid="B180-cancers-11-01599" ref-type="bibr">180</xref>
]. Verteporfin inhibits cell proliferation, angiogenesis, and migration, and induces apoptosis [
<xref rid="B181-cancers-11-01599" ref-type="bibr">181</xref>
]. It inhibits autophagy in vivo but has no effect as a single agent in tumor growth. However, it moderately sensitizes tumor cells to cytotoxic agents [
<xref rid="B132-cancers-11-01599" ref-type="bibr">132</xref>
].</p>
</sec>
<sec id="sec4dot2dot6-cancers-11-01599">
<title>4.2.6. Lysosome Inhibitors</title>
<p>The last step in autophagy is the fusion of autophagosomes with lysosomes, whose hydrolases degrade the autophagosome content. The inhibition of autophagy at this point consists of the use of lysosomal inhibitors.</p>
<p>Chloroquine (CQ) and its analog hydroxychloroquine (HCQ) [
<xref rid="B136-cancers-11-01599" ref-type="bibr">136</xref>
] are drugs used for the treatment of various diseases, such as malaria and more recently cancer [
<xref rid="B135-cancers-11-01599" ref-type="bibr">135</xref>
]. They are weak bases and the unprotonated form of CQ/HCQ can diffuse through cell membranes and enter into organelles such as lysosomes, where the high concentration of H
<sup>+</sup>
induces their protonation and consequently increases lysosomal pH [
<xref rid="B134-cancers-11-01599" ref-type="bibr">134</xref>
]. Once CQ/HCQ are protonated, they are trapped in the lysosomes producing an increase of their volume, and inhibiting the activity of lysosomal enzymes.</p>
<p>CQ and HCQ are the only autophagy inhibitors approved for clinical use. Although short-term CQ/HCQ treatment has been considered safe, retinopathy has been reported produced by long-term treatment with HCQ in about 7.5% of patients [
<xref rid="B182-cancers-11-01599" ref-type="bibr">182</xref>
] and cardiotoxicity [
<xref rid="B183-cancers-11-01599" ref-type="bibr">183</xref>
]. The prevalence depends on the dosage and the duration of treatment [
<xref rid="B184-cancers-11-01599" ref-type="bibr">184</xref>
]. This toxicity limitation, along with inconsistencies in the results obtained in the clinic, have led to the study of new and more potent autophagy inhibitors [
<xref rid="B185-cancers-11-01599" ref-type="bibr">185</xref>
]. Thus, CQ analogs that exert more potent autophagy inhibitory activity have been synthetized. Lys05 is a dimeric analog of CQ that accumulates within acidic organelles, including lysosomes, more potently than HCQ [
<xref rid="B137-cancers-11-01599" ref-type="bibr">137</xref>
]. DQ661, a dimeric quinacrine (DQ), not only inhibits lysosomal catabolism, including autophagy, but also targets palmitoyl-protein thioesterase-1, resulting in the inhibition of mTORC1 signaling. DQ661 has shown effects on tumor mouse models alone and it also overcame resistance to gemcitabine [
<xref rid="B139-cancers-11-01599" ref-type="bibr">139</xref>
]. Another antimalaria compound found to inhibit autophagy with antitumoral properties is VATG-027 [
<xref rid="B140-cancers-11-01599" ref-type="bibr">140</xref>
]. On the other hand, mefloquine is also accumulated in lysosomes disrupting autophagy, it induces apoptosis and inhibits multidrug resistance protein1 (MDR1) being effective in multidrug-resistant tumor cells [
<xref rid="B142-cancers-11-01599" ref-type="bibr">142</xref>
]. Mefloquine sensitizes chronic myeloid leukemia (CML) cells derived from patients in chronic phase to TK inhibitors showing selectivity for stem/progenitor tumoral cells to normal cells [
<xref rid="B141-cancers-11-01599" ref-type="bibr">141</xref>
].</p>
<p>CQ and its derivatives are not the only drugs that target lysosomes to inhibit autophagy; GLP (ganoderma lucidum polysaccharide) is a polysaccharide from the fungus
<italic>Ganoderma lucidium</italic>
with multiple antitumoral properties [
<xref rid="B143-cancers-11-01599" ref-type="bibr">143</xref>
]. GLP induces apoptosis in cancer cell lines [
<xref rid="B145-cancers-11-01599" ref-type="bibr">145</xref>
] and reduces tumor growth in mouse models [
<xref rid="B144-cancers-11-01599" ref-type="bibr">144</xref>
]. It has recently been seen that GLP impairs autophagy flux by reduction of lysosome acidification and the accumulation of autophagosomes has suggested to be the cause of apoptosis induction [
<xref rid="B144-cancers-11-01599" ref-type="bibr">144</xref>
]. Bafilomycin A (BafA) is a vacuolar-H
<sup>+</sup>
ATPase inhibitor that disrupts the acidification of lysosomes, vesicles, and vacuoles [
<xref rid="B146-cancers-11-01599" ref-type="bibr">146</xref>
,
<xref rid="B147-cancers-11-01599" ref-type="bibr">147</xref>
] by preventing the entry of H
<sup>+</sup>
into these organelles. BafA also inhibits the fusion of autophagosomes with lysosomes, by disruption of Ca
<sup>2+</sup>
gradients implied in this process [
<xref rid="B148-cancers-11-01599" ref-type="bibr">148</xref>
].</p>
<p>Ionophores can also disrupt lysosomal pH, impairing the autophagy process. Tambjamine analogues are anion selective ionophores derived from the naturally occurring tambjamines and induce mitochondrial swelling and autophagy blockade with cytotoxic effects in lung cancer cells and cancer stem cells (CSCs) [
<xref rid="B149-cancers-11-01599" ref-type="bibr">149</xref>
]. Monensin, nigericin, and lasalocid are cation ionophores, but only monensin presents selectivity for lysosomes [
<xref rid="B150-cancers-11-01599" ref-type="bibr">150</xref>
]. Squaramides are synthetic chloride transporters that also induce cell death by apoptosis [
<xref rid="B151-cancers-11-01599" ref-type="bibr">151</xref>
].</p>
<p>On the other hand, the WX8-family comprises five chemical analogs that disrupt the fusion of lysosomes with autophagosomes, lysosomes fission, and sequestration of molecules into the lysosomes without altering their pH. These compounds bind to PIKFYVE phosphoinositide kinase and present potent antitumoral effects on autophagic dependent cells [
<xref rid="B152-cancers-11-01599" ref-type="bibr">152</xref>
]. Vacuolin-1 activates RAB5A blocking the fusion of the autophagosomes with lysosomes, however it also inhibits the fusion of endosomes with lysosomes, resulting in a general endosomal-lysosomal degradation defective [
<xref rid="B153-cancers-11-01599" ref-type="bibr">153</xref>
].</p>
<p>Clomipramine (CM) is a FDA-approved prodrug for the treatment of psychiatric disorders the metabolite of which, desmethylclomipramine (DCMI), impairs autophagic flux blocking lysosomal degradation that sensitizes tumor cells to cancer treatment [
<xref rid="B154-cancers-11-01599" ref-type="bibr">154</xref>
]. DCMI also affects lung CSCs [
<xref rid="B186-cancers-11-01599" ref-type="bibr">186</xref>
]. Additionally, protease inhibitors can also inhibit the lysosomal degradation, such as pepstatin A (aspartyl proteases; cathepsin D and E), Leupeptin [
<xref rid="B155-cancers-11-01599" ref-type="bibr">155</xref>
] and E64d (cysteine proteases; cathepsin B, H, and L) [
<xref rid="B156-cancers-11-01599" ref-type="bibr">156</xref>
]. On the other hand, nanoparticles are usually accumulated into lysosomes by endocytosis internalization, which may cause lysosome impairment [
<xref rid="B157-cancers-11-01599" ref-type="bibr">157</xref>
]. Gold nanoparticles [
<xref rid="B158-cancers-11-01599" ref-type="bibr">158</xref>
] and nanodiamonds have shown to inhibit autophagy by disruption of lysosomal function, which sensitizes tumors to arsenical base therapy [
<xref rid="B159-cancers-11-01599" ref-type="bibr">159</xref>
].</p>
<p>Several studies have suggested that the anti-tumor effects of lysosomal inhibitors may be independent of autophagy inhibition since they also interfere in other cellular mechanisms producing non-autophagy related effects [
<xref rid="B187-cancers-11-01599" ref-type="bibr">187</xref>
,
<xref rid="B188-cancers-11-01599" ref-type="bibr">188</xref>
,
<xref rid="B189-cancers-11-01599" ref-type="bibr">189</xref>
,
<xref rid="B190-cancers-11-01599" ref-type="bibr">190</xref>
,
<xref rid="B191-cancers-11-01599" ref-type="bibr">191</xref>
,
<xref rid="B192-cancers-11-01599" ref-type="bibr">192</xref>
,
<xref rid="B193-cancers-11-01599" ref-type="bibr">193</xref>
,
<xref rid="B194-cancers-11-01599" ref-type="bibr">194</xref>
]. Remarkably, disruption of the lysosomes not only blocks autophagy, but lysosomal permeabilization releases proteases such as cathepsins that are active at cytosolic pH and participate in apoptosis and apoptosis-like and necrosis-like cell death [
<xref rid="B195-cancers-11-01599" ref-type="bibr">195</xref>
,
<xref rid="B196-cancers-11-01599" ref-type="bibr">196</xref>
,
<xref rid="B197-cancers-11-01599" ref-type="bibr">197</xref>
]. Additionally, lysosomes also participate in tumor invasion, hence, these inhibitors have shown to be effective against metastasis [
<xref rid="B138-cancers-11-01599" ref-type="bibr">138</xref>
,
<xref rid="B198-cancers-11-01599" ref-type="bibr">198</xref>
,
<xref rid="B199-cancers-11-01599" ref-type="bibr">199</xref>
,
<xref rid="B200-cancers-11-01599" ref-type="bibr">200</xref>
], targeting cancer stem cells [
<xref rid="B201-cancers-11-01599" ref-type="bibr">201</xref>
], and inducing tumor vessel normalization [
<xref rid="B202-cancers-11-01599" ref-type="bibr">202</xref>
].</p>
<p>As mentioned above, there are efforts to find genetic determinants to sensitivity or resistance to these lysosomal inhibitors. Metastatic cells are more vulnerable to CQ and BafA, suggesting that patients with metastasis could benefit from those treatments [
<xref rid="B198-cancers-11-01599" ref-type="bibr">198</xref>
]. Morgan and coworkers also showed a relationship between the expression of ID4 and metastatic potential. Additionally, overexpression of helicase-like transcription factor (HLTF) seems to be related with the resistance to HCQ, Lys05 and BafA treatment [
<xref rid="B189-cancers-11-01599" ref-type="bibr">189</xref>
] and tumors with the V600E mutation in BRAF (v-Raf murine sarcoma viral oncogene homolog B) present cytoprotective autophagy [
<xref rid="B203-cancers-11-01599" ref-type="bibr">203</xref>
].</p>
</sec>
</sec>
</sec>
<sec id="sec5-cancers-11-01599">
<title>5. Autophagy Modulation for Tumor Sensitization to Anticancer Therapies</title>
<p>It has been accepted that chemotherapy, as well as radiotherapy, could activate autophagy. This opens the possibility that modulation of autophagy may enhance sensitivity to these cancer treatments [
<xref rid="B204-cancers-11-01599" ref-type="bibr">204</xref>
]. In this section, we highlight some combination therapies that use compounds that target autophagy-inducing sensitization of cancer cells to anticancer therapies.</p>
<sec id="sec5dot1-cancers-11-01599">
<title>5.1. Autophagy Modulation to Overcome Radio-Resistance</title>
<p>One of the first-line treatments for many types of cancers is radiotherapy. The combination of autophagy inhibitors and radiation therapy has shown improved anti-tumor effects in cancer treatment. For instance, the ATG4B inhibitor NSC185058 [
<xref rid="B205-cancers-11-01599" ref-type="bibr">205</xref>
] and CQ enhance the antitumor effect of radiotherapy in glioblastoma. Furthermore, non-cytotoxic amounts of CQ enhanced the radiation sensitivity in bladder cancer cell lines [
<xref rid="B206-cancers-11-01599" ref-type="bibr">206</xref>
].</p>
<p>The activation of autophagy also radiosensitizes the cells [
<xref rid="B207-cancers-11-01599" ref-type="bibr">207</xref>
] and this effect is increased in the presence of apoptosis inhibitors [
<xref rid="B208-cancers-11-01599" ref-type="bibr">208</xref>
]. Thus, combination therapies based on autophagy stimulation have been formulated to overcome radioresistance in some tumors. For example, YCW1, an optimized HDACI, enhances radiosensitivity in breast cancer cells inducing ER stress and increasing autophagy [
<xref rid="B209-cancers-11-01599" ref-type="bibr">209</xref>
]. Similar results have been reached using a combination of radiotherapy, THC, and cannabidiol in glioma [
<xref rid="B210-cancers-11-01599" ref-type="bibr">210</xref>
] and gossypol in glioblastoma multiforme [
<xref rid="B211-cancers-11-01599" ref-type="bibr">211</xref>
].</p>
<p>As mentioned before, the effect of autophagy after radiation is not uniform in all types of tumors; it can be cytoprotective, non-cytoprotective, or have a cytotoxic effect [
<xref rid="B212-cancers-11-01599" ref-type="bibr">212</xref>
]. Hence, the efforts should be focused on the determination of some markers that could predict the effect of autophagy modulators in combination with radiotherapy. For instance, the expression of p53 has been suggested to be determinant for a radiosensitization effect of CQ [
<xref rid="B213-cancers-11-01599" ref-type="bibr">213</xref>
] and p18-CycE (proteolytic cyclin E fragment) [
<xref rid="B214-cancers-11-01599" ref-type="bibr">214</xref>
]. Nrf2 antioxidant pathway seems to be involved in autophagy-induced radioresistance, which is reversed by 3MA co-treatment [
<xref rid="B215-cancers-11-01599" ref-type="bibr">215</xref>
]. Phosphatase and tensin homolog deleted on chromosome 10 (PTEN) loss is associated with radio and chemoresistance, and activation of autophagy by rapamycin induces cytotoxic autophagy that overcomes radioresistance [
<xref rid="B216-cancers-11-01599" ref-type="bibr">216</xref>
]. </p>
<p>It should be noted that the models used to analyze these radiosensitization effects are of major importance in order to obtain feasible results. For instance, inhibition of autophagy combined with radiotherapy in immunodeficient mice has a sensitization effect; however, in immunocompetent mice it promotes tumor growth. [
<xref rid="B217-cancers-11-01599" ref-type="bibr">217</xref>
]. This opposite effect is due to the role of autophagy in the immunogenic antitumor response [
<xref rid="B218-cancers-11-01599" ref-type="bibr">218</xref>
]. Therefore, these types of studies should be performed in an immunocompetent context.</p>
</sec>
<sec id="sec5dot2-cancers-11-01599">
<title>5.2. Autophagy Modulation to Overcome Chemoresistance</title>
<p>Inhibition of autophagy may sensitize tumor cells to common drugs or may overcome the resistance acquired by those cells to chemotherapeutic agents [
<xref rid="B219-cancers-11-01599" ref-type="bibr">219</xref>
]. In this section, we highlight some of the most recent and relevant findings in combining different antitumor drugs with autophagy inhibitors and some activators.</p>
<p>CQ and HCQ potentiate the cytotoxicity of multiple drugs such as 5-fluorouracil [
<xref rid="B220-cancers-11-01599" ref-type="bibr">220</xref>
], cisplatin [
<xref rid="B221-cancers-11-01599" ref-type="bibr">221</xref>
], and temozolomide [
<xref rid="B222-cancers-11-01599" ref-type="bibr">222</xref>
,
<xref rid="B223-cancers-11-01599" ref-type="bibr">223</xref>
]. Moreover, combination treatment with CQ and trastuzumab completely suppressed tumor growth by >90% in a HER2-positive breast cancer tumor xenograft completely refractory to trastuzumab [
<xref rid="B224-cancers-11-01599" ref-type="bibr">224</xref>
].</p>
<p>Additionally other autophagy inhibitors have shown interesting results; verteporfin increased the potential of gemcitabine in an in vitro model of pancreatic cancer [
<xref rid="B109-cancers-11-01599" ref-type="bibr">109</xref>
]. SBI-0206965 overcame resistance to cisplatin in NSCLC cells [
<xref rid="B101-cancers-11-01599" ref-type="bibr">101</xref>
] and to cabozantinib in metastatic colorectal cancer [
<xref rid="B225-cancers-11-01599" ref-type="bibr">225</xref>
]. The combination of celecoxib, a specific inhibitor of cyclooxygenase-2, with CQ and SAR405 resulted in higher cell death [
<xref rid="B226-cancers-11-01599" ref-type="bibr">226</xref>
], and 3MA also enhanced cell death induced by bortezomib in glioblastoma cell lines [
<xref rid="B227-cancers-11-01599" ref-type="bibr">227</xref>
]. Moreover, the combination of the CQ analog lys05 with the second generation of tyrosin kinase inhibitor, nilotinib, has shown an additive effect in the reduction of the number of leukemia stem cells in CML mouse models [
<xref rid="B138-cancers-11-01599" ref-type="bibr">138</xref>
]. UAMC-2526 potentiates the effect of oxaliplatin in colorectal cancer xenograft mouse model by inhibition of autophagy, and tumors treated with UAMC-2526 also showed a more differentiated phenotype [
<xref rid="B124-cancers-11-01599" ref-type="bibr">124</xref>
].</p>
<p>The combination of autophagy activators and inhibitors together have also been studied; CQ and HCQ potentiate the effect of mTOR inhibitors, such as temsirolimus [
<xref rid="B228-cancers-11-01599" ref-type="bibr">228</xref>
] or everolimus in colorectal cancer cells [
<xref rid="B229-cancers-11-01599" ref-type="bibr">229</xref>
], melanoma [
<xref rid="B228-cancers-11-01599" ref-type="bibr">228</xref>
], and neuroendocrine neoplasms [
<xref rid="B230-cancers-11-01599" ref-type="bibr">230</xref>
], showing inhibition of autophagy as a mechanism to overcome resistance to mTOR inhibitors. In addition, CQ has also demonstrated to improve anticancer effects of vorinostat [
<xref rid="B231-cancers-11-01599" ref-type="bibr">231</xref>
], as well as a combination of everolimus and SAR405 showed synergy [
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
,
<xref rid="B232-cancers-11-01599" ref-type="bibr">232</xref>
]. These results would make one think that the inhibition of autophagy is a better therapeutic approach because autophagy presents a protective role in these models. However, although to a lesser extent, autophagy activators are also able to overcome chemoresistance. Temsirolimus has demonstrated to potentiate the activity of gemcitabine and cisplatin in bladder cancer cell lines [
<xref rid="B233-cancers-11-01599" ref-type="bibr">233</xref>
] and also decrease the resistance of colon cancer cells to cetuximab [
<xref rid="B234-cancers-11-01599" ref-type="bibr">234</xref>
]. Similarly, curcumin has shown to enhance gefitinib effect on primary gefitinib-resistant small-cell lung cancer cells through an autophagy-dependent synergism [
<xref rid="B235-cancers-11-01599" ref-type="bibr">235</xref>
].</p>
<p>Nevertheless, in some cases, autophagy modulation has shown controversial results in preclinical studies. For instance, it has been shown in vitro that SBI-0206965, an ULK1 inhibitor, induces apoptosis in combination with mTOR inhibitors in A549 cells [
<xref rid="B100-cancers-11-01599" ref-type="bibr">100</xref>
,
<xref rid="B102-cancers-11-01599" ref-type="bibr">102</xref>
]. However, in neuroblastoma cells, SBI-0206965 sensitizes cells to TNF-Related Apoptosis Inducing Ligand (TRAIL) treatment but not to mTOR inhibitors [
<xref rid="B100-cancers-11-01599" ref-type="bibr">100</xref>
] indicating the non-protective role of autophagy in this model. At this point, it would be necessary to use molecular markers that could predict the response of the tumors to autophagy modulators, such as v-Raf murine sarcoma viral oncogene homolog B (BRAF) V600E mutation, which has been associated with protective autophagy [
<xref rid="B236-cancers-11-01599" ref-type="bibr">236</xref>
].</p>
<p>Finally, the development of nanotechnology exploits tumor-targeting therapy directing multiple drugs to the tumor mass, including autophagy inhibitors, which have been encapsulated in different nanocarrier systems to obtain more efficient therapies. On one hand, HCQ nanoencapsulation showed more efficacy than free HCQ [
<xref rid="B237-cancers-11-01599" ref-type="bibr">237</xref>
,
<xref rid="B238-cancers-11-01599" ref-type="bibr">238</xref>
]. On the other, these multiplatform systems allow the combination of autophagy inhibitors with other chemotherapeutic agents [
<xref rid="B239-cancers-11-01599" ref-type="bibr">239</xref>
,
<xref rid="B240-cancers-11-01599" ref-type="bibr">240</xref>
,
<xref rid="B241-cancers-11-01599" ref-type="bibr">241</xref>
], diagnosis system [
<xref rid="B237-cancers-11-01599" ref-type="bibr">237</xref>
], or other therapeutic approaches, such as sonodynamic [
<xref rid="B242-cancers-11-01599" ref-type="bibr">242</xref>
] or photothermal therapy, showing efficient tumor suppression effect [
<xref rid="B243-cancers-11-01599" ref-type="bibr">243</xref>
,
<xref rid="B244-cancers-11-01599" ref-type="bibr">244</xref>
]. Additionally, CQ may be used to promote the accumulation of the drugs in the tumor site; pretreatment with CQ affects macrophages endocytic capacity, which limits nanoparticle accumulation in the liver, reducing liver clearance [
<xref rid="B245-cancers-11-01599" ref-type="bibr">245</xref>
], and improves tumor microcirculation, which promotes co-delivery of antitumoral drugs in tumors [
<xref rid="B246-cancers-11-01599" ref-type="bibr">246</xref>
].</p>
<p>All of the above suggest that modulation of autophagy may be a promising approach to overcome radio and chemoresistance. However, more efforts are needed to predict the response of patients to those treatments.</p>
</sec>
</sec>
<sec id="sec6-cancers-11-01599">
<title>6. Combination Therapy in Clinical Trials</title>
<p>Inhibition and activation of autophagy for cancer treatment has been evaluated in the clinic and clinical trials with autophagy modulators that present results are compiled in
<xref rid="cancers-11-01599-t003" ref-type="table">Table 3</xref>
.</p>
<p>CQ and HCQ have been included in 21 and 66 clinical trials for cancer treatment, respectively, 17 of which are currently active and 24 have been completed [
<xref rid="B6-cancers-11-01599" ref-type="bibr">6</xref>
]. In summary, HCQ has limited activity as a single agent, despite the fact that it inhibits autophagy in patients with different early-stage solid tumors [
<xref rid="B247-cancers-11-01599" ref-type="bibr">247</xref>
]. However, the analysis of autophagy in patients with metastatic pancreatic adenocarcinoma showed inconsistent inhibition and no significant therapeutic efficacy [
<xref rid="B248-cancers-11-01599" ref-type="bibr">248</xref>
]. The inhibition of autophagy in combination therapies of HCQ with anticancer agents such as gemcitabine, temozolomide, and bortezomib has been corroborated. However, efficacy results with these and other chemotherapeutic agents, such as erlotinib, were negligible [
<xref rid="B249-cancers-11-01599" ref-type="bibr">249</xref>
] or moderate [
<xref rid="B250-cancers-11-01599" ref-type="bibr">250</xref>
,
<xref rid="B251-cancers-11-01599" ref-type="bibr">251</xref>
]. Additionally, the combination of HCQ with chemotherapy and radiotherapy at the same time inhibited autophagy in 45–66% of patients and this combination did not improve the overall survival rate [
<xref rid="B252-cancers-11-01599" ref-type="bibr">252</xref>
]. Patients with glioblastoma that had received radiotherapy and chemotherapy were treated for 12 months with CQ showing limited results [
<xref rid="B253-cancers-11-01599" ref-type="bibr">253</xref>
]; however, chronic administration of CQ improved the overall survival rate about 50% [
<xref rid="B254-cancers-11-01599" ref-type="bibr">254</xref>
]. Additionally, the combination of radiotherapy with CQ did not improve the overall response rate in patients with brain metastasis [
<xref rid="B255-cancers-11-01599" ref-type="bibr">255</xref>
].</p>
<p>All these results show inconsistency not only at the level of autophagy inhibition but also in the efficacy outcome of this therapy. As mentioned before, the role of autophagy is context dependent, and this has been proven in the clinic. For instance, CQ overcame resistance to vemurafenib, a BRAF inhibitor, in different patients with BRAF
<sup>V600E</sup>
-mutant brain tumors [
<xref rid="B203-cancers-11-01599" ref-type="bibr">203</xref>
,
<xref rid="B256-cancers-11-01599" ref-type="bibr">256</xref>
]. However, this combination showed no synergistic effect on patients without this mutation [
<xref rid="B203-cancers-11-01599" ref-type="bibr">203</xref>
]. This points out the importance of the identification of patients that are most likely to respond to this combination therapy.</p>
<p>Regarding autophagy activators, (-)-gossypol in combination with cisplatin and etoposide has shown promising results on phase I clinical trial for small cell lung cancer [
<xref rid="B257-cancers-11-01599" ref-type="bibr">257</xref>
]. However, its combination with docetaxel or androgen deprivation therapy have not demonstrated enough efficacy on phase II clinical trial for head and neck cancer [
<xref rid="B258-cancers-11-01599" ref-type="bibr">258</xref>
] or metastatic prostate cancer [
<xref rid="B259-cancers-11-01599" ref-type="bibr">259</xref>
]. Vorinostat in combination with tamoxifen showed moderate response with 40% of response or stable disease in patients with hormone-therapy resistant breast cancer [
<xref rid="B260-cancers-11-01599" ref-type="bibr">260</xref>
].</p>
<p>Finally, the combination of autophagy activators and inhibitors, such as the combination of vorinostat with HCQ has shown promising results [
<xref rid="B261-cancers-11-01599" ref-type="bibr">261</xref>
]. Although rapalog temsirolimus is not powerful enough to be used as a single agent for the treatment of breast and renal carcinoma [
<xref rid="B262-cancers-11-01599" ref-type="bibr">262</xref>
], the combination of HCQ with rapamycin showed a moderate positive response [
<xref rid="B263-cancers-11-01599" ref-type="bibr">263</xref>
]. Moreover, HCQ combined with rapamycin in metronomic chemotherapy showed encouraging results with 40% of partial response and 84% control of disease [
<xref rid="B264-cancers-11-01599" ref-type="bibr">264</xref>
]. Finally, combination of HCQ and temsirolimus also showed stabilization of the disease in 67–74% of the patients with a consistent inhibition of autophagy [
<xref rid="B265-cancers-11-01599" ref-type="bibr">265</xref>
].</p>
</sec>
<sec sec-type="conclusions" id="sec7-cancers-11-01599">
<title>7. Conclusions</title>
<p>Targeting autophagy for cancer treatment seems to be a promising therapeutic strategy, although significant challenges remain to be addressed in order to improve the therapeutic results obtained in the clinic. In particular, since the outcome of modulating autophagy depends on the tumor context, it must be carefully defined which patients would benefit from which treatment before starting any therapeutic intervention. </p>
<p>Autophagy suppresses tumor initiation in healthy tissues, showing a cytoprotective role. Hence, the modulation of autophagy through autophagy activators might be beneficial in patients with an increased risk of developing cancers. On the other hand, once the tumor is formed, activating autophagy will induce ACD in some tumors, provoking their reduction. This strategy may be especially relevant in apoptosis-resistant tumors. Nevertheless, autophagy has a protective role in other tumors, especially those called “autophagy-dependent”; hence, the inhibition of autophagy would induce therapeutic effects in those patients. Indeed, inhibition of autophagy at early or late stages leads to different consequences; prevention of the autophagosome formation may neutralize the protective role of autophagy, sensitizing cells to chemotherapeutic agents, being a good strategy for combination regimens. Conversely, lysosomotropic agents produce autophagy vacuoles accumulation, leading to cellular stress and a consequent cytotoxic effect, being able to reduce the tumor in single therapy.</p>
<p>This review underscore the double-edged-sword role of autophagy in cancer; hence, a deeper understanding on how autophagy affects cancer progression, the search of appropriate biomarkers to identify the responder patient population to a defined autophagy modulator, and clear and suitable pharmacodynamic markers to monitor patients’ responses are eagerly needed to improve success in clinical studies with autophagy modulators.</p>
</sec>
</body>
<back>
<ack>
<title>Acknowledgments</title>
<p>We thank CERCA Programme/Generalitat de Catalunya for institutional support. M.P.H. thanks “La Caixa foundation” for her postdoctoral fellowship. A.A. thanks PFCHA/Becas Chile (Folio #72200156). D.M.G. thanks the Government of Catalonia for his predoctoral fellowship through L’Agència de Gestió d’Ajuts Universitaris i de Recerca (AGAUR; FI-DRG 2016).</p>
</ack>
<notes>
<title>Author Contributions</title>
<p>Conceptualization, V.S.-C.; Compilation and data curation, V.S.-C., M.P.-H., A.A., R.P.-T., R.Q.; Writing—original draft preparation, V.S.-C., M.P.-H., A.A., R.P.-T.; Tables, R.Q.; Figure drawing, D.M.-G.; Writing—review and editing, V.S.-C., M.P.-H.; Supervision, V.S.-C; Funding acquisition, V.S.-C. and R.P.-T. </p>
</notes>
<notes>
<title>Funding</title>
<p>This research has been partially supported by Instituto de Salud Carlos III (Grant PI18/00441) (Co-funded by European Regional Development Fund. ERDF, a way to build Europe).</p>
</notes>
<notes notes-type="COI-statement">
<title>Conflicts of Interest</title>
<p>The authors declare no conflict of interest.</p>
</notes>
<glossary>
<title>Abbreviations</title>
<array orientation="portrait">
<tbody>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ACD</td>
<td align="left" valign="middle" rowspan="1" colspan="1">autophagic cell death</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">AMPK</td>
<td align="left" valign="middle" rowspan="1" colspan="1">AMP-activated protein kinase</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ATG</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Autophagy-related proteins</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ATG16L1</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Autophagy-related 16-like protein 1</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">BafA</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Bafilomycin A</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">BH3</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Bcl-2 Homology 3</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">BRAF</td>
<td align="left" valign="middle" rowspan="1" colspan="1">v-Raf murine sarcoma viral oncogene homolog B </td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CMA</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Chaperone Mediated Autophagy </td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CB
<sub>1 y 2</sub>
</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Cannabinoid receptor 1 y 2</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CCI779</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Cell Cycle Inhibitor 779</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CML</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Chronic Myeloid Leukemia</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CQ</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Chloroquine</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">CSC</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Cancer stem cell</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">DCMI</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Desmethylclomipramine </td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">DQ</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Dimeric quinacrine</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">EGFR</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Epidermal growth factor receptors</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ER</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Endoplasmic reticulum</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">FIP200</td>
<td align="left" valign="middle" rowspan="1" colspan="1">RB1-inducible coiled-coil protein 1</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">FKBP12</td>
<td align="left" valign="middle" rowspan="1" colspan="1">FK506-binding protein 12</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">GABARAP</td>
<td align="left" valign="middle" rowspan="1" colspan="1">γ-aminobutiric acid receptor-associated proteins</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">HCQ</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Hydroxychloroquine</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">HDAC</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Histone deacetylase</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">HDACIs</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Histone deacetylase inhibitors</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">LAMP2</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Lysosome-associated membrane protein 2</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">LC3</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Microtubule-associated protein light chain 3</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">MQ</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Mefloquine</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">mTORC1</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Mammalian target of rapamycin complex 1</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">mTORC2</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Mammalian target of rapamycin complex 2</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">PE</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Phosphatidylethanolamine</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">PI3K</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Phosphoinositide 3-kinase </td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">PI3KC1</td>
<td align="left" valign="middle" rowspan="1" colspan="1">The class I phosphatidylinositol 3-kinase</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">PI3KC3</td>
<td align="left" valign="middle" rowspan="1" colspan="1">The class III phosphatidylinositol 3-kinase</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">PtdIns3P</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Phosphatidylinositol 3-phosphate </td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ROS</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Reactive oxygen species</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">SAHA</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Suberoylanilide hydroxamic acid</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">SNAP29</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Synaptosomal-associated protein 29</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">SNARE</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Soluble N-ethylmaleimide-sensitive factor activating protein receptor</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">STX17</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Syntaxin 17</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">THC</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Δ
<sup>9</sup>
-Tetrahydrocannabinol</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">TK</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Tyrosin Kinase</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">TOR</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Target of rapamycin</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">TRB3</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Telomere repeat binding factor 3</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">ULK</td>
<td align="left" valign="middle" rowspan="1" colspan="1">(Unc)-51–Like Kinase proteins</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">VPS15</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Vacuolar Protein Sorting 15</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="1" colspan="1">VPS34</td>
<td align="left" valign="middle" rowspan="1" colspan="1">Vacuolar Protein Sorting 34</td>
</tr>
</tbody>
</array>
</glossary>
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<fig id="cancers-11-01599-f001" orientation="portrait" position="float">
<label>Figure 1</label>
<caption>
<p>Mechanism of autophagy. The phases of the process of autophagy (nucleation, elongation, maturation, and degradation), with the main proteins that participate in each one, are depicted. Autophagy activators (
<bold>green</bold>
) and inhibitors (
<bold>red</bold>
) are marked where they interfere with the autophagy process. Numbers correspond to those compounds listed in
<xref rid="cancers-11-01599-t001" ref-type="table">Table 1</xref>
and
<xref rid="cancers-11-01599-t002" ref-type="table">Table 2</xref>
, respectively.</p>
</caption>
<graphic xlink:href="cancers-11-01599-g001"></graphic>
</fig>
<table-wrap id="cancers-11-01599-t001" orientation="portrait" position="float">
<object-id pub-id-type="pii">cancers-11-01599-t001_Table 1</object-id>
<label>Table 1</label>
<caption>
<p>Autophagy activators.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Mechanism of Action/Type</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Name</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Structure</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Number in
<xref ref-type="fig" rid="cancers-11-01599-f001">Figure 1</xref>
</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Refs.</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="4" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">mTOR Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Rapacmycin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i001.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B43-cancers-11-01599" ref-type="bibr">43</xref>
,
<xref rid="B44-cancers-11-01599" ref-type="bibr">44</xref>
,
<xref rid="B45-cancers-11-01599" ref-type="bibr">45</xref>
,
<xref rid="B46-cancers-11-01599" ref-type="bibr">46</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Temsirolimus (CCI779)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i002.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">2</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B47-cancers-11-01599" ref-type="bibr">47</xref>
,
<xref rid="B48-cancers-11-01599" ref-type="bibr">48</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Everolimus (RAD001)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i003.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">3</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B49-cancers-11-01599" ref-type="bibr">49</xref>
,
<xref rid="B50-cancers-11-01599" ref-type="bibr">50</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">AZD8055</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i004.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">4</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B51-cancers-11-01599" ref-type="bibr">51</xref>
,
<xref rid="B52-cancers-11-01599" ref-type="bibr">52</xref>
]</td>
</tr>
<tr>
<td rowspan="3" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">BH3 Mimetics</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">(-)-gossypol (AT-101)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i005.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">5</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B53-cancers-11-01599" ref-type="bibr">53</xref>
,
<xref rid="B54-cancers-11-01599" ref-type="bibr">54</xref>
,
<xref rid="B55-cancers-11-01599" ref-type="bibr">55</xref>
,
<xref rid="B56-cancers-11-01599" ref-type="bibr">56</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Obatoclax (GX15-070)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i006.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">6</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B57-cancers-11-01599" ref-type="bibr">57</xref>
,
<xref rid="B58-cancers-11-01599" ref-type="bibr">58</xref>
,
<xref rid="B59-cancers-11-01599" ref-type="bibr">59</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">ABT-737</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i007.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">7</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B60-cancers-11-01599" ref-type="bibr">60</xref>
]</td>
</tr>
<tr>
<td rowspan="2" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Cannabinoids</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Δ9-Tetrahydrocannabinol (THC)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i008.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">8</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B61-cancers-11-01599" ref-type="bibr">61</xref>
,
<xref rid="B62-cancers-11-01599" ref-type="bibr">62</xref>
,
<xref rid="B63-cancers-11-01599" ref-type="bibr">63</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">JWH-015</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i009.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">9</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B64-cancers-11-01599" ref-type="bibr">64</xref>
]</td>
</tr>
<tr>
<td rowspan="2" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Histone Deacetylase Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Suberoylanilide hydroxamic acid (SAHA, Vorinostat)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i010.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">10</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B65-cancers-11-01599" ref-type="bibr">65</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">MHY2256</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i011.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">11</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B66-cancers-11-01599" ref-type="bibr">66</xref>
]</td>
</tr>
<tr>
<td rowspan="4" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Natural Products</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Betulinic acid</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i012.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">12</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B67-cancers-11-01599" ref-type="bibr">67</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Resveratrol</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i013.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">13</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B68-cancers-11-01599" ref-type="bibr">68</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">δ-Tocotrienol</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i014.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">14</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B69-cancers-11-01599" ref-type="bibr">69</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Curcumin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i015.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">15</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B70-cancers-11-01599" ref-type="bibr">70</xref>
]</td>
</tr>
<tr>
<td rowspan="2" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Others</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lapatinib</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i016.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">16</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B71-cancers-11-01599" ref-type="bibr">71</xref>
,
<xref rid="B72-cancers-11-01599" ref-type="bibr">72</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">APO866</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i017.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">17</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B73-cancers-11-01599" ref-type="bibr">73</xref>
]</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="cancers-11-01599-t002" orientation="portrait" position="float">
<object-id pub-id-type="pii">cancers-11-01599-t002_Table 2</object-id>
<label>Table 2</label>
<caption>
<p>Autophagy inhibitors.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th colspan="2" align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1">Mechanism of Action</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Name</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Structure</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Number in
<xref ref-type="fig" rid="cancers-11-01599-f001">Figure 1</xref>
</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Refs.</th>
</tr>
</thead>
<tbody>
<tr>
<td rowspan="6" colspan="2" align="center" valign="middle" style="border-bottom:solid thin">ULK Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Compound 6</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i018.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B96-cancers-11-01599" ref-type="bibr">96</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">MRT68921</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i019.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">2</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B97-cancers-11-01599" ref-type="bibr">97</xref>
,
<xref rid="B98-cancers-11-01599" ref-type="bibr">98</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">MRT67307</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i020.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">3</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B97-cancers-11-01599" ref-type="bibr">97</xref>
,
<xref rid="B98-cancers-11-01599" ref-type="bibr">98</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SBI-0206965</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i021.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">4</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B99-cancers-11-01599" ref-type="bibr">99</xref>
,
<xref rid="B100-cancers-11-01599" ref-type="bibr">100</xref>
,
<xref rid="B101-cancers-11-01599" ref-type="bibr">101</xref>
,
<xref rid="B102-cancers-11-01599" ref-type="bibr">102</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">ULK-100</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i022.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">5</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B103-cancers-11-01599" ref-type="bibr">103</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">ULK-101</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i023.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">6</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B103-cancers-11-01599" ref-type="bibr">103</xref>
]</td>
</tr>
<tr>
<td rowspan="9" colspan="2" align="center" valign="middle" style="border-bottom:solid thin">Pan PI3k Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">3MA</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i024.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">7</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B104-cancers-11-01599" ref-type="bibr">104</xref>
,
<xref rid="B105-cancers-11-01599" ref-type="bibr">105</xref>
,
<xref rid="B106-cancers-11-01599" ref-type="bibr">106</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">3 MA derivatives</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i025.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">8</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B107-cancers-11-01599" ref-type="bibr">107</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Wortmannin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i026.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">9</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B108-cancers-11-01599" ref-type="bibr">108</xref>
,
<xref rid="B109-cancers-11-01599" ref-type="bibr">109</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">LY294002</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i027.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">10</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B110-cancers-11-01599" ref-type="bibr">110</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SF1126</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i028.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">11</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B111-cancers-11-01599" ref-type="bibr">111</xref>
,
<xref rid="B112-cancers-11-01599" ref-type="bibr">112</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">PI103</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i029.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">12</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">KU55933</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i030.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">13</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B114-cancers-11-01599" ref-type="bibr">114</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Gö6976</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i031.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">14</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B114-cancers-11-01599" ref-type="bibr">114</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">GSK1059615</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i032.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">15</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B115-cancers-11-01599" ref-type="bibr">115</xref>
,
<xref rid="B116-cancers-11-01599" ref-type="bibr">116</xref>
]</td>
</tr>
<tr>
<td rowspan="5" colspan="2" align="center" valign="middle" style="border-bottom:solid thin">VPS34 (PI3KC3) Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SAR405</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i033.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">16</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B113-cancers-11-01599" ref-type="bibr">113</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">VPS34-IN1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i034.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">17</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B117-cancers-11-01599" ref-type="bibr">117</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">PIK-III</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i035.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">18</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B118-cancers-11-01599" ref-type="bibr">118</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Compound 31</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i036.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">19</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B119-cancers-11-01599" ref-type="bibr">119</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Spautin-1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i037.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">20</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B120-cancers-11-01599" ref-type="bibr">120</xref>
]</td>
</tr>
<tr>
<td rowspan="8" colspan="2" align="center" valign="middle" style="border-bottom:solid thin">ATG Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">ATG7 inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i038.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">21</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">WO2018/089786</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">ATG7 inhibitor, miR154</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">UAGGUUAUCCGUGUUGCCUUCG</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">22</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B121-cancers-11-01599" ref-type="bibr">121</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NSC185058</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i039.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">23</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B122-cancers-11-01599" ref-type="bibr">122</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Tioconazol </td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i040.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">24</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B123-cancers-11-01599" ref-type="bibr">123</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">UAMC-2526</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i041.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">25</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B124-cancers-11-01599" ref-type="bibr">124</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">LV320</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i042.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">26</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B125-cancers-11-01599" ref-type="bibr">125</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">S130</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i043.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">27</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B126-cancers-11-01599" ref-type="bibr">126</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">FMK-9a</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i044.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">28</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B127-cancers-11-01599" ref-type="bibr">127</xref>
,
<xref rid="B128-cancers-11-01599" ref-type="bibr">128</xref>
,
<xref rid="B129-cancers-11-01599" ref-type="bibr">129</xref>
]</td>
</tr>
<tr>
<td colspan="2" align="center" valign="middle" style="border-bottom:solid thin" rowspan="1">Autophagy Formation</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Verteporfin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i045.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">29</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B130-cancers-11-01599" ref-type="bibr">130</xref>
,
<xref rid="B131-cancers-11-01599" ref-type="bibr">131</xref>
,
<xref rid="B132-cancers-11-01599" ref-type="bibr">132</xref>
,
<xref rid="B133-cancers-11-01599" ref-type="bibr">133</xref>
]</td>
</tr>
<tr>
<td rowspan="18" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Lysosome Inhibitors</td>
<td rowspan="7" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Lysosomotropic Agents</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Chloroquine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i046.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">30</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B134-cancers-11-01599" ref-type="bibr">134</xref>
,
<xref rid="B135-cancers-11-01599" ref-type="bibr">135</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Hydroxychloroquine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i047.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">31</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B136-cancers-11-01599" ref-type="bibr">136</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lys05</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i048.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">32</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B137-cancers-11-01599" ref-type="bibr">137</xref>
,
<xref rid="B138-cancers-11-01599" ref-type="bibr">138</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">DQ661</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i049.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">33</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B139-cancers-11-01599" ref-type="bibr">139</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">VATG-027</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i050.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">34</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B140-cancers-11-01599" ref-type="bibr">140</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Mefloquine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i051.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">35</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B141-cancers-11-01599" ref-type="bibr">141</xref>
,
<xref rid="B142-cancers-11-01599" ref-type="bibr">142</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Ganoderma lucidum polysaccharide (GLP)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">36</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B143-cancers-11-01599" ref-type="bibr">143</xref>
,
<xref rid="B144-cancers-11-01599" ref-type="bibr">144</xref>
,
<xref rid="B145-cancers-11-01599" ref-type="bibr">145</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Vacuolar H
<sup>+</sup>
ATPase Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Bafilomycin A1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i052.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">37</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B146-cancers-11-01599" ref-type="bibr">146</xref>
,
<xref rid="B147-cancers-11-01599" ref-type="bibr">147</xref>
,
<xref rid="B148-cancers-11-01599" ref-type="bibr">148</xref>
]</td>
</tr>
<tr>
<td rowspan="3" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Ionophores</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Tambjamines</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i053.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">38</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B149-cancers-11-01599" ref-type="bibr">149</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Monensin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i054.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">39</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B150-cancers-11-01599" ref-type="bibr">150</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Squaramides</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i055.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">40</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B151-cancers-11-01599" ref-type="bibr">151</xref>
]</td>
</tr>
<tr>
<td rowspan="3" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Inhibition of Autophagosome-Lysosome Fusion </td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">WX8 family</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i056.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">41</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B152-cancers-11-01599" ref-type="bibr">152</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Vacuolin-1</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i057.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">42</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B153-cancers-11-01599" ref-type="bibr">153</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Desmethylclomipramine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i058.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">43</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B154-cancers-11-01599" ref-type="bibr">154</xref>
]</td>
</tr>
<tr>
<td rowspan="3" align="center" valign="middle" style="border-bottom:solid thin" colspan="1">Acid Protease Inhibitors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Pepstatin A</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i059.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">44</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B155-cancers-11-01599" ref-type="bibr">155</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Leupeptin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i060.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">45</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B155-cancers-11-01599" ref-type="bibr">155</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">E64d</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">
<inline-graphic xlink:href="cancers-11-01599-i061.jpg"></inline-graphic>
</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">46</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B156-cancers-11-01599" ref-type="bibr">156</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Others</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Nanoparticles</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">47</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B157-cancers-11-01599" ref-type="bibr">157</xref>
,
<xref rid="B158-cancers-11-01599" ref-type="bibr">158</xref>
,
<xref rid="B159-cancers-11-01599" ref-type="bibr">159</xref>
]</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap id="cancers-11-01599-t003" orientation="portrait" position="float">
<object-id pub-id-type="pii">cancers-11-01599-t003_Table 3</object-id>
<label>Table 3</label>
<caption>
<p>Clinical trials results with autophagy modulators. Autophagy modulator column has been added.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Clinicaltrials.Gov ID</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Treatment (Dose Per Day)</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Autophagy Modulator</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Condition</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Study Phase</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Result</th>
<th align="center" valign="middle" style="border-top:solid thin;border-bottom:solid thin" rowspan="1" colspan="1">Refs.</th>
</tr>
</thead>
<tbody>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01273805</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Metastatic Pancreatic cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B248-cancers-11-01599" ref-type="bibr">248</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (800 mg)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Early stage solid tumors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Autophagy inhibition, apoptosis</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B247-cancers-11-01599" ref-type="bibr">247</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00771056</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">B-cell chronic lymphocytic leukemia</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">50% efficacy. No adverse events</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg) + bortezomib</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Myeloma</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Autophagy Inhibition. Moderate response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B251-cancers-11-01599" ref-type="bibr">251</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00786682</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg) + docetaxel</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Prostate cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Terminated; lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01649947</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg) + Paclitaxel + Carboplatin + Bevacizumab </td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NSCLC</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Evaluation of Bevacizumab addition to the drug cocktail</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01026844</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1000 mg) + Erlotinib</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Advanced NSCLC</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Safe but low efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B249-cancers-11-01599" ref-type="bibr">249</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00977470</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1000 mg) + Erlotinib</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Advanced NSCLC</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Not completed; lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01978184</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg) + Gemcitabine + paclitaxel</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Pancreatic cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Moderate results</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B266-cancers-11-01599" ref-type="bibr">266</xref>
,
<xref rid="B267-cancers-11-01599" ref-type="bibr">267</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01128296</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg) + Gemcitabine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Pancreatic cancer (stage IIb III)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I–II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">65% Autophagy inhibition</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B268-cancers-11-01599" ref-type="bibr">268</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00486603</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (600 mg) + Temozolomide + radiation</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Glioblastoma multiforme</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I–II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Autophagy inhibition in 45–66%. 70% affected by serious adverse effects.
<break></break>
Lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B252-cancers-11-01599" ref-type="bibr">252</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg) + Temozolomide</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Advanced solid tumors and melanoma</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Autophagy inhibition. Moderate results</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B250-cancers-11-01599" ref-type="bibr">250</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01842594</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg) + Rapamycin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor + Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Sarcoma</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Terminated; 60% partial response.</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B269-cancers-11-01599" ref-type="bibr">269</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01687179</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg) + Rapamycin</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor + Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lymphaglioleiomyomatosis</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Well tolerated. Limited response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B263-cancers-11-01599" ref-type="bibr">263</xref>
,
<xref rid="B270-cancers-11-01599" ref-type="bibr">270</xref>
,
<xref rid="B271-cancers-11-01599" ref-type="bibr">271</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (1200 mg) + Temsirolimus</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor + Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Advanced solid tumors and melanoma</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Well tolerated, autophagy inhibition. Moderate response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B265-cancers-11-01599" ref-type="bibr">265</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (600 mg) + Vorinostat</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor + Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Advanced solid tumors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Well tolerated, moderate response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B261-cancers-11-01599" ref-type="bibr">261</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">HCQ (400 mg) + Rapamycin + metronomic conventional chemotherapy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor + Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Solid tumors</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Encouraging results</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B264-cancers-11-01599" ref-type="bibr">264</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (150 mg)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">GBM</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Encouraging results</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B185-cancers-11-01599" ref-type="bibr">185</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (150 mg) + Carmustine</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">GBM</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Limited response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B253-cancers-11-01599" ref-type="bibr">253</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (250 mg) + radiotherapy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">GBM</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Pilot</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Encouraging results (5 patients)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B272-cancers-11-01599" ref-type="bibr">272</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT01894633</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (150 mg) + radiotherapy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Brain metastais</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Limited response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B255-cancers-11-01599" ref-type="bibr">255</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (250 mg) + radiotherapy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Brain metastasis</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Pilot</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Well tolerated</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B273-cancers-11-01599" ref-type="bibr">273</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">CQ (150 mg) + vemurafenib</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inhibitor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">BRAF
<sup>V600E</sup>
Brain tumor</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Encouraging results (6 patients)</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B203-cancers-11-01599" ref-type="bibr">203</xref>
,
<xref rid="B256-cancers-11-01599" ref-type="bibr">256</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00365599</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Vorinostat (400 mg) + Tamoxifen</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">hormone-therapy resistant breast cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Moderate response</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B260-cancers-11-01599" ref-type="bibr">260</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">(-)-gossypol (80 mg) + cisplatin + etoposide</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">SCLC</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">I</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Encouraging results</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B257-cancers-11-01599" ref-type="bibr">257</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1"></td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">(-)-gossypol (80 mg) + docetaxel</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Head and neck cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B258-cancers-11-01599" ref-type="bibr">258</xref>
]</td>
</tr>
<tr>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">NCT00666666</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">(-)-gossypol (20 mg) + androgen deprivation therapy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Inducer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">metastatic prostate cancer</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">II</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">Lack of efficacy</td>
<td align="center" valign="middle" style="border-bottom:solid thin" rowspan="1" colspan="1">[
<xref rid="B259-cancers-11-01599" ref-type="bibr">259</xref>
]</td>
</tr>
</tbody>
</table>
</table-wrap>
</floats-group>
</pmc>
</record>

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