Medical Oncology (2020) 37:19

https://doi.org/10.1007/s12032-020-1345-2

REVIEW ARTICLE

Preclinical and clinical combination therapies in the treatment

of anaplastic thyroid cancer
Daniela Gentile1 · Paola Orlandi1 · Marta Banchi1 · Guido Bocci1 

Received: 28 December 2019 / Accepted: 12 February 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Anaplastic thyroid cancer (ATC) is the most aggressive form of thyroid cancer, and novel therapies are urgently needed to
prolong patient survival and improve clinical outcomes. Very few scientific reviews have examined the literature on com-
bination therapies with the goal of describing the available preclinical and clinical data and suggesting future clinical com-
bination treatment schedules. The present review focuses on preclinical and clinical studies of drug combination therapies
in ATC. The relevant literature from PubMed and Scopus was reviewed in this article; the ClinicalTrials.gov database was
searched for clinical trials not yet published. Recent data from preclinical models strongly support the idea that combination
treatments that utilize drugs from different antineoplastic classes have synergistic antitumour activity in ATC. However,
rapid translation of these therapies into the clinic is impeded by the difficulty in recruiting enough patients for randomized
clinical trials. Although promising results have been obtained in preclinical studies, additional clinical research is required
to elucidate the efficacy of combination treatments for clinical practice.

Keywords  Anaplastic thyroid cancer · Combination treatment · Synergism · Clinical trials · Mouse models

Introduction neck. However, early diagnosis of ATC is very rare, and

Thyroid tumours are typically classified into benign thyroid
adenomas, papillary thyroid cancer (PTC), follicular thyroid
cancer (FTC), medullary thyroid cancer (MTC) and ana-
plastic thyroid cancer (ATC). Differentiated thyroid cancer
(DTC) usually indicates PTC and FTC, which originate from
follicular cells, whereas MTC originates from parafollicular
cells [1]. PTC, FTC and MTC are collectively called DTC,
as they show differentiated features of their origin cells, and
generally have a good prognosis with > 98% 5-years survival
[1]. Conversely, ATC is undifferentiated, and is the most
aggressive form of thyroid cancer [2, 3]. Although it repre-
sents only 1–2% of all thyroid tumours, it accounts for up to
50% of all thyroid cancer-related mortalities. ATC is most
common in people over age 60, and has a mean survival of
only six months after diagnosis [4]. ATC can be diagnosed
by fine needle aspiration biopsy of either a rapidly growing
thyroid mass, or an abnormal lymph node in the patient’s
* Guido Bocci
guido.bocci@med.unipi.it
1
Dipartimento di Medicina Clinica e Sperimentale, Università
di Pisa, Scuola Medica – Via Roma 55, 56126 Pisa, Italy
usually is discovered incidentally during a routine physical
examination. As ATC grows, it compresses the trachea and
causes dyspnoea, dysphagia, neck pain, and hoarseness [4].
Indeed, ATC patients have an aggressive course, and present
with locally advanced disease or metastasis [5]. Although
the causes of ATC are unknown, thyroid cancer may arise
de novo, or from one of the differentiated cancers, as sug-
gested by the simultaneous occurrence of areas, in the same
tumour mass, of differentiated or poorly differentiated thy-
roid carcinoma [6].
ATC responds poorly to conventional therapies and
requires a multidisciplinary approach for its management.
According to the American Thyroid Association guidelines,
the options for improving patient prognosis are surgery and
radiotherapy, followed by chemotherapy [7]. However, it is
important to emphasize that any treatment used alone usu-
ally fails to control local disease, which is often the cause of
death [8]. Previous studies have suggested that surgery with
adjuvant radiotherapy improves patient survival, while other
studies recommend adding both radiotherapy and chemo-
therapy to the routine management of ATC [9]. Complete
surgical resection remains the cornerstone of therapy in
resectable tumours. Radiotherapy is often administered

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preoperatively to reduce or destroy the tumour as well as
post-operatively, to ablate the remaining thyroid tissue,
eliminate any suspected micrometastases, or remove recur-
rent disease [9]. Chemotherapy is usually administered
for advanced ATC treatment, and includes drugs such as
doxorubicin, paclitaxel, cisplatin, and carboplatin. The
clinical activity of these commonly used chemotherapeu-
tics (i.e. doxorubicin) is low, with a response rate of 22%.
Thus, more active compounds need to be employed in the
therapeutic strategy against ATC [10]. Due to the failure
of single-agent chemotherapy, a combination of two or
more drugs such as paclitaxel, cisplatin, doxorubicin, peg-
filgrastim and docetaxel has been suggested as therapeutic
for ATC patients [10]. Moreover, a second-line treatment
could use targeted therapies including tyrosine kinase inhibi-
tors (TKIs), anti-angiogenic drugs, and multikinase inhibi-
tors [8]. In addition, RAF/MAPK signalling is an integral
part of ATC progression, and some molecular therapeutics
such as the BRAF inhibitor (i.e. vemurafenib) and the MEK
inhibitor (i.e. selumetinib) target this signalling cascade
[8]. In general, these single-targeted inhibitors have failed
to show significant therapeutic responses in ATC patients,
which has led to the use of multikinase inhibitors that act on
two or more targets [8]. Recently, molecular characteriza-
tion of ATC tumours has facilitated an investigation into a
variety of molecular-targeted agents that inhibit TK recep-
tors, as these receptors are responsible for tumour growth
and angiogenesis [8]. Moreover, some anecdotal accounts
of sunitinib’s effects on ATC patients have been reported
[11, 12]. Several TK inhibitors are currently under clinical
investigation. Indeed, sorafenib, imatinib, and axitinib have
all been tested in small clinical trials, and have shown prom-
ising disease control rates that range from 35 to 75% [13].
In the last few years, several TKIs have been tested for the
treatment of advanced, progressive and radioactive iodine
(RAI)-refractory thyroid cancers. Of these, lenvatinib and
sorafenib have been approved by the Food and Drug Admin-
istration (FDA) and the European Medical Agency for the
treatment of radioactive iodine-refractory and progressive
DTC, but not in poorly DTC [14]. Sorafenib is a multikinase
inhibitor that inhibits RAF, VEGFRs, the PDGF receptor,
and RET, lenvatinib is a multikinase inhibitor that acts on
VEGFRs [15].
Combination treatments in ATC​
Considering that ATC is very aggressive and that no chemo-
therapeutic or targeted-therapy drug has demonstrated sat-
isfactory activity acting alone (with the exception of dab-
rafenib and trametinib combination on BRAF V600E-mutant
ATC), recent research efforts have focused on novel drugs
and, above all, on new drug combinations. The common
13
Medical Oncology (2020) 37:19
issues associated with monotherapy (single-agent admin-
istration) include drug resistance at cellular and tumour
levels, a harsh tumour microenvironment that hinders drug
penetration and efficacy, tumour heterogeneity, and dose-
limiting toxicity [16]. These issues are applicable to ATC
as well. The combination of chemotherapy regimens that
contain two or more anticancer drugs is a practice that has
been applied clinically for decades, in a variety of cancers
[17]. Similarly, a combination of different drugs is often
used in preclinical studies, and sometime in clinical trials,
to improve therapeutic efficacy in ATC [8]. However, it is
important to determine which drug combinations are syn-
ergistic, and which have data to suggest that similar drug
combinations will fail clinically. To date, very few reviews
have been conducted on combination treatments in ATC,
with the goal of describing preclinical data and identifying
future combination therapy schedules to be used clinically.
Therefore, the present review will discuss the preclinical and
clinical studies that have used drug combination therapies
for ATC. The relevant literature from PubMed and Scopus
were reviewed in this article; the ClinicalTrials.gov database
was searched for clinical trials not yet published.
Methodology
Data sources and searches
The PubMed and Scopus databases were searched for rel-
evant research articles published between January 2000 and
December 2019 using the search terms “anaplastic thyroid
cancer” AND “combination treatment”; “anaplastic thyroid
cancer” AND “synergism”; “anaplastic thyroid cancer”
AND “combination” AND “clinical trials”; “anaplastic
thyroid cancer” AND “mouse models” AND “combina-
tion”. Research articles published in English that reported
preclinical and clinical combination of drugs in anaplastic
thyroid cancer were included in this review. No restrictions
were adopted for the geographical origin of the articles: data
from Asia, Africa, Europe, North and South America and
Oceania were allowed.
Inclusion/exclusion criteria
Research studies were included in the review if they met the
following inclusion criteria: (1) the study looked at the pre-
clinical combination therapies in vitro and in vivo for ATC;
(2) the study examined the clinical combination studies in
ATC; (3) the study reported data from abstracts on ATC
combined therapies presented at international meetings but
not yet published in extenso on scientific journals. Publica-
tions were excluded if they were reviews, commentaries, edi-
torials or letters to the editor. However, additional articles,
such as reviews and editorials which dealt with the general
Medical Oncology (2020) 37:19 Page 3 of 15  19
concepts in the treatment of ATC and the mechanisms of
cited drugs were included into some sections of the review.
Following removal of duplicate studies, the authors indepen-
dently reviewed each article for potential eligibility based on
the title and abstract. The full text was obtained for articles
considered to be eligible by each author.
Data synthesis and analysis
The authors independently reviewed data from the identi-
fied studies. Each study was analysed and a summary of the
findings was elaborated. The results of this review process
were compared, and any discrepancies were resolved by con-
sensus following discussion. Using the search items “ana-
plastic thyroid cancer” AND “combination treatment” we
identified 450, and 205 articles in the PubMed and Scopus
databases, respectively; using the search items “anaplastic
thyroid cancer” AND “synergism” we identified 49, and 24
articles in these two databases, respectively; whereas the
search items “anaplastic thyroid cancer” AND “combina-
tion” AND “clinical trials” identified 41, and 61 articles in
PubMed, and Scopus, respectively. Finally, adopting the
terms anaplastic thyroid cancer” AND “mouse models”
AND “combination”, we found 81 and 13 articles in Pub-
med and Scopus, respectively. After the removal of duplicate
studies, we identified and reviewed a total of 163 articles, of
which 39 met the inclusion criteria and were included in the
study (Tables 1 and 2).
Preclinical studies
Several studies have been performed to investigate the syn-
ergistic relationship between two or three drugs in ATC.
Several of these have shown compelling antitumour effects
in in vitro and in vivo models. In the following sections, we
review the most recent preclinical studies on the manage-
ment of ATC (Table 1).
Chemotherapy‑based combination studies
The simultaneous combination of the topoisomerase I inhib-
itor camptothecin analogue irinotecan and the TK inhibi-
tor sunitinib showed synergistic ATC antitumour activity
in both in vitro and in vivo experiments [18]. In particular,
when these drugs were given simultaneously, they showed
a high degree of synergism in ATC cells. Specifically, they
increased the intracellular concentration of SN-38, the active
metabolite of irinotecan. Moreover, this synergistic combi-
nation greatly decreased the gene expression and protein lev-
els of VEGF, colony stimulating factor-1, and ATP-binding
cassette transporter G2 in ATC cells [18]. In another pre-
clinical study, a combination therapy of irinotecan and the
monoclonal antibody cetuximab (an EGFR inhibitor) caused
tumour growth arrest and blocked ATC progression in an
orthotopic mouse model [19]. The combination of irinotecan
and the VEGFR-2 TKI PTK787/ZK222584 (vatalanib) also
caused a decrease in ATC growth in an orthotopic mouse
model, as well as a decrease in both the tumour endothelium
and tumour microvessel density [20]. Recently, Di Desidero
and colleagues have investigated the in vitro activity in ATC
of the camptothecin analogue topotecan, a drug belonging to
the same therapeutic class of irinotecan, in combination with
the tyrosine kinase inhibitor pazopanib. Interestingly, the
concomitant schedule caused a strong synergism with a sig-
nificant increase of intracellular concentrations of topotecan
lactone, decreasing the mRNA expression of ATP-binding
cassette transporter G2, hypoxia-inducible factor-1α and
vascular endothelial growth factor [21].
The taxane paclitaxel (a microtubule inhibitor) plus the
TKI lenvatinib showed a significant antitumour effect in
ATC cells through an increased percentage of ATC cells
in G2/M phase [22]. In addition, tumour size was reduced
in an ATC xenograft treated with the same drug combina-
tion, where tumour reduction was greater compared with
lenvatinib or paclitaxel monotherapy [22]. Manumycin,
a potent and selective farnesyl-transferase inhibitor [23],
enhanced the cytotoxic effect of the chemotherapeutic drug
paclitaxel, and the combination of these drugs increased
apoptotic cell death in ATC cells compared with either drug
alone [24]. This combination was also effective in vivo, with
no significant toxicity observed [24]. In a subsequent study,
paclitaxel plus manumycin was reported to be an effec-
tive drug combination against ATC xenograft growth and
was able to inhibit tumour angiogenesis [25]. Moreover,
in an ATC xenograft model, the triple-drug combination
of paclitaxel plus manumycin and minocycline (an anti-
biotic with potent inhibitory effects on matrix metallo-
proteinases) resulted in the lowest average tumour growth
rate and the longest survival, compared with manumycin
alone, paclitaxel alone, or manumycin plus paclitaxel [26].
Other triple-drug combinations (i.e. combrestatin A4 phos-
phate + paclitaxel + manumycin and combretastatin A4
phosphate + paclitaxel + carboplatin) demonstrated excel-
lent antineoplastic activity and marked vascular disruption
activity in ATC xenograft models [27]. Paclitaxel in combi-
nation with the novel high-affinity peroxisome proliferator-
activated receptor-γ (PPARγ) agonist RS5444 demonstrated
an additive anti-proliferative activity in cell culture, but also
inhibited ATC tumour growth in vivo [28]. While RS5444
did not induce apoptosis by itself, it doubled the apoptotic
index of paclitaxel alone, when given in combination with
the chemotherapeutic [28]. In contrast, some studies have
described instances in which drug combinations exhibit
antagonistic or non-synergistic relationships. For example,
paclitaxel and the cholesterol-lowering drug lovastatin were
cytotoxic in two ATC cell lines, and increased apoptosis
13
 Table 1  Combination treatments on ATC preclinical models
Combination studies
13
Chemotherapy-based combination studies
Irinotecan (0.01–100 μM)  + sunitinib (0.01–
100 μM)
Irinotecan (100 mg/kg/week i.p.) + sunitinib
(25 mg/kg/every 2 days i.p.)
Cetuximab (0.5 g/mL) + irinotecan
Irinotecan (50 mg/kg once per week i.p.) + cetux- Mice: Male athymic nude mice, age 8 to
imab (1 mg/injection twice per week i.p.)
Irinotecan (50 mg/kg once/week i.p.) + PTK787/
ZK222584 (vatalanib)
50 mg/kg once/day by oral gavage
Topotecan (0.01–100 μM) + pazopanib (0.01–
100 μM)
Paclitaxel (500 nM) + lenvatinib (5 µM)
Paclitaxel (5 mg/kg twice per week i.p.) + len-
vatinib (5 mg/kg/day oral route)
Manunycin (0–100 µM) + paclitaxel (0–10 µM)
Manumycin (7.5 mg/kg i.p.) + paclitaxel (20 mg/
kg i.p.)
Manumycin (15 mg/kg·week oral) + paclitaxel
(40 mg/kg·week i.p.)
Paclitaxel (50 mg/kg/day i.p.) + manumycin
(2.5 mg/kg/day i.p.) + minocycline (subcuta-
neous implantation of a slow-release tablet
(10 mg released over 60 days)
Manumycin (3 mg/kg days on days 1–5
i.p.) + paclitaxel (50 mg/kg days on days 1 of
each 7-days cycle i.p.)
Combrestatin A4 phosphate 50 mg/kg/daily, days
1–5, 2 h after the manumycin or paclitaxel
injection
Paclitaxel (0.01–1000 nM) + RS5444 (0.1–
1000 nM)
Paclitaxel (0.2–0.3 mg/0.1 ml twice weekly
i.p.) + 0.025% RS5444
Preclinical models
ATC cell lines: 8305C and FB3
Mice: 6-week-old CD nu/nu male
ATC cell line: ARO
12 weeks
Mice: Male athymic nude mice, age 8 to
12 weeks
ATC cell lines: 8305C and FB3
ATC cell lines: C643, 8305C and 8505C
Mice: Female athymic nude mice
ATC cell lines: ARO, C643, DRO, Hth-74, KAT- Manumycin enhanced the cytotoxic effect of
4, and KAT-18
Mice: 7-week-old nude mouse
Mice: 7-week-old nude mouse (nu/nu BALB-c
mice bred)
Mice: 5-week-old nude mouse (nu/nu BALB-c)
Mice: 5-week-old nude (nu/nu BALB-c)
ATC cell line: DRO
Mice: 3–4 week athymic female nude mice
(Harlan)
19  
Results References
Significant synergistic ATC antitumour activity Di Desidero et al. [18]
in vitro and in vivo; increased intracellular
Page 4 of 15
SN-38 concentrations; decreased expression of
VEGF, colony stimulating factor-1 and ATP-
binding cassette transporter G2
Significant synergistic ATC antitumour growth Kim et al. [19]
and progression; decreased incidence of lymph
node metastasis, laryngeal invasion, and
tumour microvessel density
ATC growth decreased; decline of tumour Kim et al. [20]
endothelium and microvessel density
Significant synergistic ATC antitumour activ- Di Desidero et al. [21]
ity in vitro; increased intracellular topotecan
lactone concentrations; decreased expression of
VEGF, colony stimulating factor-1, hypoxia-
inducible factor-1α and ATP-binding cassette
transporter G2
Significant antitumour effects in ATC cells; Jing et al. [22]
increased percentage of ATC cells in G2/M
phase; reduced tumour size in vivo
Yeung et al. [24]
paclitaxel in all six of the cell lines
The combination had significant inhibitory
effects on tumour growth
Inhibited ATC xenograft growth and tumour Xu et al. [25]
angiogenesis
Lowest average tumour growth rate compared to She et al. [26]
monotherapies; longer survival than manumy-
cin alone, paclitaxel alone, or manumycin plus
paclitaxel in vivo
Antineoplastic activity and a marked vascular Yeung et al. [27]
disruption in vivo
Medical Oncology
Additive anti-proliferative activity in vitro; inhi- Copland et al. [28]
(2020) 37:19
bition of ATC tumour growth in vivo; RS5444
doubled the apoptotic index of paclitaxel alone
 Table 1  (continued)
Combination studies Preclinical models Results References

Paclitaxel (5,10,20 nM) + lovastatin (5,10,20 µM) ATC cell lines: 8505C and BHT-101 Cytotoxic in both ATC cell lines; caused Chung et al. [29]
Paclitaxel (2.5, 5, 15, 10, 20 nM) + lovastatin (5, antagonism that affected the cytotoxicity and
Medical Oncology

10, 20, 30, 40 µM) pro-apoptotic effects on 8505C cells

Baicalein (0, 10, 20, 50, and 100 µM) + docetaxel ATC cell line: 8505C Induced apoptosis and inhibited the metastatic Park et al. [30]
(10 nM) process of ATC cells by downregulating the
expression of apoptotic and angiogenic pro-
teins, and by blocking the ERK and Akt/mTOR
pathways
(2020) 37:19

Selinexor (25, 50, 100, 200, 400 nM) + doxoru- ATC cell lines: SW1736 and ATC351 Synergistic decrease in cell proliferation of both Garg et al. [31]
bicin (25, 50,100,200, 400 nM) ATC cell lines
Tyrosine kinase inhibitors-based combination studies
Sunitinib (10 µM) + SL327 (10 µM) ATC cell lines: CAL62 and KAT4 Reduced viability, increased apoptosis and sup- Wang et al. [32]
Sunitinib (25 mg/kg/day for 2 weeks CAL62 and KAT4 (doxorubicin-resistant ATC pressed migration of cells; induced significant
i.p.) + SL327 (25 mg/kg/day for 2 weeks i.p.) cells) additive suppression of tumour growth in vivo
Mice: nud/nud mice
Sorafenib (0.89, 1.79, 3.58 µmol/L) + quinacrine ATC cell lines: THJ-16 T ATC cells responded in an additive/synergistic Abdulghani et al. [33]
(0.42, 0.85, 1.7, 3.4,6.8 µmol/L) Mice: manner; improved survival of immunodeficient
Sorafenib (30 mg/kg daily for 5 C57BL6/J mice mice injected orthotopically with ATC cells
day0.42 s) + quinacrine (100 mg/kg every other compared to mice administered with either
day via oral gavage) compound alone or doxorubicin; inhibited
expression of the pro-survival MCL-1 factor,
signal transducer and activator of transcription
3 (pSTAT3), and dampened NFκB signalling
Sorafenib ­IC50 6.3 µmol/L + withaferin ­IC50 ATC cell lines: BCPAP Synergistic efficacy in anaplastic thyroid cancers Cohen et al. [34]
0.155 µmol/L SW1736 in vitro with significant pro-apoptotic effects
Sorafenib ­IC50 7.6 µmol/L + withaferin A ­IC50
2.5 µmol/L
HNHA (0.5, 1, 5, 10, 20, 40, 80 µM) + sorafenib ATC cell lines:8505C, SNU-80, and GSA1 Synergistically decreased cell viability and Park et [35]
(0.5, 1, 5, 10, 20, 40, 80 µM) Mice: female BALB/c nude mice significantly increased apoptotic cell death
HNHA (6.5 mg/kg i.p.) + sorafenib (25 mg/kg in ATC cells, as proved by the cleavage of
once every 2 days orally) caspase-3 and DNA fragmentation; signifi-
cantly decreased the vessel density and tumour
volume in ATC xenograft model, increasing
survival
Pazopanib (800 nM) + trametinib (10 nM) ATC cell lines: BCPAP, 8505C and CAL62 cells Significant tumour volume reduction of 50% or Ball et al. [36]
Pazopanib (100 mg/kg daily by oral gav- Mice: 4- to 6-week-old female athymic nude (nu/ more in tumours harbouring K ­ RASG12R and
age) + trametinib (1 mg/kg daily by oral gavage) nu) mice ­BRAFV600E mutations by modulation of the
ERK pathway
Apatinib (20 μM) + chloroquine (10 µM) ATC cell lines: KHM-5 M and C643 Induced protective autophagy and apoptosis Feng et al. [37]
Apatinib (50 mg/kg daily via oral gavage) + chlo- Mice: 4-week-old male BALB/c nude mice through the downregulation of p-Akt and
Page 5 of 15 

roquine (60 mg/kg daily via oral gavage) p-mTOR signals via the Akt/mTOR pathway
in vitro and in vivo
19

13
 Table 1  (continued)
19  

Combination studies Preclinical models Results References

13
MK-2206 (1 μM) + tyrphostin AG 1296 (1 μM) ATC cell lines: AL62 and KAT4 Suppressed ATC cell viability, migration and Che et al. [38]
MK-2206 (100 mg/kg) + tyrphostin AG1296 Mice: nud/nud mice invasion, and tumour growth; induced apop-
(100 mg/kg for 2 weeks i.p.) tosis
Page 6 of 15

Combination between different antineoplastic drugs

Anti-PD-L1 antibody (10F.9G2) (200 µg/mouse/ Mice: 10-week-old female SCID mutant mice
every other day i.p.) + PLX4720 (PLX4720-
impregnated chow 4 total doses)
PLX4720 (10 μM) + dasatinib (50 nM)
PLX4720-impregnated chow ad libitum and
orally gavaged + dasatinib (50 mg/kg 5 days)
PLX4720 (1 μM) + U0126 (10 μM)
Troglitazone (5 μM) + lovastatin (1 μM)
Lovastatin (0.5, 1, and 2 μM) + troglitazone (5 ATC cell line: SW1736
and 10 μM)
Lovastatin (2 mg/kg/day) + troglitazone (5 mg/
kg/day)
Omipalisib (0–100 nM) + palbociclib (0–100 nM) ATC cell line: Mouse (T4888M, T3533, T1860, Omipalisib potentiated and extended the activity
Omipalisib 0.3 mg/kg/day + palbociclib 30 mg/
kg/day, via oral gavage
ATC cell lines: 8505c, BCPAP, TBP-3868, TBP- Reduced the tumour size in an orthotopic ATC
3743, TBPt-3403 and TBPt-3610R
Mice: B6129SF1/J syngeneic mice
ATC cell lines: BCPAP and SW1736
ATC cell lines: 8305C and SW1736
Mice: Bagg’s albino (BALB)/c nude mice
T1903, A274, A275, T7152, T7189)
Human (THJ16T, CAL62, C643, OCUT2,
T238, 8505C, SW1736, THJ21T, T243, T235,
PD-L1 potentiated the effect of PLX4720 on Brauner et al. and Gunda et al. [39, 40]
tumour regression and intensified the antitu-
mour response; increased CD8+ T-cell infiltra-
tion and improved T-cell cytotoxicity profile;
reduced ATC tumour volumes, prolonged mice
survival and improved antitumour immune
profile; maximal tumour reduction was associ-
ated with increased cytotoxicity and number
of CD8+ T cells, NK cells, and M1-polarized
tumour-associated macrophages; decrease in
myeloid-derived suppressor-like cells
Vanden Borre et al. [41]
mouse model, increased immune cell infiltra-
tion and induced apoptosis
No enhanced inhibition of the invasive potential Ingeson-Carlsson et al. [42]
of ATC cells
Significant inhibition of the EGF-induced migra- Chin et al. [43]
tion of ATC cells by increasing E-cadherin
expression and decreasing the vimentin expres-
sion. cAMP response element-binding protein
(CREB) and ERK phosphorylation level was
decreased in ATC cells
Anti-proliferative activity in ATC cell culture Zhong et al. [45]
systems and a tumour regression in the mouse
xenograft model, through a cell cycle arrest at
G0/G1 phase
Wong et al. [46]
of palbociclib in all the tested ATC cell lines;
low-dose combination inhibited tumour growth
in vivo
Medical Oncology

HTH104, ACT1)
Mice: NOD-scid IL2rγnull (NSG) mice, aged 6- to
8-weeks old
BP-14 (5, 10, 25 and 50 nM) and everolimus (25, ATC cell lines: FRO, SW1736, 8505C Strong synergistic effect; significant loss of cell Allegri et al. [47]
50, 100 and 150 nM) viability and downregulation of epithelial–mes-
enchymal transition-related genes
(2020) 37:19
 Table 1  (continued)
Combination studies
BI6727 (600, 1000, 1750 nM) + BKM120 (600,
1000, 1750 nM)
BI6727 (8 mg/kg/day via oral gavage) + BKM120 Mice: 6–8 week-old 129S6/SvE mice
(24 mg/kg/day via oral gavage)
SAHA (1–4 μM) + PJ34 (5–30 μM)
PXD101 (1, 3, and 5 μM) + AUY922 (1, 3, and
5 μM)
SNX5422 (5 μM) + HDAC inhibitors (PXD101,
SAHA, trichostatin A) (5 μM)
Carfilzomib (0, 4, 6, 8, 10, 12 nm) + CUDC-101
(0, 0.4, 0.8, 1.2, 1.6, 2 μM)
13
Preclinical models
ATC cell lines: T4888M, A275, THJ16T,
OCUT2
ATC cell line: SW1736
ATC cell lines: 8505C and CAL62
ATC cell lines: 8505C and CAL62
ATC cell lines: 8505C, C-643, SW-1736,
THJ16T and THJ-29T
Results References
Significant synergistic effect on ATC cells; De Martino et al. [48]
enhanced growth suppression at doses for
Medical Oncology
which single drugs showed no effect, and led to
massive reduction of tetraploid cell popula-
tion; combined inhibition of PI3K and PLK1
was effective in vivo in the immunocompetent
allograft ATC model
Synergistic effect against SW1736 cell growth Baldan et al. [49]
(2020) 37:19
in vitro
AUY922 had synergistic activity with PXD101 Kim et al. [50]
in induction of cytotoxicity in conjunction with
the inactivation of PI3K/Akt signalling and
activation of DNA damage response
Synergistic effects in induction of ATC cell Kim et al. [51]
death; SNX5422 synergizes with HDAC
inhibitors to induce cytotoxicity, suppression
of PI3K/Akt/mTOR signalling and survival,
and the overexpression of DNA damage-related
proteins in ATC cells
Inhibited cellular proliferation and caused cell Zhang et al. [52]
death in multiple ATC cell lines; increased
anti-ATC effect was associated with a syner-
gistically enhanced G2/M cell cycle arrest and
increased caspase 3/7 activity; increased p21
expression and poly (ADP-ribose) polymerase
protein cleavage
Page 7 of 15 
19

13
Table 2  Clinical trials regarding combination schedules in ATC patients
Combination treatments Patients enrolled
Paclitaxel (80 mg/m2/weekly) + valproic acid 25
(1000 mg/day) vs. paclitaxel alone
Sorafenib (200 mg twice daily) + temsiroli- 36
mus (25 mg weekly)
Dabrafenib (150 mg twice daily) + trametinib 16
(2 mg once daily)
Efatutazone (0.15, 0.3, or 0.5 mg doses twice 15
daily) + paclitaxel (every three weeks)
Triple association of combretastatin (60 mg/ 80
m2 for days 1, 8, 15 for 6 cycles), paclitaxel
(200 mg/m2 on day 1), and carboplatin
(AUC 6 on day 1 following paclitaxel) vs.
paclitaxel + carboplatin
Crolibulin (8–20 mg/m2) + cisplatin 27 (16 ATC patients) I/II
(75–100 mg/m2)
Phase Results
II/III Not impaired paclitaxel pharmacokinetics;
median overall survival and the median
time to progression were not found statisti-
cally different in the two arms
II Active combination, with a progression-free Five patients suffered of bowel perforation
survival rate at 1 year of 30.5%, in ATC
patients
II An overall response rate of 69% and a
complete response; durable responses,
with a 12-month Kaplan–Meier estimate of
response duration around 90%
I Seven patients achieved a stable disease, and Grade 3–4 septic shock, dysphagia, dyspnea,
1 patient a partial response
II/III No significant differences of overall survival Combination schedule usually well toler-
between the two arms
One complete response and a stable disease
19  
Page 8 of 15
Adverse drug reactions References
No severe adverse effect was observed. In Catalano et al. [53]
one patient, paclitaxel was reduced to 75%,
as a consequence of allergic reaction
Sherman et al. [55]
(2), excessive fatigue (2), and pneumonitis
(1), leaving the trial; the most common
grade 3 and 4 toxicities included: hypergly-
cemia, fatigue, anaemia, and oral mucositis
Common adverse events were fatigue (38%), Subbiah et al. [56]
pyrexia (37%), and nausea (35%); grade
3–4 diarrhoea, anaemia, and hyperglycae-
mia were also described
Smallridge et al. [58]
anaemia, pneumonia, loss of conscious-
ness, and anaphylactic reaction were
described
Sosa et al. [59]
ated but with described grade 3 and 4
hematologic adverse events (neutropenia,
leukopenia and anaemia)
The most common grade 3 toxicities were: Gramza et al. [60]
lymphopenia, hyponatremia, anae-
mia, hypertension during infusion, and
hypophosphatemia. A laryngeal haem-
orrhage related to tumour erosion was
Medical Oncology
described
(2020) 37:19
Medical Oncology (2020) 37:19 Page 9 of 15  19
in 8505C cells. However, in these cells, the drug combina-
tion had antagonistic effects on both cytotoxicity and pro-
apoptotic events [29]. Therefore, rationally selecting proven
combinations of drugs is crucial for improving therapeutic
effects on this type of anaplastic tumour.
Park and colleagues reported that the simultaneous
administration of the flavonoid baicalein and the microtube
stabilizer docetaxel, induced apoptosis and inhibited the
metastasis of ATC cells by downregulating antiapoptotic and
angiogenic proteins and by blocking the ERK and Akt/mam-
malian target of rapamycin (mTOR) pathways [30]. Finally,
the combination of the exportin-1 inhibitor selinexor, with
the topoisomerase II inhibitor doxorubicin, caused a syner-
gistic decrease in the cellular proliferation of several ATC
cell lines [31].
Tyrosine kinase inhibitor‑based combination studies
The combination of the multi-targeted TK inhibitor sunitinib
and the MEK1/2 inhibitor SL327 caused reduced viability,
increased apoptosis, and suppressed migration of doxoru-
bicin-resistant ATC cells. Moreover, this combination had
a significantly additive effect on repression of doxorubicin-
resistant ATC tumour growth in vivo [32]. Abdulghani and
colleagues also reported that ATC cells responded in an
additive/synergistic manner to the combination of sorafenib
and the nuclear factor kappa B (NFκB) inhibitor quina-
crine [33]. Notably, this drug combination also improved
the survival of immunodeficient mice injected orthotopi-
cally with ATC cells, as compared with mice administered
either doxorubicin or one compound alone [33]. Moreover,
at the molecular level, quinacrine and sorafenib dampened
NFκB signalling, and inhibited the expression of both signal
transducer and activator of transcription 3 (STAT3) and the
pro-survival factor myeloid cell leukaemia-1 (MCL-1) [33].
Sorafenib plus withaferin A (WA), a natural withanolide,
showed synergistic efficacy in papillary and anaplastic thy-
roid cancers in vitro, with significant pro-apoptotic effects
[34]. The histone deacetylase inhibitor N-hydroxy-7-(2-
naphthylthio) heptanomide (HNHA) and sorafenib syner-
gistically decreased cell viability, and significantly increased
apoptotic cell death, as demonstrated by caspase-3 cleav-
age and DNA fragmentation in ATC cells. Moreover, the
combination therapy of HNHA and sorafenib significantly
decreased vessel density and tumour volume in an ATC xen-
ograft model, thereby increasing the survival of the mice
[35]. The combination of the TK inhibitor pazopanib and
the MEK inhibitor trametinib led to a 50% or greater reduc-
tion in tumour volume, for tumours harbouring ­KRASG12R
and ­BRAFV600E mutations. This significant reduction was
mediated through modulation of the ERK pathway [36].
The combination of a VEGFR-2 inhibitor such as apatinib
and the autophagy inhibitor chloroquine, induced apoptosis
in vitro and in vivo by downregulating p-Akt and p-mTOR
signals via the Akt/mTOR pathway [37]. The combined
administration of the Akt inhibitor MK-2206 and tyrphostin
AG1296, a novel PDGFR inhibitor, suppressed ATC cell
viability, migration, and invasion. This combination also
induced apoptosis and suppressed ATC tumour growth [38].
Combination between different antineoplastic drugs
Eran Brauner and collaborators showed that anti-PD-L1
immunotherapy potentiated the effect of the BRAFV600E
inhibitor PLX4720 on tumour regression and intensified the
antitumour immune response in an immunocompetent model
of ATC. This was achieved through increased CD8+ T-cell
infiltration, and an improved cytotoxic T-cell profile [39].
Another study that combined PLX4720 with antibodies to
PD-L1 or PD-1 dramatically reduced murine ATC volumes,
prolonged mice survival time, and improved the antitumour
immune profile [40]. Indeed, in this study maximal tumour
reduction was associated with increased cytotoxicity, and
increased ­CD8+ T-cell and NK cell number. M1-polar-
ized tumour-associated macrophages were also increased,
whereas a decrease in myeloid-derived suppressor-like cells
was described [40]. Moreover, the combination of PLX4720
and dasatinib, a Src tyrosine receptor/Bcr-Abl family inhibi-
tor, reduced tumour size, increased immune cell infiltration,
and induced apoptosis in an orthotopic ATC mouse model
[41]. Conversely, PLX4720 and the MEK inhibitor U0126
did not enhance the inhibition of ATC cells’ invasive poten-
tial, suggesting that migration and invasion in ATC cells are
mediated by other non-MEK mechanisms [42].
Co-administration of the PPARγ ligand troglitazone
and lovastatin exhibited significant inhibition of the EGF-
induced migration of ATC cells, by increasing E-cadherin
expression and decreasing vimentin expression [43]. Moreo-
ver, in ATC cells co-treated with troglitazone and lovastatin,
both cAMP response element-binding protein (CREB) and
ERK phosphorylation levels were decreased [43]. Indeed,
CREB and p-ERK are two crucial signalling molecules for
EGF-induced cysteine-rich 61 expression, which is a secre-
tory protein involved in the regulation of cell adhesion,
DNA synthesis, angiogenesis, cell survival, and cell migra-
tion [44]. Lovastatin and troglitazone co-administration also
cause cell cycle arrest at G0/G1, leading to anti-proliferative
activity in ATC cell culture systems, and tumour regression
in a mouse xenograft model [45].
Wong et al. established that omipalisib, a PI3K/mTOR
inhibitor, potentiated and extended the activity of palbo-
ciclib, a cyclin-dependent kinase (CDK) inhibitor, in all
tested ATC cell lines [46]. More importantly, their low-dose
combination was extremely effective in inhibiting tumour
growth in vivo [46]. Allegri and colleagues also reported
a strong synergistic effect of the new CDK inhibitor BP-14
13
 19   Page 10 of 15
in combination with everolimus, a mTOR inhibitor. This
drug pairing demonstrated a significant loss in cell viabil-
ity in three human ATC cell lines, and downregulation of
epithelial–mesenchymal transition-related genes in two of
them [47].
Another example of combined treatment using two novel
antineoplastic drugs was a treatment with BI6727, a polo-
like kinase 1 (PLK1) inhibitor, and BKM120, a PI3K inhibi-
tor. This combination resulted in a significant synergistic
effect on ATC cells [48]. The two drugs together enhanced
growth suppression at doses for which each single drug
showed no effect and led to a massive reduction in the tetra-
ploid cell population. Finally, the combined inhibition of
PI3K and PLK1 was extremely effective in vivo, in an immu-
nocompetent allograft model of ATC [48].
The combination of suberoylanilide hydroxamic acid
(SAHA), a HDAC inhibitor, and PJ34, a poly ADP ribose
polymerase (PARP) inhibitor, exhibited a synergistic effect
against SW1736 cell growth in vitro [49]. Similar synergis-
tic effects were observed with another HDAC inhibitor, the
compound PXD101, and the heat shock protein 90 (hsp90)
inhibitor NVP-AUY922 (AUY922). Indeed, AUY922
showed synergistic activity with PXD101 in inducing cyto-
toxicity in conjunction with the inactivation of PI3K/Akt
signalling, and the activation of a DNA damage response in
ATC cells [50]. Moreover, the combination of another hsp90
inhibitor, SNX5422, and various HDAC inhibitors such as
PXD101, SAHA, and trichostatin A (TSA), revealed syner-
gistic effects in inducing ATC cell death. Indeed, SNX5422
synergizes with HDAC inhibitors, inducing the suppres-
sion of PI3K/Akt/mTOR signalling and survivin [51]. The
second-generation proteasome inhibitor carfilzomib and the
histone deacetylase and multikinase inhibitor CUDC-101
synergistically inhibited cellular proliferation, and caused
cell death in multiple ATC cell lines [52]. This increased
anti-ATC effect was attributed to the drug combination’s
effects on enhanced G2/M cell cycle arrest and increased
caspase 3/7 activity. Interestingly, the treatment with carfil-
zomib and CUDC-101 also increased p21 expression and
poly (ADP-ribose) polymerase protein cleavage [52].
Clinical studies on combined treatments
Newer strategies involving systemic treatments are desper-
ately needed for ATC patients. It is important to note that
clinical trials of potentially effective treatments for ATC are
hampered by its low incidence and aggressiveness, which
limits patient enrolment, limits the treatment time-frame,
and leads to poor statistical power [8]. However, some ran-
domized or single-arm clinical trials using combined treat-
ments have been performed (Table 2).
Catalano and colleagues [53] carried out a randomized
controlled phase II/III trial on a total of 25 ATC patients
13
Medical Oncology (2020) 37:19
across 5 centres in northwest Italy. The experimental arm
received a combination of paclitaxel (80 mg/m2/weekly)
and valproic acid (1000 mg/day), whereas the control arm
received paclitaxel alone. Valproic acid has emerged as a
promising antineoplastic agent due to its activity as a his-
tone deacetylase inhibitor [53, 54]. The co-administration
of valproic acid did not influence the pharmacokinetics of
paclitaxel, but the median overall survival and the median
time to progression were not statistically different between
the two arms [53].
In a phase II, single-arm study conducted in 36 patients
with radioactive iodine-refractory thyroid carcinoma,
sorafenib (200 mg twice daily) and temsirolimus (25 mg
weekly), appeared to be an active combination in compari-
son to historical data using sorafenib only. This combination
showed a progression-free survival rate at 1 year of 30.5%
for patients who had received no prior treatment [55].
In another phase II, open-label trial, the dabrafenib plus
reatment schedule had important clinical activity in 16
patients with predefined BRAFV600E mutations, and a good
toxicity profile [56]. Indeed, dabrafenib (150  mg twice
daily) plus trametinib (2 mg once daily) combination ther-
apy resulted in a confirmed overall response rate of 69%. In
addition, one patient showed a complete response, achiev-
ing resolution of multiple pulmonary metastases within the
first 8 weeks of therapy. Responses were also durable, with
a 12-month Kaplan–Meier estimate of response duration
around 90% [56].
A multicenter phase I/II dose-finding study has been
conducted in 15 ATC patients treated with efatutazone and
paclitaxel. Efatutazone is an oral PPARγ agonist that was
previously tested as a monotherapy in patients with solid
tumours [57]. In this study, it was taken orally twice daily at
0.15, 0.3, or 0.5 mg doses, and paclitaxel was administered
every three weeks by intravenous infusion. This combination
was safe and tolerated, with 7 patients achieving a stable
disease state, and 1 patient showing a partial response [58].
A multicentre, open-label, randomized controlled trial
was designed to compare the overall survival of ATC
patients treated with the triple combination of combretasta-
tin (also named fosbretabulin; 60 mg/m2 on day 1, 8, 15 for
6 cycles), paclitaxel (200 mg/m2 on day 1), and carboplatin
area under curve (AUC) 6 on day 1 following paclitaxel,
compared to the double treatment of paclitaxel and car-
boplatin. This study enrolled 80 patients out of a planned
180, and did not show statistical significance in improving
overall survival with the addition of combretastatin (5.2 vs.
4.0 months). However, the combination schedule was well
tolerated, and no significant cardiovascular adverse drug
reactions were registered [59].
A Phase I/II randomized trial was performed to investi-
gate the effect of crolibulin (dose range from 8 to 20 mg/
m2), a microtubule inhibitor, plus cisplatin (dose range
Medical Oncology (2020) 37:19 Page 11 of 15  19
from 75 to 100 mg/m2) in 27 adults with solid tumours,
including 16 ATC patients. Of these ATC patients, one had
a complete response, and another achieved a stable disease.
However, grade 3 and 4 toxicities were registered in at least
one third of patients [60]. A phase I trial (NCT00004074)
to investigate the effectiveness of interleukin-12 and tras-
tuzumab in patients who have ATC with high levels of
HER2/neu and have not responded to previous therapy has
been completed, but results are not yet available. Finally,
a phase I, pharmacokinetic and biologic correlative study
(NCT00005842) using the farnesyl-transferase inhibitor
R115777 (NSC702818) and trastuzumab in combination
has been performed in patients with advanced or metastatic
ATC cancer. Patients received trastuzumab IV over 90 min
on days 1, 8, 15, and 22, plus oral R115777 twice daily for
3 weeks. Treatment continued every 28 days in the absence
of disease progression or unacceptable toxicity. Cohorts of
3 to 6 patients received escalating doses of R115777 until
the maximum tolerated dose (MTD) was determined. The
MTD is defined as the dose at which no more than 1 of 6
patients experience dose-limiting toxicities. This trial has
been completed, but results have not been published yet.
Ongoing clinical trials on combination schedules
Ongoing ATC clinical trials were retrieved from www.clini​
caltri​ als.gov using the search phrase “anaplastic thyroid can-
cer” (last accessed November 2019). The search was filtered
to “recruiting”, and “active” trials. Five ongoing clinical tri-
als that use combined treatments were identified with this
search, and their characteristic are reported in Table 3.
A pilot study indicated to be early phase I
(NCT03085056) is currently recruiting ATC patients to test
the safety and tolerability of the therapeutic combination
of paclitaxel (80 mg/m2 weekly for 3 out of 4 weeks) plus
trametinib (2 mg p.o. daily during each 4 week cycle). This
Table 3  Ongoing clinical Combination treatments
trials regarding combination
schedules in ATC patients
Paclitaxel + trametinib
Cohort I (B-raf mutation): vemu-
rafenib + cobimetinib + atezoli-
zumab
Cohort II (RAS, NF1, or NF2 muta-
tion): cobimetinib + atezolizumab
Cohort III (non-B-raf/non-RAS
mutation): bevacizumab + atezoli-
zumab
Cohort IV: nab-paclitaxel + atezoli-
zumab
Paclitaxel + efatutazone
Lovastatin + vildagliptin
Nivolumab + ipilimumab
study will also evaluate the combination’s effect on tumour
shrinkage and growth.
A multicentre phase II Study (NCT02152137) is currently
active, but not recruiting, to evaluate the effects of efatuta-
zone in combination with paclitaxel, in patients affected by
advanced ATC. Patients receive paclitaxel intravenously
over 3 h on day 1, and efatutazone dihydrochloride orally
twice daily on days 1 through 21.
An active but not recruiting pilot prognostic study
(NCT02862470) has been set up to analyse exosomal bio-
logical markers in thyroid cancer patients treated with lov-
astatin and vildagliptin, an oral anti-hyperglycaemic agent
of the new a dipeptidyl peptidase-4 inhibitor class of drugs
[61]. The investigators expect to enrol 30 patients with pap-
illary, follicular, or ATC tumours, and collect their urine
samples before surgery, immediately after surgery and post-
operatively at 3, 6 and 12 months.
Another phase II study (NCT03246958) plans to inves-
tigate the effects of nivolumab, a monoclonal antibody
directed against PD-1 [62], plus ipilimumab, an antibody
against cytotoxic T-lymphocyte antigen 4 [63], in RAI-
refractory, aggressive thyroid cancers. This study also will
include exploratory cohorts in medullary cancer and ATC,
and is in the recruiting phase. The combination of nivolumab
and ipilimumab is currently approved by FDA as treatment
for patients with metastatic melanoma [64]. Ipilimumab will
be administered via IV infusion, starting two weeks after
nivolumab.
Finally, a phase II, non-randomized, open-label clinical
trial is currently recruiting patients affected by anaplastic and
poorly differentiated thyroid carcinomas (NCT03181100).
The treatment is centred on the combinations of atezoli-
zumab, a humanized anti-programmed cell death ligand-1
(PD-L1) monoclonal antibody [65], with vemurafenib, cobi-
metinib, bevacizumab and nab-paclitaxel, depending on the
mutational status of the tumours. The primary aim of the
Phase Status ClinicalTrials.
gov Identifier
Early phase I Recruiting NCT03085056
Phase II Recruiting NCT03181100
Phase II Active but not recruiting NCT02152137
Pilot prognostic study Active but not recruiting NCT02862470
Phase II Recruiting NCT03246958
13
 19   Page 12 of 15
study is to determine if targeted therapy plus atezolizumab
will lead to improved overall survival in ATC patients. In
particular, the first cohort of B-RAF mutated ATC patients
receives vemurafenib p.o. twice daily on days 1–21, cobi-
metinib p.o. once daily on days 1–21, and atezolizumab
i.v. over 30–60 min on days 1 and 15, whereas the second
cohort including patients with RAS, NF1, or NF2 mutations
is treated with cobimetinib and atezolizumab.
A third and a fourth cohort of patients not harbouring
any mutation in B-RAF and RAS genes will be adminis-
tered with atezolizumab and bevacizumab or nab-paclitaxel.
Cycles will be repeated every 21 days in the absence of dis-
ease progression and unacceptable toxicity.
Concluding remarks and future perspective
ATC is a complex disease with a bad prognosis [66]. Con-
ventional treatments based on surgery, radioiodine and
chemotherapy always fail to cure ATC [66]. To date, new
insights from preclinical research on the genetic alterations
and dysfunction of different signalling pathways that affect
ATC development and biology offer the unprecedented pos-
sibility of having therapies for these new molecular targets.
Currently, enormous effort is being made to understand ATC
molecular pathogenesis, as exemplified by the elucidation
of the fundamental role of several major signalling path-
ways, and related molecular derangements. Indeed, many
of these molecular alterations represent novel diagnostic
and prognostic molecular markers, and therapeutic targets
for thyroid cancer. This then provides new opportunities for
further research, and clinical development of novel treat-
ment strategies. To date, results obtained with experimental
models support the idea that combination treatments seem to
have synergistic antitumour activity in ATC, although their
rapid translation into the clinics is impeded by the difficulty
in recruiting enough patients for randomized clinical stud-
ies. Moreover, embracing a personalized approach based on
advanced genomics and proteomics will be crucial for devel-
oping tailored treatment plans that improve the chances of
clinical success. For some authors, new affordable genomic
analyses and the possibility to test these new drugs in pri-
mary cell cultures propagated in vitro from each ATC patient
could ameliorate the personalization of therapy, increasing
therapeutic effectiveness and avoiding the use of ineffec-
tive treatments [67]. However, the preclinical and clinical
research on combination treatments in ATC may face a great
challenge in the near future. On one hand, efforts could be
focused on the molecular characterization of tumours from
individual patients, and identifying the best corresponding
drug treatment, using novel and still experimental com-
pounds. This choice is of course highly desirable, because of
its high probability of success, but it could be achieved only
13
Medical Oncology (2020) 37:19
in highly specialized centres with no budget limitations. On
the other hand, a pragmatic approach could also be possible
and sustainable, using off-label drugs already registered in
other neoplastic or non-neoplastic diseases.
Indeed, preclinical settings should emphasize giving
already in-use antineoplastic drugs, such as chemothera-
peutics (e.g. campthotecins or microtubule inhibitors) and
TKIs (e.g. sorafenib, levatinib, pazopanib or sunitinib) in
combination. This could achieve new therapeutic successes
in a clinical setting, using drugs with already known toxicity
profiles, at lower costs, and with easier patient management.
However, it is also possible that well-known drugs combined
in new schedules may lead to unexpected toxicities.
In conclusion, although continuous efforts and promising
results have been obtained in the preclinical research area,
additional clinical studies are still required to better eluci-
date the activity of combination treatments in the context of
clinical practice.
Author contributions  GB had the idea for the article. DG, PO, MB
and GB performed the literature search and data analysis. DG and GB
drafted and/or critically revised the work.
Funding  This study was supported by a grant from Associazione Itali-
ana per la Ricerca sul Cancro (AIRC; IG-17672) to GB.
Compliance with ethical standards 
Conflict of interest  All authors declare that they have no conflicts of
interest.
Ethical approval  Human and animal rights: no animal or human was
involved in this study.
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