Trifluorothymidine (TFT) is part of the oral drug formulation TAS-102. Both 5-fluorouracil (5-FU) and TFT can inhibit thymidylate synthase and be incorporated into DNA. TFT shows only moderate cross-resistance to 5-FU. Therefore, we examined whether mechanistic differences in cell death could underlie their different modes of action in colorectal cancer cell lines (WiDR, Lovo92 and Colo320). Drug cytotoxicity was determined by SRB-and clonogenic assays, cell death by flow cytometry (PI and annexin V), caspase cleavage by Western blotting and activity assays and in vivo activity in the hollow fiber assay. The IC 50 values of TFT were 1-6 fold lower than for 5-FU, and clonogenic survival was less than 0.9% at 3 lM TFT, while 2-20% of the cells still survived after 20 lM 5-FU. In general, TFT was a more potent inducer of apoptosis than 5-FU, although the contribution of caspases varied between the used cell lines and necrosis-like cell death was detected. Accordingly, both drugs induced caspase (Z-VAD) independent cell death and lysosomal cathepsin B was involved. Activation of autophagy recovery mechanisms was only triggered by 5-FU, but not by TFT as determined by LC3B expression and cleavage. Inhibition of autophagy by 3-MA in 5-FU exposed cells reduced cell survival. Also, in vivo TFT (as TAS-102) caused more cell death than a 5-FU formulation. We conclude that TFT and 5-FU induce cell death via both caspase-dependent and independent mechanisms. The TFT was more potent than 5-FU, because it induces higher levels of cell death and does not elicit an autophagic survival response in the cancer cell lines. This provides a strong molecular basis for further application of TFT in cancer therapy.5-Fluorouracil (5-FU) based therapy is part of the standard therapy for colorectal (CRC) and breast cancer. In order to exert its cytotoxic effect, 5-FU has to be activated to its monophosphate form, FdUMP. FdUMP is a strong irreversible inhibitor of thymidylate synthase (TS) by forming a stable ternary complex. In its triphosphate forms, FUTP and FdUTP, 5-FU can be incorporated into the RNA and DNA, respectively. 1 The effect of 5-FU in combination with leucovorin has increased survival, 2 but resistance is often encountered. 5-FU-resistance is related to a decreased level of 5-FUactivating enzymes, including orotate phosphoribosyl-transferase and uridine kinase, 3 and an increased expression of the target TS. 4 Recent improvements have been made by replacing bolus injections and inconvenient continuous infusions by oral fluoropyrimidine formulations, such as Xeloda (capecitabine) and UFT. 5 Another type of oral formulation, TAS-102, has recently been introduced into the clinic and consists of trifluorothymidine (TFT), in combination with a specific inhibitor of thymidine phosphorylase (TP), TPI. TAS-102, is currently tested in phase II studies against colorectal and gastric cancer. 6 Similar to 5-FU, TFT can inhibit TS in its monophosphate form (TF-TMP), 7 however TFT does not form a ternary complex as for 5-FU, but binds co...