The antimalarial agent artesunate (ART) activates programmed cell death (PCD) in cancer cells in a manner dependent on the presence of iron and the generation of reactive oxygen species. In malaria parasites, ART cytotoxicity originates from interactions with heme-derived iron within the food vacuole. The analogous digestive compartment of mammalian cells, the lysosome, similarly contains high levels of redox-active iron and in response to specific stimuli can initiate mitochondrial apoptosis. We thus investigated the role of lysosomes in ART-induced PCD and determined that in MCF-7 breast cancer cells ART activates lysosome-dependent mitochondrial outer membrane permeabilization. ART impacted endolysosomal and autophagosomal compartments, inhibiting autophagosome turnover and causing perinuclear clustering of autophagosomes, early and late endosomes, and lysosomes. Lysosomal iron chelation blocked all measured parameters of ART-induced PCD, whereas lysosomal iron loading enhanced death, thus identifying lysosomal iron as the lethal source of reactive oxygen species upstream of mitochondrial outer membrane permeabilization. Moreover, lysosomal inhibitors chloroquine and bafilomycin A1 reduced ART-activated PCD, evidencing a requirement for lysosomal function during PCD signaling. ART killing did not involve activation of the BH3-only protein, Bid, yet ART enhanced TNF-mediated Bid cleavage. We additionally demonstrated the lysosomal PCD pathway in T47D and MDA-MB-231 breast cancer cells. Importantly, non-tumorigenic MCF-10A cells resisted ARTinduced PCD. Together, our data suggest that ART triggers PCD via engagement of distinct, interconnected PCD pathways, with hierarchical signaling from lysosomes to mitochondria, suggesting a potential clinical use of ART for targeting lysosomes in cancer treatment.Artemisinin, the active principle of the Chinese medicinal herb Artemisia annua L., and its water-soluble derivative, artesunate (ART), 3 are potent antimalarial treatments (1). Additionally, these compounds selectively activate programmed cell death (PCD) in cancer cells (2-4) and inhibit angiogenesis in both in vitro and in vivo models (7). Importantly, preliminary in vivo investigations indicate a therapeutic potential for cancer treatment (5-7), and clinical studies have already shown an excellent safety record in malaria treatment (8). Successful compassionate use of ART in uveal melanoma patients indicates its potential for cancer therapy (9). Components of canonical PCD pathways have been implicated in ART-activated cell death, including p53 (10), Bcl2 family-mediated mitochondrial dysfunction (10, 11), and enhanced reactive oxygen species (ROS) production (12-14). However, detailed understanding of the molecular mechanisms and the sequence of events during ART-induced cell death in cancer cells is limited.The malaria parasite digests iron-rich hemoglobin in its acidic food vacuole, and the interaction of ART with hemederived iron results in lethal ROS generation (15). The parasite food vacuole is analogous...