The purpose of these experiments was to assess the synergistic activity of silibinin with chemotherapy agents in clinical use against prostate cancer. Silybin-phytosome, a commercially available formulation containing silibinin, has recently been studied in a phase I clinical trial. The silibinin doses used in the present study are clinically achievable based on the preliminary phase I data. DU145, PC-3 and LNCaP prostate cancer cells were seeded in 96-well plates in triplicate. Twenty-four hours later, silibinin (10, 20 and 40 lM) and either mitoxantrone or docetaxel were added to the designated wells. Seventy-two hours post-treatment, cell viability was determined with a tetrazolium-based assay. The combination index (CI) for determination of a synergistic effect was calculated, with values of <0.9 indicating synergy and values >1.1 antagonism. Apoptosis was also assessed using a luminescent assay after 72 hr of treatment with media alone, silibinin, mitoxantrone, or silibinin plus mitoxantrone. Silibinin showed a synergistic effect with mitoxantrone, as measured by reduction in cell viability. The CI values ranged from 0.413 to 2.650 for the combination of silibinin and mitoxantrone; in contrast, treatment with docetaxel and silibinin showed little or no synergy, with CI values of 0.898-4.469. In concordance with these findings, the addition of silibinin increased the level of apoptosis compared to mitoxantrone alone, particularly in the PC-3 cells. The combination of silibinin and mitoxantrone exhibits a pattern of synergy in reducing cell viability with increased apoptosis. These data are important in the planning of future clinical applications of silibinin. ' 2007 Wiley-Liss, Inc.Key words: silibinin; mitoxantrone; docetaxel; prostate cancer Prostate cancer is the most common non-skin cancer diagnosed in men. In 2005, the American Cancer Society estimates that 232,000 men were diagnosed and 30,000 died from prostate cancer in the United States. 1 Early stage or organ confined cases may be cured with surgical prostatectomy or radiation therapy, although, some low-risk patients may also choose watchful waiting. 2,3 Disease that has spread beyond the prostate is generally first treated with hormonal ablation. The addition of cytotoxic chemotherapy is used in selected hormone-refractory patients, with this approach demonstrating a small ( 2 month) survival advantage. 4,5 Milk thistle (Silybum marianum) has a long history of use in humans and is commonly used in the treatment of liver disease. 6,7 Silymarin, the name of the crude milk thistle extract, is composed of several stereoisomers including silibinin (or silybin), silychristin and silydianin. 8 Silibinin and silymarin have been shown to inhibit in vitro cell growth in several cancer models including prostate, 9-11 bladder, 12,13 colon, 14,15 breast, 16,17 cervical, 18 skin 19,20 and lung cancer. 21,22 Additional in vivo experiments have demonstrated an anti-cancer effect of silibinin and silymarin in models of prostate, 23 skin, 24,25 bladder 26 and col...