Unraveling the Crosstalk Between Ferroptosis and Cuproptosis for Rational Nanomedicine Design in Cancer

Abstract

Ferroptosis and cuproptosis constitute two key metal-dependent regulated cell death pathways with distinct execution mechanisms, yet they exhibit intricate crosstalk revolving around glutathione (GSH) metabolism, iron‑sulfur cluster proteins, and shared regulators such as Nrf2 and FDX1. Co‑activating both pathways can overcome compensatory resistance and create a self‑amplifying lethal cascade. Nanomedicine provides an enabling platform to exploit this interplay through rationally designed nanotherapeutics that achieve spatiotemporally controlled metal ion delivery, tumor microenvironment‑responsive release, and integration with external stimuli or immunotherapy. This review delineates the molecular convergence of ferroptosis and cuproptosis, presents a framework for rational nanomedicine design based on prioritized disabling of antioxidant defenses and sequential activation strategies, and surveys representative nanoplatforms including copper‑based nanozymes, bimetallic nanoparticles, ionophore‑loaded regulators, and endogenous metal mobilizers. The synergy with photothermal, sonodynamic, and immune checkpoint blockade therapies is also discussed, highlighting immunogenic cell death induction and the conversion of “cold” tumors into “hot” ones. The work further clarifies current challenges and future perspectives toward clinical translation, thus providing a practical framework to inspire the rational design of next‑generation metal‑based nanomedicines.

Introduction

The evolving landscape of regulated cell death has fundamentally reshaped our understanding of cancer therapy. For decades, the induction of apoptosis has been the cornerstone of anticancer treatment, yet the pervasive ability of malignant cells to evade this programmed death, currently recognized as a hallmark of cancer, has driven the search for alternative therapeutic strategies that can circumvent intrinsic and acquired resistance mechanisms.^1,2 This challenge has catalyzed a paradigm shift toward harnessing non-apoptotic forms of regulated cell death, including necroptosis, pyroptosis, ferroptosis, and most recently cuproptosis, as conceptually distinct avenues for eliminating therapy-resistant tumor cells.^3,4 Unlike apoptosis, which relies on caspase activation and mitochondrial outer membrane permeabilization, these alternative death modalities engage fundamentally different molecular machineries, offering the potential to overcome classical chemoresistance.

Among these emerging death pathways, ferroptosis and cuproptosis stand out as two metal-dependent newcomers that have garnered intense interest over the past decade. Ferroptosis, first formally described in 2012 by the Stockwell laboratory, is an iron-dependent form of non-apoptotic cell death driven by the lethal accumulation of lipid peroxides in cellular membranes.^5,6 Its discovery challenged the prevailing notion that iron-mediated oxidative damage primarily serves as a secondary executor rather than a primary death trigger. A decade later, Tsvetkov et al introduced cuproptosis as a distinct copper-driven cell death modality, characterized by the direct binding of excess copper to lipoylated tricarboxylic acid (TCA) cycle enzymes, leading to proteotoxic stress and mitochondrial dysfunction.^7,8 Despite their distinct execution mechanisms—iron-catalyzed lipid peroxidation versus copper-induced protein aggregation—these two pathways share intriguing connections through metal metabolism, mitochondrial function, and common regulatory nodes, raising the possibility that they may be therapeutically co-targeted for synergistic anticancer effects.

The concept of “crosstalk” between ferroptosis and cuproptosis has recently emerged as a frontier in cancer biology, with profound therapeutic implications.⁹ Rather than functioning as isolated pathways, accumulating evidence indicates that these two metal-dependent death programs converge at multiple levels: the glutathione (GSH)-GPX4 antioxidant axis serves as a shared vulnerability;^10,11 mitochondrial iron‑sulfur (Fe‑S) cluster homeostasis represents another critical intersection;¹² and the transcription factor NFE2L2 (Nrf2) orchestrates a compensatory response that simultaneously defends against both death modalities.¹³ Understanding this interplay is crucial because cancer cells may engage compensatory survival mechanisms when only one pathway is targeted, whereas co‑activation of both ferroptosis and cuproptosis could overcome such resistance and generate a self‑amplifying lethal cascade.¹⁴ The therapeutic potential of this synergistic strategy lies in its ability to simultaneously attack tumor cells through two distinct mechanisms, thereby lowering the threshold for cell death and minimizing the likelihood of adaptive resistance.

Nanomedicine has emerged as an enabling platform to exploit the ferroptosis‑cuproptosis crosstalk for rational cancer therapy.¹⁵ Nanocarriers offer unique advantages that are particularly well‑suited for co‑targeting these metal‑dependent pathways. They enable the co‑delivery of iron and copper species or ionophore‑drug combinations in a single formulation and can be engineered with tumor microenvironment (TME)-responsive release logics (eg, pH‑sensitive, GSH‑labile, or ROS‑activatable) to achieve spatiotemporally controlled metal ion deployment.^16–18 Moreover, the exquisitely engineered nanovehicles can facilitate simultaneous modulation of multiple ions and signaling pathways, even providing a versatile scaffold for integrating additional therapeutic modalities such as photothermal, sonodynamic, or immunotherapeutic interventions.¹⁹

This review aims to unravel the molecular crosstalk between ferroptosis and cuproptosis and provide a blueprint for rationally designing nanotherapeutics that co‑target these two death pathways. The core mechanisms of ferroptosis and cuproptosis are first delineated, followed by a systematic analysis of their convergence points. Subsequently, a framework for rational nanomedicine design exploiting this crosstalk is presented, representative nanoplatforms are discussed according to their working logics, and the integration of external stimuli and immunotherapy is discussed. Finally, we address current challenges and future perspectives, with the goal of guiding the development of next‑generation metal‑based nanotherapeutics that harness the synergistic power of ferroptosis and cuproptosis for enhanced anticancer efficacy.

Molecular Mechanisms of Ferroptosis and Cuproptosis: A Tale of Two Metals

Ferroptosis—the Iron-Catalyzed Lipid Peroxidation Death

Ferroptosis is an iron-dependent, non-apoptotic form of regulated cell death driven by lethal accumulation of lipid peroxides in cellular membranes.^5,20 Its occurrence is determined by the balance between pro-oxidant execution systems and antioxidant defenses, as schematized in Figure 1. The core execution machinery relies on the peroxidation of polyunsaturated fatty acid (PUFA)-containing phospholipids.²¹ Lysophosphatidylcholine acyltransferase 3 (LPCAT3) and acyl-CoA synthetase longchain family member 4 (ACSL4) orchestrate the incorporation of PUFAs into membrane phospholipids, generating substrates for oxidation by iron-containing lipoxygenases (ALOXs) or via the Fenton reaction (Fe²⁺ + H₂O₂ → ·OH).^22,23 This generates a self-amplifying chain reaction of lipid peroxyl radicals within polyunsaturated fatty acid-containing phospholipids (PUFA-PEs), which ultimately compromises membrane integrity and leads to cell death.

Figure 1.

Overview of ferroptosis mechanisms. The execution system (iron-dependent lipid peroxidation) and defense system (GPX4/FSP1) are counteracted with additional regulation by signaling pathways. Adapted from Kang H, Meng F, Liu F, et al. Nanomedicines Targeting Ferroptosis to Treat Stress-Related Diseases. Int J Nanomedicine. 2024;19:8189–8210. http://creativecommons.org/licenses/by/4.0/²⁴ licensed under CC-BY 4.0.

Cells have evolved multi-layered defense systems to counteract this lethal cascade.^24,25 The primary defense is the GPX4/GSH axis, which depends on System Xc⁻-mediated cystine import and subsequent GSH synthesis, with GPX4 directly reducing toxic lipid hydroperoxides to non-toxic lipid alcohols.^22,26 A parallel, GSH-independent defense is provided by ferroptosis suppressor protein 1 (FSP1), which localizes to the plasma membrane and reduces CoQ10 to its antioxidant form ubiquinol, acting as a lipophilic radical-trapping antioxidant.^25,27 Cells can also remodel membrane composition by incorporating monounsaturated fatty acids (MUFAs) via MBOAT1/2, reducing the availability of oxidizable PUFA substrates.²⁸ Additionally, endogenous radical-trapping antioxidants such as vitamin E and tetrahydrobiopterin, as well as ESCRT-III-mediated plasma membrane repair, further contribute to ferroptosis suppression.^29,30

Iron homeostasis is a critical determinant of ferroptosis sensitivity, as the labile iron pool (LIP) directly fuels the Fenton reaction and serves as a cofactor for ALOX enzymes.²² Iron uptake is mediated by transferrin receptor 1 (TFR1), while excess iron is sequestered within ferritin.³¹ The cargo receptor NCOA4 mediates ferritinophagy, delivering ferritin to lysosomes for degradation and releasing iron to the LIP, thereby promoting ferroptosis.³² Nrf2 coordinates the expression of multiple antioxidant and iron metabolism genes, suppressing ferroptosis. p53 exhibits context-dependent dual roles, either promoting ferroptosis by repressing SLC7A11 or inhibiting it via DPP4 blockade.^22,26 The Hippo pathway effectors YAP1 and TAZ promote ferroptosis by upregulating ACSL4 and TFRC.²² Ferroptosis represents a promising therapeutic target for cancer, neurodegenerative disorders, ischemia-reperfusion injury, and inflammatory conditions.^6,24

Cuproptosis—the Copper-Driven Protein Aggregation Death

While copper imbalance has long been associated with cytotoxicity, the discovery of cuproptosis has redefined the mechanistic understanding of copper-induced cell death. First formally described in 2022 by Tsvetkov et al, cuproptosis is a distinct, regulated form of cell death driven by the direct interaction of excess intracellular copper with mitochondrial metabolic pathways.⁷ Unlike apoptosis, ferroptosis, or necroptosis, cuproptosis does not rely on classic executioner proteins such as caspases or on lipid peroxidation. Instead, its hallmark is the copper-induced aggregation of specific lipoylated enzymes within the TCA cycle, leading to profound mitochondrial proteotoxic stress.^8,33

The core mechanism of cuproptosis is initiated when monovalent copper (Cu⁺) accumulates in the mitochondria (Figure 2). This pool of Cu⁺ directly binds to the lipoylated subunits of key TCA cycle enzymes, most notably dihydrolipoamide S-acetyltransferase (DLAT) (a component of the pyruvate dehydrogenase complex) and dihydrolipoamide S‑succinyltransferase (DLST).^7,34 Protein lipoylation is a rare post-translational modification that is essential for the catalytic function of these metabolic nodes.³⁵ The high affinity between Cu⁺ and the sulfur atoms within the lipoyl moiety promotes the aberrant oligomerization and aggregation of these proteins. Concurrently, cuproptosis is characterized by a widespread loss of iron-sulfur (Fe-S) cluster proteins, which are vital cofactors for mitochondrial respiratory complexes and other metabolic enzymes.^36,37 This dual insult, toxic protein aggregation coupled with Fe-S cluster destabilization, cripples mitochondrial metabolism and ultimately triggers cell death.

Figure 2.

Schematic of the cuproptosis pathway. Cu²⁺ enters the cell either via a copper ionophore or through transporters such as ZnT1. In the cytosol, Cu²⁺ is reduced to Cu⁺ by a metalloreductase (eg, FDX1 or other reductases). Cu⁺ is then distributed by copper chaperones, such as ATOX1, CCS, and COX17. Excess copper is exported by ATP7A/ATP7B. Dysregulated copper accumulation leads to aggregation of lipoylated DLAT, loss of Fe‑S cluster proteins, and mitochondrial proteotoxic stress, ultimately triggering cuproptosis.

A critical upstream regulator of this pathway is ferredoxin 1 (FDX1). FDX1 serves a dual function: it reduces Cu²⁺ to the more reactive Cu⁺, and it is essential for the lipoylation of TCA cycle enzymes by supporting lipoic acid synthase (LIAS).^7,38 Consequently, cells with high FDX1 expression and a reliance on mitochondrial respiration for energy production are exquisitely sensitive to cuproptosis, whereas those that rely on glycolysis are largely resistant. The susceptibility to cuproptosis is also governed by the broader network of copper proteostasis, including import via the high-affinity copper transporter CTR1 (SLC31A1), import via Zinc transporter 1 (ZnT1), which has been shown to mediate copper uptake, intracellular chaperoning by antioxidant 1 copper chaperone (ATOX1), copper chaperone for superoxide dismutase (CCS), and cytochrome c oxidase copper chaperone (COX17), and efflux via ATP7A and ATP7B.^8,37 Furthermore, ZnT1-driven copper influx can promote cuproptosis under conditions of copper overload.³⁹ Meanwhile, buffering systems such as metallothioneins (MTs) and GSH can sequester excess copper and thus modulate sensitivity to cuproptotic death.^11,40

It is important to distinguish cuproptosis from other forms of copper-induced oxidative stress. While excess copper can certainly trigger the production of ROS via Fenton-like chemistry, this is not the primary executioner of cuproptosis. In the defining study, neither general antioxidants nor inhibitors of apoptosis or ferroptosis could rescue cells from cuproptosis, whereas specific copper chelators were potently protective.⁷ Therefore, cuproptosis is defined not by oxidative damage, but by a unique, copper-driven disruption of mitochondrial protein homeostasis, thus placing it as a distinct “cell-sabotage” pathway at the intersection of metal biology and mitochondrial metabolism.³⁶

Unraveling the Crosstalk Network Where Ferroptosis and Cuproptosis Converge

The convergence of ferroptosis and cuproptosis is most evident at the level of GSH, a molecule that suppresses both pathways yet is vulnerable to reciprocal disruption. In ferroptosis, GSH acts as an essential cofactor for GPX4, enabling the detoxification of lethal phospholipid hydroperoxides. In cuproptosis, GSH serves as the major intracellular copper chelator, binding Cu⁺ to prevent the aggregation of lipoylated mitochondrial proteins and the destabilization of Fe‑S clusters. Critically, copper ions directly antagonize GPX4 by binding to its cysteines C107 and C148, promoting GPX4 aggregation and autophagic degradation via TAX1BP1.¹⁰ This not only triggers cuproptosis but also sensitizes cells to ferroptosis, creating a potent synergy. A shared compensatory response is orchestrated by the Nrf2/KEAP1 axis: both ferroptotic and cuproptotic stressors activate Nrf2, upregulating SLC7A11 (enhancing cystine uptake for GSH synthesis), γ‑glutamylcysteine synthetase (boosting GSH production), and metallothioneins (buffering excess copper). This rescue program represents a key barrier that must be overcome in co‑targeting strategies.

Mitochondria serve as the primary battleground where the two death pathways amplify each other. The mitochondrial matrix harbors both a labile iron pool and a labile copper pool. Iron drives Fenton chemistry to generate hydroxyl radicals, while copper catalyzes Fenton‑like reactions, together producing overwhelming hydroxyl radicals (∙OH) that initiate the iron-catalyzed peroxidation of PUFA-rich inner membranes, propagating a localized chain reaction of lipid peroxyl radicals. The most critical intersection is the family of Fe‑S cluster proteins, essential cofactors for the electron transport chain (ETC). When Cu⁺ accumulates in the matrix, it binds to and destabilizes these clusters, causing their collapse. This leads to two devastating consequences. First, it causes ETC dysfunction, a hallmark of cuproptosis. Second, the release of ferrous iron from degraded clusters fuels additional ROS and lipid peroxidation, thereby lowering the threshold for ferroptosis.¹² Metabolic reprogramming toward oxidative phosphorylation (OXPHOS) further integrates both pathways: cuproptosis intrinsically requires an intact TCA cycle and lipoylated enzymes (eg, DLAT) that become aggregation targets under copper overload, while increased OXPHOS elevates mitochondrial ROS, sensitizing cells to ferroptosis. Hypoxia reversal strategies that shift metabolism from glycolysis to OXPHOS thus increase vulnerability to both death programs.

Systemic and cellular metal homeostasis provides additional layers of interplay. Copper‑dependent multicopper ferroxidases (ceruloplasmin and hephaestin) are required for iron export by oxidizing Fe²⁺ to Fe³⁺ for transferrin loading. Copper deficiency therefore impairs iron efflux, raising intracellular iron and promoting ferroptosis. Conversely, copper overload nanotherapies can disrupt this balance. At the uptake level, the divalent metal transporter 1 (DMT1) may mediate co‑import of Fe²⁺ and Cu²⁺, particularly in the acidic tumor microenvironment, offering a potential dual delivery route. Polyamine metabolism further links both fates: spermidine and spermine biosynthesis consumes S‑adenosylmethionine and can influence the transsulfuration pathway that generates cysteine for GSH. Spermidine suppresses ferroptosis by upregulating SLC7A11 and GPX4 via ATF4, but excess polyamines may exert pro‑oxidant effects.⁴¹ This bidirectional regulation renders polyamine metabolism as an emerging shared vulnerability.

Whether copper excess drives ferroptosis, cuproptosis, or a hybrid state depends on contextual factors. The most critical determinant is mitochondrial respiration status. Cuproptosis strictly requires an active TCA cycle and pre‑existing lipoylated proteins, whereas ferroptosis can proceed in their absence if iron‑mediated lipid peroxidation is initiated. FDX1 expression acts as a gatekeeper, as it reduces Cu²⁺ to Cu⁺ and promotes lipoylation of TCA enzymes.⁷ Cells with high FDX1 and robust OXPHOS are primed for cuproptosis, while those with lower FDX1 but elevated iron may default to ferroptosis when copper is introduced. This context‑dependence provides a rational basis for sequential therapeutic intervention: first sensitize cells to ferroptosis via GSH depletion or GPX4 inhibition, then deliver a copper ionophore to execute cuproptosis. Such a strategy orchestrates both lethal mechanisms in a temporally coordinated manner, leveraging the identified crosstalk nodes—GSH, Fe‑S clusters, FDX1, and mitochondrial metabolism (Figure 3)—to surmount resistance and elicit robust tumor cell death.

Figure 3.

The crosstalk mechanisms between ferroptosis and cuproptosis. (a) GSH constitutes a key regulatory axis: Fe²⁺-induced ROS production and copper chelation are linked to GPX4 autophagic degradation; (b) mitochondria act as the central hub where the two death pathways converge and mutually reinforce each other. Fe²⁺ (Fenton) and Cu⁺(Fenton-like) generate ROS and drive PUFA peroxidation, while Cu⁺ disrupts Fe‑S clusters, causing electron transport chain dysfunction and releasing Fe²⁺ that sensitizes ferroptosis; (c) metal homeostasis and polyamine metabolism further modulate both death pathways, and the final outcome depends on cellular context (eg, FDX1 expression and iron load).

Rational Nanomedicine Design Exploiting the Crosstalk

The rational design of nanomedicines that simultaneously target ferroptosis and cuproptosis hinges upon precise spatiotemporal control over two critical dimensions: the selection of appropriate metal ion sources and the logic by which these ions are deployed in the tumor microenvironment (TME). For metal ion selection, researchers have primarily explored iron (Fe⁰, Fe²⁺/³⁺) and copper (Cu⁺/²⁺) as the core effectors, given their respective roles as catalysts of Fenton/Fenton-like reactions and direct triggers of mitochondrial proteotoxic stress. Beyond single-metal systems, bimetallic frameworks, particularly iron-copper composites, have garnered substantial interest as they enable synergistic amplification of oxidative damage. In this context, Fe- and Cu-based metal-organic frameworks (MOFs) have emerged as particularly versatile platforms, functioning not only as nanocarriers for therapeutic cargoes but also as direct sources of metal ions for ferroptosis induction.⁴² Bimetallic Fe-Cu MOFs, such as those developed by Xu et al, enable the co-delivery of both metal species, thereby instigating the synergistic interplay of cuproptosis and ferroptosis in a single nanoplatform.¹⁹ The integration of Fe³⁺ and Cu²⁺ within a single nanoparticle offers the advantage of sequentially engaging both death pathways, as the distinct redox potentials and biological targets of these metal ions can be exploited in a temporally coordinated fashion. Importantly, ferroptosis‑first, cuproptosis‑first, and simultaneous/self‑accelerating represent three alternative platform‑specific activation logics rather than a universal hierarchy. The choice among them depends on tumor biomarker profiles (FDX1, GPX4, GSH, and OXPHOS status) and the nanoplatform’s release kinetics, as detailed above.

The effective deployment of these metal ions demands a delivery system that responds intelligently to the unique chemical cues of the TME. The tumor microenvironment is characterized by distinct physiological attributes compared to normal tissues, including lower pH, elevated concentrations of ROS, and heightened levels of GSH.⁴³ Among these, GSH stands out as a particularly critical determinant in the crosstalk between ferroptosis and cuproptosis. Intracellular GSH functions both as a cofactor for the lipid peroxide-detoxifying enzyme GPX4 (thereby suppressing ferroptosis) and as a copper-chelating agent that buffers excess Cu⁺ ions (thereby inhibiting cuproptosis).¹¹ This dual protective role positions GSH as the central node in the ferroptosis-cuproptosis crosstalk network. Consequently, the most widely adopted response logic in rationally designed nanoplatforms is a GSH-depletion-first, LPO-induction-second cascade. Such a strategy sequentially dismantles cellular antioxidant defenses, thereby creating a permissive environment for lethal oxidative damage.

Among these three design logics, the GSH‑depletion‑first (ferroptosis‑first) approach has been most extensively explored. In this paradigm, the most sophisticated nanoplatforms are designed to orchestrate a sequential activation strategy that first releases copper to deplete GSH and stabilize FDX1, followed by iron delivery to maximize lipid peroxide accumulation. The rationale for this sequence derives from the distinct molecular dependencies of the two cell death pathways. Cuproptosis requires an active TCA cycle and the presence of lipoylated mitochondrial enzymes, with FDX1 serving as a central mediator, which reduces Cu²⁺ to Cu⁺ and is essential for protein lipoylation, thereby acting as the gatekeeper for cuproptosis sensitivity.^44,45 By contrast, ferroptosis can proceed independently of TCA cycle activity, relying primarily on iron-catalyzed peroxidation of PUFA. Therefore, a temporally sequenced approach that first deploys copper to engage FDX1-dependent cuproptosis may simultaneously destabilize iron-sulfur clusters, releasing Fe²⁺ that fuels the downstream ferroptotic cascade. As demonstrated, the self-amplifying loop between ferroptosis and cuproptosis can be explored for nanomedicine design that releases both iron and copper. Ferroptosis depletes GSH and damages mitochondria, leading to copper accumulation that triggers cuproptosis. In turn, cuproptosis disrupts Fe‑S proteins and releases more iron, fueling further ferroptosis.⁴⁶ The integration of copper-first or copper-simultaneous release logic can be further refined by leveraging the TME’s high GSH concentration not merely as a barrier to be overcome but as an internal trigger for cascade activation.

The decision matrix (Table 1) offers a practical framework for translating tumor biomarker profiles into nanoplatform design choices. We recommend a three-step evaluation. First, cuproptosis readiness should be assessed by FDX1 and OXPHOS status, which determine whether copper ionophores are prioritized or whether pre-sensitization via FDX1 upregulation is required. Second, antioxidant capacity must be evaluated, as elevated GSH/GPX4 levels necessitate a GSH-depletion-first approach to relieve copper sequestration and peroxide detoxification. Third, metal transporter and immune profiles need characterization, where CTR1/ATP7A guide exogenous versus endogenous copper mobilization, and immune infiltrate determines whether ICD alone suffices or requires ICB combination, given that cold tumors exploit dual-pathway-driven PD-L1 upregulation. This systematic logic enables strategies to specific vulnerabilities, and these modalities are not mutually exclusive but can be synergistically integrated into bimetallic or multifunctional platforms to tackle complex resistance phenotypes. Altogether, these design principles establish a rational framework for engineering nanoplatforms that exploit the interconnected regulatory networks of ferroptosis and cuproptosis to maximize therapeutic efficacy while minimizing off-target toxicity.

Table 1.

Decision Matrix for Ferroptosis-Cuproptosis Nanoplatform Design Based on Tumor Phenotype and Biomarker Profiling

Tumor Phenotype/Biomarker	Prioritized Design Strategy	Rationale	Nanoplatform	Ref.
High OXPHOS + High FDX1	Cuproptosis-first: copper ionophore delivery + mitochondrial targeting	FDX1 reduces Cu2+ to Cu+ and supports protein lipoylation; active TCA cycle provides lipoylated substrates (DLAT) for copper-induced aggregation	ES@CuO, ES-Cu-MOF, Cu(HEDTC)2 nanomicelles	[47]
High GSH + High GPX4	GSH-depletion-first: GSH-responsive nanocarriers + GPX4 silencing	GSH chelates Cu[+] (blocking cuproptosis) and serves as GPX4 cofactor (blocking ferroptosis); depleting GSH removes both brakes simultaneously	cRDT@FC nanoparticles, CuFeGA MPNs	[48]
Low FDX1 + Low GPX4	Endogenous metal mobilization: GPX4 siRNA + FDX1 plasmid or FDX1 activator	Low FDX1 limits cuproptosis sensitivity; gene delivery can restore FDX1 while GPX4 silencing lowers ferroptosis threshold	Fe[2]⁺-nucleotide-GPX4 siRNA coordination NPs, quercetin + ES-Cu combination	[49]
High CTR1/ZnT1 + Low ATP7A/B	Copper overload: Cu-based nanozymes or Cu-MOFs	High copper influx and low efflux create natural copper accumulation; exogenous copper supplementation amplifies this vulnerability	CuO nanozymes, Cu-doped MnO2 NPs, Cu-MOFs	[50]
High LIP + Low Nrf2	Iron-first: iron-based nanozymes + Fenton reaction amplification	Abundant labile iron pool provides substrate for Fenton chemistry; low Nrf2 means weak antioxidant counter-response	Fe-Cu bimetallic MOFs, core-shell Fe@Cu NPs	[51]
High GSH + Low CTR1	Dual GSH depletion + copper transporter upregulation	High GSH buffers both pathways; low CTR1 limits copper entry—need to overcome both barriers simultaneously	Bimetallic chitosan/HA nanoparticles (5FCN), CuFe@DMSA NPs	[52]
Low immunogenicity (“cold” tumor)	ICD-focused: ferroptosis-cuproptosis co-activation + anti-PD-1/PD-L1	Dual death pathways expose DAMPs (CRT, HMGB1, ATP) to prime T cell responses; metal overload upregulates PD-L1, creating vulnerability to ICB	CuP/Er + aPD-L1, CCDL + αPD-L1, Cu-BTO + US	[53]
High H2O2 + Hypoxic	External stimulation-integrated: photothermal/sonodynamic + catalytic ion therapy	Hyperthermia or ultrasonic cavitation accelerates Fenton/Fenton-like reactions and enhances metal release from nanocarriers	O2-PFH@CHPI (NIR), Cu2O/Cu2-ₓSe nanocapsules (US)	[54]

Abbreviations: OXPHOS, oxidative phosphorylation; FDX1, ferredoxin 1; GSH, glutathione; GPX4, glutathione peroxidase 4; CTR1, copper transporter 1 (SLC31A1); ATP7A/B, copper efflux transporters; LIP, labile iron pool; Nrf2, nuclear factor erythroid 2-related factor 2; ICD, immunogenic cell death; ICB, immune checkpoint blockade; DAMP, damage-associated molecular pattern; CRT, calreticulin; HMGB1, high mobility group box 1.

Nanoplatforms for Ferroptosis-Cuproptosis Synergy

A deep understanding of ferroptosis and cuproptosis mechanisms has guided the design of recent nanoplatforms. These systems are refined to enable programmed cargo release or signaling regulation. The underlying rationale involves GSH depletion and FDX1 stabilization, followed by targeted delivery of metal ions to maximize lipid peroxidation and/or mitochondrial proteotoxic stress. Within this framework, four distinct strategies have recently emerged.

Copper-Based Nanozymes for Dual Action

Among various copper-based nanoplatforms, copper oxide nanoparticles (CuO or Cu₂O) represent promising candidates due to their intrinsic dual functionality. They can simultaneously deplete GSH and catalyze Fenton-like reactions. This synergy establishes a self-amplifying loop that bridges ferroptosis and cuproptosis.^55,56 The mechanistic basis lies in the redox cycling between Cu²⁺ and Cu⁺. Upon internalization, Cu²⁺ reacts with endogenous GSH. This reaction not only consumes this antioxidant but also reduces Cu²⁺ to Cu⁺.¹⁵ The generated Cu⁺ then serves a dual role. It drives a Fenton-like reaction to convert H₂O₂ into highly cytotoxic hydroxyl radicals (•OH). At the same time, excessive Cu⁺ accumulation in mitochondria triggers the aggregation of lipoylated TCA cycle proteins, initiating cuproptosis.^57,58

Notably, the GSH-depleting action is not merely a supportive step but a critical amplifier of both pathways. By lowering GSH levels, copper-based nanozymes impair the cellular antioxidant defense, allowing lipid peroxides to accumulate for ferroptosis while simultaneously promoting Cu⁺ overload in mitochondria to enhance cuproptotic cell death. To further augment this cascade, recent designs have incorporated self-supplying H₂O₂ capabilities or surface modifications for mitochondrial targeting. For instance, MitCuOHA (triphenylphosphonium-modified copper oxide nanorod) exhibits cysteine oxidase-like, glutathione oxidase-like, and peroxidase-like activities, enabling efficient depletion of both cysteine and GSH with concurrent •OH generation.⁵⁹ Similarly, Cu₂O@Au nanocomposites take advantage of the glucose oxidase-mimicking activity of Au nanoparticles to generate endogenous H₂O₂, thereby sustaining the Fenton-like reaction even within the H₂O₂-limited tumor microenvironment.⁶⁰ Otherwise, a mitochondria-targeted nanozyme platform, MIL-Cu_1.8S-TPP/FA, integrates iron-based metal-organic frameworks with copper sulfide nanodots, enabling targeted delivery of copper ions to mitochondria and iron ions to tumor cells. This heterojunction structure exhibits synergistic peroxidase-like catalytic activity and effectively modulates key ferroptosis- and cuproptosis-related markers including GPX4, GSH, FDX1, and HSP70.⁶¹

Collectively, these copper-based nanozymes achieve two therapeutic goals with a single agent. The same copper species simultaneously orchestrates GSH depletion, ROS generation, and mitochondrial proteotoxic stress, thereby offering a streamlined yet potent platform for synergistic ferroptosis-cuproptosis therapy. Notably, while copper-based nanozymes generate ROS through Fenton-like reactions, this oxidative activity should not be conflated with cuproptosis induction. Cuproptosis is defined by DLAT aggregation and Fe-S cluster loss, not by ROS production per se.

Bimetallic Nanoparticles for Tandem

The tandem design of iron/copper-bimetallic and core/shell nanoparticles represents a sophisticated implementation of the sequential activation strategy.^62,63 In this architecture, the iron core serves as a sustained reservoir for •OH production via Fenton chemistry, while the copper shell enables targeted aggregation of lipoylated mitochondrial proteins following shell degradation. This spatial segregation ensures that copper is released first upon cellular uptake, given its direct exposure to the intracellular environment, thereby initiating the GSH-depletion cascade before iron is liberated.

The cascaded logic has been implemented through various engineering strategies. One illustrative approach is the construction of disulfide bond-containing or copper ion-chelating nanoparticles that rapidly consume intracellular GSH upon cellular uptake. The depletion of GSH simultaneously inactivates the GPX4-mediated ferroptosis defense and eliminates the copper-buffering capacity that normally protects against cuproptosis. A representative system is the cRDT@FC nanoparticles developed by Fu et al, wherein disulfide bonds and Cu²⁺ ions jointly consume high concentrations of GSH within cancer cells, resulting in nanostructure disintegration and drug release.⁶⁴ The GSH-mediated reduction of Cu²⁺ to Cu⁺ then synergizes with Fe²⁺ to catalyze Fenton reactions, generating abundant hydroxyl radicals that serve as the primary initiators for site-specific, iron-dependent lipid peroxidation chain reactions. This cascade design ensures that the initial GSH depletion step primes the cell for subsequent metal-catalyzed oxidative injury, creating a coordinated sequential attack that overcomes the intrinsic antioxidant barriers of cancer cells. Recently, Encinas‑Gimenez et al⁶⁵ further validated this GSH‑depletion paradigm with CuFe@DMSA nanoparticles, where leached copper ions catalyze GSH conversion while simultaneously producing ROS, ultimately demonstrating that cells undergo a ferroptosis‑like cell death together with cell cycle arrest and apoptosis, and confirming in vivo that this mechanism leads to significant tumor growth reduction.

Beyond the core-shell configuration, alternative bimetallic architectures have also demonstrated effective tandem functionality. For instance, a bimetallic chitosan/hyaluronic acid nanoparticle (5FCN) with a Fe/Cu mass ratio of 5:5 was developed to release Fe³⁺ and Cu²⁺ in the acidic tumor microenvironment (Figure 4). These ions react with GSH to weaken antioxidant defenses, and as H₂O₂ is consumed, the rising Cu⁺ level within cells causes lipoylated protein aggregation, thereby amplifying cuproptosis in triple-negative breast cancer (TNBC).⁶⁶ The strategic combination of iron and copper within a single nanoplatform thus capitalizes on the complementary mechanisms of both cell death pathways, offering a powerful strategy for cancer therapy.

Figure 4.

Schematic illustration of a bimetallic chitosan/hyaluronic acid nanoparticle with an Fe/Cu mass ratio of 5:5 (5FCN) for self-amplifying ferroptosis/cuproptosis in triple-negative breast cancer (TNBC). (a) Preparation of 5FCN; and (b) Anti-TNBC mechanism of 5FCN. The upwards and downwards pink arrows denote an increase and a decrease in concentration or unit, respectively. Adapted from Wang J, Wang J, Zhang J, et al. Bimetallic chitosan/hyaluronic acid nanoparticles self-amplify ferroptosis/cuproptosis in triple-negative breast cancer. Int J Biol Macromol. 2025;308(Pt 4):142535. http://creativecommons.org/licenses/by/4.0/⁶⁶ licensed under CC-BY 4.0.

Nano-Regulators with Ionophore Activity

The targeted regulation of copper transport activity has emerged as a cornerstone strategy for inducing cuproptosis in cancer therapy.⁶⁷ This regulation can be achieved through two primary modalities: first, the direct co-delivery of ionophores with copper sources or ferroptosis inducers to amplify intracellular copper overload; second, the genetic or pharmacological disruption of protective cellular pathways (eg, autophagy) to enhance copper ion influx and retention. Among these, nanomedicines that simultaneously deliver copper ions and ionophores have garnered considerable attention due to their ability to achieve spatiotemporally controlled copper accumulation while minimizing systemic toxicity.^68,69

A representative paradigm in this domain is the intelligent cuproptosis-inducing nanosystem (ES@CuO) developed by Lu et al,⁷⁰ which encapsulates CuO nanoparticles with the copper ionophore elesclomol (ES) (Figure 5). This nanoplatform exploits the acidic tumor microenvironment to trigger the degradation of CuO, leading to the synchronous release of Cu²⁺ and ES. Mechanistically, after cellular internalization, ES acts as a molecular shuttle via a Trojan horse effect that directs copper ions specifically to the mitochondria, where they bind to lipoylated components of the TCA cycle. This process induces the aggregation of DLAT and downregulates iron-sulfur cluster proteins such as FDX1, culminating in cuproptosis. FDX1 downregulation, when observed, reflects the collapse of Fe‑S cluster proteins as a downstream consequence rather than a sensitizing mechanism. Notably, the ES@CuO nanoplatform not only directly suppresses B16 melanoma growth but also triggers immunogenic cell death (ICD), as evidenced by the release of damage-associated molecular patterns (DAMPs). In addition to direct copper oxide-based systems, organic copper complexes have also demonstrated potent cuproptosis-inducing capabilities. Wu et al⁷¹ pioneered the application of Bis(2-hydroxyethyl)dithiocarbamic acid copper(II) [Cu(HEDTC)₂] as a novel copper ionophore for inducing cuproptosis in B16 melanoma cells. Unlike traditional ionophores such as ES or disulfiram (DSF) that rely on endogenous serum copper to form active complexes, Cu(HEDTC)₂ intrinsically contains copper ions, thereby overcoming the clinical limitation of variable serum copper levels. The authors further constructed a Soluplus-based nanomicelle system (CS-NM) to encapsulate Cu(HEDTC)₂, enhancing its aqueous solubility and tumor accumulation via EPR effect. This “Winged Cu” nanosystem achieved approximately 5-fold higher intracellular copper levels compared to controls, with an IC₅₀ of 14.12 μM against B16 cells, demonstrating superior copper delivery efficiency and cytotoxic potency.

Figure 5.

Schematic illustration of the mechanism of a cuproptosis-inducing nanosystem (ES@CuO) combined with PD-1 for synergistic tumor immunotherapy in melanoma. Adapted from Lu X, Chen X, Lin C, et al. Elesclomol loaded copper oxide nanoplatform triggers cuproptosis to enhance antitumor immunotherapy. Adv Sci (Weinh). 2024;11(18):e2309984. http://creativecommons.org/licenses/by/4.0/⁷⁰ licensed under CC-BY 4.0.

A complementary strategy to potentiate cuproptosis involves the co-delivery of copper ionophores with additional therapeutic modalities. Luo et al⁷² developed a copper(II)-based metal-organic framework (Cu-MOF) nanoplatform encapsulating ES to induce cuproptosis burst and sequential ICD for cancer immunotherapy. The nano-regulator (ES-Cu-MOF) effectively released Cu²⁺ and ES in response to the intracellular acidic environment, resulting in elevated mitochondrial ROS generation, DLAT aggregation, and loss of Fe-S cluster proteins (including FDX1), with the latter serving as an indicator of ongoing cuproptotic damage rather than a sensitizing event. In vivo studies demonstrated that ES-Cu-MOF accumulated preferentially in tumor tissues, promoted dendritic cell (DC) maturation, and enhanced cytotoxic CD8⁺ T cell infiltration, leading to effective suppression of both primary and distant tumors. A further innovative approach to enhance cuproptosis sensitivity involves metabolic modulation. Meng et al⁷³ designed a biomimetic copper-based nanoplatform (SCTDM) co-loaded with the lactate modulator syrosingopine (Su3118) and the copper ionophore DSF. The released Su3118 inhibits lactate efflux, which disrupts glycolysis and forces tumor cells to rely on mitochondrial respiration, thereby increasing their dependence on the TCA cycle. This metabolic reprogramming renders cancer cells highly vulnerable to cuproptosis. Concurrently, DSF delivers copper ions into mitochondria, triggering lipoylated protein aggregation, Fe-S cluster protein downregulation, and irreversible cuproptotic cell death. Thus, this work demonstrates that metabolic modulation can effectively sensitize tumor cells to ionophore-targeted cuproptosis therapy.

Beyond direct copper delivery, emerging strategies have integrated autophagy interference to amplify cuproptotic stress, as protective autophagy often limits the efficacy of cuproptosis-based therapies. Li et al⁷⁴ developed a self-amplifying cuproptosis nanoregulator (SC/TpA@HA) that co-delivers a shikonin-copper coordination complex (SHK-Cu) and a CRISPR/Cas9 plasmid targeting ATG5, a key autophagy-related gene. SHK-Cu releases copper ions upon intracellular GSH activation, triggering DLAT oligomerization and Fe-S cluster protein loss, downstream damage events that collectively execute cuproptotic cell death. Concurrently, CRISPR/Cas9-mediated ATG5 knockout prevents autophagosome formation, creating an autophagic flux trap that accumulates copper-damaged mitochondria. This dual intervention—copper overload combined with autophagy blockade—dramatically amplifies cuproptosis and enhances ICD. This work elegantly demonstrates that combining copper ionophore delivery with genetic disruption of cellular defense mechanisms represents a powerful paradigm for amplifying cuproptosis.

In conclusion, nanomedicines that target copper ionophores represent a versatile and powerful strategy for cuproptosis-based cancer therapy (Table 2). The exemplary systems discussed above illustrate diverse approaches ranging from direct copper delivery and autophagy interference to metabolic modulation and photothermal synergy. These advances underscore the translational potential of ionophore-targeting nanomedicines for enhancing both cuproptosis and antitumor immunotherapy, while also highlighting the importance of combinatorial strategies to overcome cellular resistance mechanisms.

Table 2.

Representative Nanomedicine Design for Ionophore-Driven Cuproptosis

Nanoplatform	Copper Source	Ionophore	Additional Mechanism	Cancer Model	Key Outcome	Ref.
ES@CuO	CuO NPs	Elesclomol	PD-1 combination	B16 melanoma	Enhanced cuproptosis and T cell infiltration	[70]
CS-NM	Cu(HEDTC)2 (intrinsic)	Cu(HEDTC)2	Soluplus nanomicelle	B16 melanoma	5× copper uptake, IC50 14.12 μM	[71]
ES-Cu-MOF	Cu-MOF	Elesclomol	ICD induction	MCA205 fibrosarcoma	Distant tumor suppression	[72]
SCTDM	TA-Cu complex	Disulfiram (DSF)	Lactate modulation (Su3118) + PTT	CT26 colorectal cancer	Post-surgical recurrence prevention	[73]
SC/TpA@HA	SHK-Cu complex	SHK (phenolic)	CRISPR-ATG5 knockout	Renca renal carcinoma	Autophagy blockade amplifies cuproptosis	[74]

Nanomedicines Enabling Endogenous Metal Mobilization

Despite the notable anticancer efficacy achieved by delivering exogenous ferroptosis/cuproptosis enhancers, their long‑term application faces a common limitation. Repeated administration of iron or copper compounds carries a risk of systemic metal accumulation and off‑target toxicity. Cancer cells, however, already contain measurable quantities of labile iron and copper, most of which are sequestered in ferritin, metallothioneins, or other storage proteins. This endogenous metal pool is often sufficient to trigger cell death if it can be liberated and if the cells simultaneously lose their antioxidant protection. Nanomedicines that mobilize these endogenous reserves thus offer a conceptually distinct approach that reduces dependence on exogenous metal ions while still engaging both ferroptotic and cuproptotic pathways.

The design of such nanomedicines depends upon two coordinated actions that repurpose the endogenous labile iron and copper pools. One is the delivery of a metal‑free or metal‑sparse nanoparticle that, in response to the tumor microenvironment, triggers the liberation of Fe²⁺/Fe³⁺ or Cu²⁺ from intracellular storage proteins. The other is the simultaneous delivery of small interfering RNA (siRNA) or bioactive molecule against key negative regulators of metal‑induced death, most notably GPX4 for ferroptosis and FDX1 for cuproptosis, thereby sensitizing cancer cells to the mobilized endogenous metals. Unlike exogenous metal supplementation strategies that simply increase total metal load, this dual approach lowers the threshold at which endogenous or locally released metals become lethal. For ferroptosis, GPX4 siRNA directly weakens the cell’s primary defense against lipid peroxidation, so that even modest iron release can provoke fatal membrane damage. For cuproptosis, the situation is more nuanced. FDX1 is a positive regulator that reduces Cu²⁺ to Cu⁺ and supports protein lipoylation. Therefore, FDX1 overexpression, not silencing, sensitizes cells to cuproptosis. Some recent nanoplatforms have instead delivered FDX1 plasmid DNA or used small molecules to enhance FDX1 activity, whereas others have focused on the copper‑buffering system (eg, glutathione depletion) to achieve a similar sensitization effect.^75,76

Metal‑releasing nanoparticles designed for endogenous mobilization typically exploit the acidic pH, high GSH concentration, or elevated H₂O₂ level of the tumor microenvironment as internal triggers. One representative system is a coordination nanoparticle self‑assembled from Fe²⁺ ions, nucleotides, and GPX4 siRNA. Under weak acidic conditions, the particle dissociates and simultaneously releases Fe²⁺ and siRNA. The liberated Fe²⁺ drives Fenton chemistry to generate hydroxyl radicals, while the co‑released GPX4 siRNA suppresses the enzyme that would otherwise detoxify lipid hydroperoxides. This dual action has been shown to lower the ferroptosis threshold by more than an order of magnitude compared to iron delivery alone.¹⁹ A conceptually distinct strategy for cuproptosis involves the use of small molecule enhancers rather than siRNA. In this context, the natural flavonol quercetin has been identified as a potent FDX1 activator. Molecular docking and pull‑down assays confirmed that quercetin directly binds to FDX1, and when combined with the copper ionophore complex ES‑Cu, it significantly upregulated FDX1 expression in lenvatinib‑resistant hepatocellular carcinoma cells, thereby enhancing cuproptosis sensitivity. This combination enhanced mitochondrial oxidative phosphorylation, increased intracellular copper accumulation by more than tenfold, and triggered lipoylated DLAT aggregation and Fe‑S cluster protein loss as downstream damage events, ultimately reversing drug resistance through cuproptosis activation.⁴⁹ Together, these examples illustrate that mobilizing endogenous metal pools, whether through iron release combined with GPX4 silencing or through copper ionophore delivery coupled with FDX1 upregulation, can effectively lower the death threshold of resistant tumor cells.

Nanoplatforms Integrated with External Stimuli and Immunotherapy

External energy inputs such as photothermal or ultrasound stimulation can accelerate metal ion release and catalytic activity, while the resulting dual death pathways expose DAMPs to trigger immunogenic cell death. This effect, combined with immune checkpoint blockade, offers a strategy to convert cold tumors into hot ones. Recent efforts have focused on integrating external stimuli and immunotherapy into ferroptosis‑cuproptosis nanoplatforms.

Photo/Ultrasound-Enhanced Catalytic Ion Therapy

Photothermal, photodynamic, and sonodynamic modalities offer more than mere ROS generation. They can accelerate Fenton and Fenton‑like reactions through local hyperthermia or ultrasonic cavitation, disrupt the TCA cycle flux by damaging iron‑sulfur cluster proteins and key dehydrogenases, and enhance metal ion release from nanocarriers by increasing membrane permeability or modulating metal transporter expression. For example, ultrasound irradiation has been shown to upregulate the copper influx transporter SLC31A1 and downregulate the efflux transporter ATP7A, leading to sustained intracellular copper overload. These combined effects lower the threshold for both ferroptosis and cuproptosis, enabling low‑dose metal administration while maintaining potent antitumor efficacy.

In a related example of photo‑enhanced catalytic ion therapy, Zhang et al⁷⁷ developed a copper‑doped hollow Prussian blue nanozyme loaded with a photosensitizer and oxygen carrier (O₂‑PFH@CHPI). Upon near‑infrared irradiation, the photothermal effect accelerated Fenton‑like reactions and glutathione depletion, while the released Cu⁺ ions induced DLAT aggregation (a hallmark of cuproptotic damage) and GPX4 inactivation, co‑activating cuproptosis and ferroptosis in a self‑amplifying loop that disrupted mitochondrial metabolism and exacerbated oxidative stress (Figure 6). It is important to clarify that the observed ROS elevation in such systems reflects copper-induced oxidative stress secondary to cuproptotic injury, rather than the primary execution mechanism of cuproptosis itself. For ultrasound‑enhanced therapy, Cai and co‑workers designed a Cu₂O/Cu₂-_xSe bilayer nanocapsule that functions as a stimulus‑responsive “cuproptosis switch”, where sonodynamic effects triggered by ultrasound irradiation accelerated ROS production, depleted GSH, and promoted mitochondrial Cu⁺ accumulation, resulting in complete eradication of primary and distant tumors in mouse models.⁷⁸ Together, these encouraging findings demonstrate that photo/ultrasound-enhanced catalytic ion therapy provides a promising approach to potentiate both cuproptosis and ferroptosis through the amplification of intratumoral metal ion toxicity and metabolic disruption.

Figure 6.

Construction of cuproptosis/ferroptosis co-activated nanoparticles (O₂-PFH@CHPI NPs) and their in vivo anticancer effect. (a) Synthetic route of O₂-PFH@CHPI NPs. (b) Schematic illustration of ferroptosis and cuproptosis induced by O₂-PFH@CHPI. (c) Cell viabilities of Huh7 cells treated with O₂-PFH@CHPI + NIR, with or without the ferroptosis inhibitor Lip-1 and the cuproptosis inhibitor UK-5099. (d) Immunofluorescence images of Huh7 cells stained with anti-GPX4 antibody (green) and cytoskeleton (red) following treatment. (e) Immunofluorescence images of Huh7 cells stained with anti-DLAT antibody (green) and cytoskeleton (red). (f) CLSM images of Huh7 cells stained with C11-BODIPY581/591. (g) CLSM images of Huh7 cells stained with Liperfluo. (h) Western blot analysis of LIAS and FDX1 expression in Huh7 cells. (i) JC-1 staining of Huh7 cells. (j) Semiquantitative analysis of mitochondrial health (healthy vs damaged), determined by the green-to-red fluorescence intensity ratio. (k) Photographs of excised tumors after treatment. (l) Average tumor weight. (m) Body weight curves of mice across different treatment groups. (n) Hematological and blood biochemistry analyses of healthy mice at various time points following O₂-PFH@CHPI NP administration. Group labels: 1) control, 2) NIR alone, 3) CHP alone, 4) CHP + NIR, 5) O₂-PFH@CHPI alone, and 6) O₂-PFH@CHPI + NIR. Data expressed as mean ± SD (n = 3). *p ≤ 0.05,**p ≤ 0.01, ***p ≤ 0.001; ns, not significant. Adapted from Zhang X, Zhu J, Wang S, et al. A copper/ferrous-engineering redox homeostasis disruptor for cuproptosis/ferroptosis co-activated nanocatalytic therapy in liver cancer. Adv Funct Mater. 2024;34:2402022. © 2024, Wiley-VCH GmbH.⁷⁷

Ferroptosis-Cuproptosis Immunogenic Cell Death

Beyond their direct cytotoxic effects, the concurrent activation of ferroptosis and cuproptosis can potently induce ICD, a form of regulated cell death capable of converting dying tumor cells into endogenous therapeutic vaccines. ICD is defined by the exposure or release of DAMPs, including calreticulin (CRT) exposure on the cell surface, high mobility group box 1 (HMGB1) release from the nucleus, and ATP secretion into the extracellular milieu. These signals collectively facilitate the recruitment and maturation of dendritic cells (DCs), which subsequently prime tumor-specific T cell responses.⁷⁹

Several recent studies have demonstrated that ferroptosis and cuproptosis co-activation triggers a robust ICD response. For instance, in the work by Chen et al.⁸⁰ Cu-BTO nanoparticles under ultrasound (US) irradiation not only generated substantial ROS and depleted GSH but also induced marked CRT membrane translocation, HMGB1 extracellular release, and ATP secretion in 4T1 breast cancer cells. Notably, the conditioned medium from Cu-BTO + US-treated tumor cells effectively promoted dendritic cell maturation, with a maturation rate reaching 37.0%, as evidenced by flow cytometry analysis of CD11c⁺CD80⁺CD86⁺ cells. In vivo, tumors treated with Cu-BTO + US exhibited enhanced CRT exposure and HMGB1 release within the tumor microenvironment, accompanied by increased DC maturation in tumor-draining lymph nodes (26.6%) and elevated infiltration of CD8⁺ and CD4⁺ T cells into tumor tissues, ultimately achieving an 83.7% tumor inhibition rate and effective prevention of lung metastasis.

Similar ICD-promoting effects have been observed in other ferroptosis/cuproptosis-co-activating nanoplatforms. For instance, He et al developed a trimetallic AuBiCu-PEG nanosensitizer that synergistically induces both ferroptosis and cuproptosis under X-ray irradiation, effectively promoting radiotherapy-induced ICD and reshaping the immunosuppressive tumor microenvironment.⁸¹ In another case, Zhang et al⁸² designed a single-site copper(I) nanomodulator (CuNTD) with photothermal-enhanced cascade catalytic activity, which triggers robust ICD through synergistic ferroptosis and cuproptosis, leading to effective dendritic cell maturation and significantly prolonged in vivo survival of model mouse, as illustrated in Figure 7. These findings highlight that leveraging ICD through concurrent ferroptosis and cuproptosis provides a dual advantage: directly eradicating primary tumors while simultaneously initiating an in-situ vaccination effect to suppress distant metastasis.

Figure 7.

Schematic representation of the synthesis of single-site copper(i) nanomodulators (CuNTD) and the photothermal-amplified ROS storms, ferroptosis, and cuproptosis cascade-inducing ICD augmented TNBC immunotherapy. The green and Orange arrows denote signal flow, and ⊥ denotes a blocking event. Adapted from Zhang Y, Ya S, Huang J, et al. Spatial isolation of single copper(i) sites for cascade enzyme-like catalysis and simultaneous ferroptosis/cuproptosis boosted immunotherapy. Exploration (Beijing). 2025;5:20240275. http://creativecommons.org/licenses/by/4.0/⁸² licensed under CC-BY 4.0.

Nanotherapy Combined with Immune Checkpoint Blockade

In spite of the robust ICD induced by ferroptosis-cuproptosis co-activated nanoplatforms, the antitumor immune response is often restrained by adaptive immune resistance, particularly the upregulation of programmed death-ligand 1 (PD-L1) on tumor cells.⁸³ This immune checkpoint engages PD-1 on T cells, leading to T cell exhaustion and immune evasion. Therefore, combining ferroptosis-cuproptosis nanotherapy with immune checkpoint blockade (ICB) represents a rational strategy to relieve immunosuppression and maximize therapeutic efficacy.

Several recent studies have demonstrated the synergistic potential of such combination regimens. In a notable example, Li et al developed a core-shell nanoscale coordination polymer (CuP/Er) for the co-delivery of copper peroxide and erastin, a classical ferroptosis inducer. In both MC38 colon adenocarcinoma and 4T1 triple-negative breast cancer models, CuP/Er treatment not only induced robust ICD but also significantly upregulated PD-L1 expression on tumor cells.⁸⁴ When combined with anti-PD-L1 antibody (aPD-L1), CuP/Er plus aPD-L1 achieved a tumor growth inhibition index of 97.7% in MC38 tumors and 99.1% in 4T1 tumors, with three out of six mice in the latter group becoming tumor-free. The upregulation of PD-L1 following ferroptosis-cuproptosis induction appears to be a common phenomenon. Similar observations have been reported in other studies,^85–87 where copper-based nanoplatforms or ferroptosis inducers consistently elevate PD-L1 expression, creating a window of opportunity for ICB intervention. For instance, Zhao et al engineered a laser-activated lipid nanoplatform (CCDL) that triggers concurrent cuproptosis, ferroptosis, and pyroptosis in colorectal cancer (Figure 8). They noted that “metal overload-associated PD-L1 upregulation” makes these cell death pathways attractive targets to enhance ICB responsiveness, and combining CCDL with αPD-L1 blockade elicited a robust abscopal effect, achieving 92% inhibition of distant tumors and reshaping the immunosuppressive microenvironment.⁸⁸ This rational design enables in situ vaccine-like nanoplatforms that leverage the crosstalk between ICD and checkpoint upregulation to convert immunologically “cold” tumors into “hot” ones, thereby overcoming intrinsic resistance to ICB monotherapy.⁸⁹

Figure 8.

Mechanistic schematic of CCDL-mediated multimodal cell death converting an immunologically “cold” colorectal microsatellite-stable (MSS) tumor into a “hot” tumor susceptible to ICB therapy. CCDL (CuFeS₂–CA–DAC–Lipo), a lipid-based nanoplatform composed of CuFeS₂ co-encapsulating decitabine (DAC) and chlorogenic acid (CA). The upwards red arrow signifies increased expression. Adapted from Zhao R, Wang X, Wang J, et al. Rewiring metal-dependent cell death to unlock immunotherapy in colorectal cancer. Nano Lett. 2026;26:4755–4765. © 2026, American Chemical Society.⁸⁸

Collectively, these studies establish that ferroptosis-cuproptosis co-activated nanotherapy not only serves as an in-situ vaccine to prime antitumor immunity but also sensitizes tumors to immune checkpoint blockade by upregulating PD-L1. This two-pronged strategy, simultaneously triggering ICD and relieving checkpoint-mediated immunosuppression, holds great promise for achieving durable systemic antitumor responses and preventing metastasis.

Challenges and Future Perspectives

Despite the considerable promise of ferroptosis/cuproptosis-interwoven nanotherapy platforms, several critical challenges must be addressed before these strategies can be translated into the clinical stage. A primary obstacle lies in the difficulty of distinguishing the relative contributions of each death pathway to tumor regression in vivo. Current detection strategies rely largely on in vitro biomarkers—lipoylated DLAT aggregation for cuproptosis and GPX4 downregulation along with PUFA oxidation for ferroptosis—which do not translate well to live tissues.⁹⁰ Although recent progress in fluorescence imaging has yielded probes capable of monitoring hydroxyl radical fluctuations during both ferroptosis and cuproptosis in living systems, and integrated nanodiagnostic materials (eg, copper oxide) combine imaging with ROS generation to track tumor responses, quantification of how much tumor cell death arises from cuproptosis versus ferroptosis remains elusive. This knowledge gap constrains the rational optimization of nanoplatform composition and dosing schedules, and underscores the urgent need for noninvasive imaging tools that can dissect metal-dependent death pathways in real time within the tumor microenvironment.⁹¹

Another major concern, in addition to the difficulty of tracking these pathways in living systems, is that the materials may cause systemic toxicity and off-target metal accumulation. Long-term administration of copper and iron compounds carries inherent risks, including copper-mediated neurotoxicity resembling Wilson disease⁹² and iron-induced hemochromatosis.⁹³ To minimize collateral damage to healthy tissues, current nanotechnology offers an array of mitigation strategies, from active targeting ligands (eg, tumor cell membrane coatings for homotypic targeting and immune evasion^94,95) to responsive release mechanisms triggered by unique tumor microenvironment cues.⁹⁶ However, it must be acknowledged that the in vivo shielding efficacy of these TME-responsive coatings is often overstated. Therefore, future preclinical studies must move beyond mere efficacy validation. It is urgent to define the precise therapeutic window, particularly the margin between the maximum tolerated dose (MTD) and the minimal effective dose (MED), and to conduct rigorous pharmacokinetic (PK) and toxicokinetic (TK) evaluations that encompass long-term clearance and organ-specific retention, thereby establishing robust safety margins. Nevertheless, the complex, multi-metallic compositions of the current generation of ferroptosis-cuproptosis nanoplatforms introduce additional layers of toxicity liability that are not yet fully characterized. As a complementary challenge, adaptive resistance mechanisms represent another critical barrier. While Nrf2 is an established shared regulator, the review must acknowledge that under prolonged bimetallic stress, cancer cells can actively upregulate alternative metal-efflux pumps (eg, ATP7A/ATP7B for copper, ferroportin for iron) and remodel intracellular thiol kinetics (eg, increasing glutathione or metallothionein synthesis). These dynamic adaptive responses can effectively neutralize and extrude excess metal ions, thereby extinguishing the intended therapeutic cascade. Future nanoplatforms must therefore incorporate strategies to inhibit these efflux systems or temporally overcome this metabolic adaptation. Moreover, metabolic heterogeneity across tumors poses an equally formidable barrier. Cancer cells with low mitochondrial respiration or reduced FDX1 expression are inherently resistant to cuproptosis,⁹⁷ consistent with FDX1’s role as a positive upstream determinant of cuproptosis sensitivity, whereas those with robust antioxidant defenses may resist ferroptosis.⁹⁸ In this context, the rational design of adaptive nanomedicines capable of switching death modality on the basis of metabolic diagnosis or dynamic microenvironment cues represents a crucial direction for overcoming resistance and extending the applicability of this therapeutic paradigm.

Looking toward clinical translation, the path from preclinical proof-of-concept to bedside application remains long and winding. Most studies are conducted in standard subcutaneous xenograft or syngeneic models. While these models provide critical proof-of-concept for localized metal overload, they inherently fail to recapitulate the complex stromal architecture, dense extracellular matrix, and metabolic heterogeneity (such as varying FDX1/GPX4 expression) of spontaneous human tumors. Furthermore, the hyper-physiological metal ion concentrations achieved in these localized, rapidly growing murine tumors do not necessarily predict therapeutic responses in patients with varying nutritional statuses or genetic backgrounds. Hence, claims regarding imminent clinical translation must be approached with caution. To bridge this gap, rigorous pharmacokinetic and pharmacodynamic assessments in larger animal models are needed to gauge the behavior and long-term toxicity of these nanoplatforms in more clinically relevant contexts.⁹⁹ Equally important is the identification of the cancer types most likely to benefit from ferroptosis-cuproptosis co-activation strategies. Clear cell renal cell carcinoma (ccRCC) emerges as a particularly compelling candidate, given its hallmark VHL mutation-associated metabolic reprogramming, which confers cysteine- and GPX4-dependent sensitivity to ferroptosis, and its reliance on an intact TCA cycle that may render it vulnerable to cuproptosis under conditions of copper overload.¹⁰⁰ Notably, sorafenib, a frontline targeted agent for advanced liver and kidney cancers, has been reported to induce ferroptosis in renal cell carcinoma cells, and its combination with copper ionophores has shown synergistic growth inhibition.¹⁰¹ Hepatocellular carcinoma, particularly in the context of sorafenib resistance, similarly exhibits metabolic vulnerabilities that may be exploited by dual metal-based interventions.

Beyond direct anticancer efficacy, the ICD elicited by ferroptosis-cuproptosis co-activation, together with the observed PD-L1 upregulation following metal overload, renders these nanoplatforms ideal for integration with immune checkpoint blockade. Indeed, copper-doped polydopamine nanoparticles have recently been shown to sensitize lung tumors to anti-PD-L1 therapy, improving therapeutic efficacy by approximately fivefold.¹⁰² Taken together, these insights advocate for a precision oncology approach wherein patient stratification, informed by genomic and metabolic profiling, directs the selective deployment of ferroptosis-cuproptosis co-activation therapies toward tumor types with intrinsic vulnerabilities to these metal-dependent cell death programs. As the field continues to mature, collaborative efforts bridging material science, mechanistic cell biology and clinical oncology will be indispensable to surmount these hurdles and translate the promise of ferroptosis-cuproptosis nanotherapeutics into tangible clinical benefit.

Conclusion

The intricate crosstalk between ferroptosis and cuproptosis centers on the GSH‑GPX4 axis, mitochondrial iron‑sulfur cluster homeostasis, and coordinated metal metabolism. These two death pathways share key regulatory nodes, most notably GSH, which suppresses cuproptosis by chelating Cu⁺ and ferroptosis as a GPX4 cofactor. They also engage in a self‑amplifying loop where copper overload destabilizes Fe‑S clusters to release iron, fueling ferroptosis, while iron‑driven lipid peroxidation further impairs mitochondrial function to potentiate cuproptosis. Nanomedicine can exploit this interplay through rationally engineered platforms, including copper‑based nanozymes, bimetallic core‑shell nanoparticles, ionophore‑loaded regulators, and endogenous metal mobilizers. These systems achieve spatiotemporally controlled GSH depletion, cascade ROS generation, and sequential engagement of both death modalities. As integrated with photothermal, sonodynamic, or immune checkpoint blockade strategies, such nanoplatforms eradicate primary tumors and convert immunologically “cold” microenvironments into “hot” ones via ICD and PD‑L1 upregulation. The field is now shifting from single‑pathway targeting toward integrated modulation of cell death networks. Future metal‑based nanomedicines should energetically exploit the ferroptosis‑cuproptosis crosstalk, harnessing metabolic vulnerabilities to achieve durable, metastasis‑suppressive antitumor immunity.

Funding Statement

This work was collectively supported by the Guangdong Basic and Applied Basic Research Foundation (2023A1515012326).

Disclosure

The authors report no conflicts of interest in this work.