Objective To investigate the anti-tumor effects and mechanisms of sonodynamic therapy (SDT) combined with anlotinib on non-small cell lung cancer (NSCLC).

Methods A549 and H1299 cells were used as the research models and the following groups were established: control, anlotinib, SDT, and SDT-anlotinib. Cell viability and migration ability were assessed using the CCK-8 and cell scratch assays. Additionally, flow cytometry was employed to determine reactive oxygen species (ROS）levels, apoptosis, and cell cycle; Western blot was performed to detect Caspase-3 and Cyclin D1 expression; and ROS elimination experiments were conducted to explore the mechanisms of combined SDT and anlotinib treatment.

Results In comparison to the anlotinib group, the SDT-anlotinib group demonstrated a notable inhibition in the proliferation of lung cancer cells cell viability: A549: (49.96±4.82)% vs. (86.79±2.64)%, P<0.01; H1299: (31.91±4.87)% vs. (88.04±2.16)%, P<0.001 and migration healing rate: A549: (4.23±0.17)% vs. (14.28±0.05)%, P<0.05; H1299:(13.68±2.16)% vs. (42.81±8.11)%, P<0.001. Furthermore, the combination therapy group exhibited a notable induction of apoptosis apoptosis rate: (12.58±0.815)% vs. (8.43±0.56)%, P<0.05. Mechanistic studies have demonstrated that anlotinib resistance is associated with ROS levels. Treatment with the ROS scavenger N-acetylcysteine (NAC) has been shown to decrease intracellular ROS content, increase the IC₅₀ of anlotinib, and reduce sensitivity. Intracellular ROS levels in tumor cells were significantly higher in SDT-anlotinib group compared to that in the anlotinib group (934.14±2.01) vs. (166.75±1.45), P<0.001. Additionally, Caspase-3 activation was observed, accompanied by a reduction in Cyclin D1 expression.

Conclusions The combination of SDT and anlotinib exerted a pronounced anti-tumor effect. Activation of the ROS pathway led to the activation of Caspase-3 and the downregulation of Cyclin D1, resulting in the inhibition of lung cancer cell proliferation and the induction of apoptosis.