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Ibanez KR, Huang TT, Lee JM. Combination Therapy Approach to Overcome the Resistance to PI3K Pathway Inhibitors in Gynecological Cancers. Cells 2024; 13:1064. [PMID: 38920692 PMCID: PMC11201409 DOI: 10.3390/cells13121064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/16/2024] [Accepted: 06/18/2024] [Indexed: 06/27/2024] Open
Abstract
The PI3K signaling pathway plays an essential role in cancer cell proliferation and survival. PI3K pathway inhibitors are now FDA-approved as a single agent treatment or in combination for solid tumors such as renal cell carcinoma or breast cancer. However, despite the high prevalence of PI3K pathway alterations in gynecological cancers and promising preclinical activity in endometrial and ovarian cancer models, PI3K pathway inhibitors showed limited clinical activity in gynecological cancers. In this review, we provide an overview on resistance mechanisms against PI3K pathway inhibitors that limit their use in gynecological malignancies, including genetic alterations that reactivate the PI3K pathway such as PIK3CA mutations and PTEN loss, compensatory signaling pathway activation, and feedback loops causing the reactivation of the PI3K signaling pathway. We also discuss the successes and limitations of recent clinical trials aiming to address such resistance mechanisms through combination therapies.
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Van Cauwenberge J, Van Baelen K, Maetens M, Geukens T, Nguyen HL, Nevelsteen I, Smeets A, Deblander A, Neven P, Koolen S, Wildiers H, Punie K, Desmedt C. Reporting on patient's body mass index (BMI) in recent clinical trials for patients with breast cancer: a systematic review. Breast Cancer Res 2024; 26:81. [PMID: 38778365 PMCID: PMC11112918 DOI: 10.1186/s13058-024-01832-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/30/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND The proportion of patients with breast cancer and obesity is increasing. While the therapeutic landscape of breast cancer has been expanding, we lack knowledge about the potential differential efficacy of most drugs according to the body mass index (BMI). Here, we conducted a systematic review on recent clinical drug trials to document the dosing regimen of recent drugs, the reporting of BMI and the possible exclusion of patients according to BMI, other adiposity measurements and/or diabetes (leading comorbidity of obesity). We further explored whether treatment efficacy was evaluated according to BMI. METHODS A search of Pubmed and ClinicalTrials.gov was performed to identify phase I-IV trials investigating novel systemic breast cancer treatments. Dosing regimens and exclusion based on BMI, adiposity measurements or diabetes, documentation of BMI and subgroup analyses according to BMI were assessed. RESULTS 495 trials evaluating 26 different drugs were included. Most of the drugs (21/26, 81%) were given in a fixed dose independent of patient weight. BMI was an exclusion criterion in 3 out of 495 trials. Patients with diabetes, the leading comorbidity of obesity, were excluded in 67/495 trials (13.5%). Distribution of patients according to BMI was mentioned in 8% of the manuscripts, subgroup analysis was performed in 2 trials. No other measures of adiposity/body composition were mentioned in any of the trials. Retrospective analyses on the impact of BMI were performed in 6 trials. CONCLUSIONS Patient adiposity is hardly considered as most novel drug treatments are given in a fixed dose. BMI is generally not reported in recent trials and few secondary analyses are performed. Given the prevalence of patients with obesity and the impact obesity can have on pharmacokinetics and cancer biology, more attention should be given by investigators and study sponsors to reporting patient's BMI and evaluating its impact on treatment efficacy and toxicity.
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Affiliation(s)
- Josephine Van Cauwenberge
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium
- Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Karen Van Baelen
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium
- Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Marion Maetens
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium
| | - Tatjana Geukens
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Ha Linh Nguyen
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium
| | - Ines Nevelsteen
- Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Ann Smeets
- Department of Surgical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Anne Deblander
- Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Patrick Neven
- Department of Gynecological Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Stijn Koolen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
- Department of Hospital Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - Hans Wildiers
- Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - Kevin Punie
- Department of Medical Oncology, GZA Hospitals Sint-Augustinus, Wilrijk, Belgium
| | - Christine Desmedt
- Laboratory for Translational Breast Cancer Research, Department of Oncology, KU Leuven, Herestraat 49, Box 808, 3000, Louvain, Belgium.
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Li Y, Li H, Xiang Z. Alpelisib-related adverse events: The FDA Adverse Event Reporting System Database (FAERS) pharmacovigilance study. Heliyon 2024; 10:e27599. [PMID: 38510044 PMCID: PMC10951579 DOI: 10.1016/j.heliyon.2024.e27599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/03/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024] Open
Abstract
Background Alpelisib was approved for treatment of breast cancer. We assessed the safety signals associated with alpelisib by data mining the FDA pharmacovigilance database. Methods Data from the second quarter of 2019 to the fourth quarter of 2022 had been retrieved from the FAERS database. Disproportionality analysis by reporting odds ratio were used to evaluate the potential association between adverse events (AEs) and alpelisib. Results A total of 5,980,090 reports were extracted, 18,149 of them were chosen with alpelisib as the suspected drug. After combining the same PRIMARYID, 5647 patients remained. We observed 10 system organ classes (SOCs) with a reported number >50 and associated with alpelisib as gastrointestinal disorders, general disorders and administration site conditions, metabolism and nutrition disorders, skin and subcutaneous tissue disorders, investigations and neoplasms benign, malignant and unspecified (incl cysts and polyps), immune system disorders, nervous system disorders, psychiatric disorders, eye disorders. The median time to AEs in these patients was 13 days, with an IQR (Interquartile Range) of 7-70 days. 61.12% AEs happened within the initial month of alpelisib usage. Conclusion Our study provided a more in-depth and extensive understanding of AEs that may be associated with alpelisib, which will help to reduce the risk of AEs in the clinical treatment of alpelisib. AEs with novel preferred term (PTs) were constipation, dysphagia, diabetic ketoacidosis, feeding disorder, urticaria, eye disorders and vision blurred. 61.12% of cases developed AEs within 30 days after taking alpelisib.
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Affiliation(s)
- Yun Li
- Department of Pharmacy, Yueyang Central Hospital, Yueyang, 414000, Hunan, PR China
| | - Hang Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, PR China
| | - Zhongyuan Xiang
- Department of Laboratory Medicine, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, PR China
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Chen R, Wu J, Che Y, Jiao Y, Sun H, Zhao Y, Chen P, Meng L, Zhao T. Machine learning-driven prognostic analysis of cuproptosis and disulfidptosis-related lncRNAs in clear cell renal cell carcinoma: a step towards precision oncology. Eur J Med Res 2024; 29:176. [PMID: 38491523 PMCID: PMC10943875 DOI: 10.1186/s40001-024-01763-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/01/2024] [Indexed: 03/18/2024] Open
Abstract
Cuproptosis and disulfidptosis, recently discovered mechanisms of cell death, have demonstrated that differential expression of key genes and long non-coding RNAs (lncRNAs) profoundly influences tumor development and affects their drug sensitivity. Clear cell renal cell carcinoma (ccRCC), the most common subtype of kidney cancer, presently lacks research utilizing cuproptosis and disulfidptosis-related lncRNAs (CDRLRs) as prognostic markers. In this study, we analyzed RNA-seq data, clinical information, and mutation data from The Cancer Genome Atlas (TCGA) on ccRCC and cross-referenced it with known cuproptosis and disulfidptosis-related genes (CDRGs). Using the LASSO machine learning algorithm, we identified four CDRLRs-ACVR2B-AS1, AC095055.1, AL161782.1, and MANEA-DT-that are strongly associated with prognosis and used them to construct a prognostic risk model. To verify the model's reliability and validate these four CDRLRs as significant prognostic factors, we performed dataset grouping validation, followed by RT-qPCR and external database validation for differential expression and prognosis of CDRLRs in ccRCC. Gene function and pathway analysis were conducted using Gene Ontology (GO) and Gene Set Enrichment Analysis (GSEA) for high- and low-risk groups. Additionally, we have analyzed the tumor mutation burden (TMB) and the immune microenvironment (TME), employing the oncoPredict and Immunophenoscore (IPS) algorithms to assess the sensitivity of diverse risk categories to targeted therapeutics and immunosuppressants. Our predominant objective is to refine prognostic predictions for patients with ccRCC and inform treatment decisions by conducting an exhaustive study on cuproptosis and disulfidptosis.
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Affiliation(s)
- Ronghui Chen
- School of Clinical Medicine, Shandong Second Medical University, Weifang, 261053, China
- Department of Oncology, People's Hospital of Rizhao, Rizhao, 276826, China
| | - Jun Wu
- Department of Oncology, People's Hospital of Rizhao, Rizhao, 276826, China
| | - Yinwei Che
- Department of Central Laboratory, Shandong Provincial Key Medical and Health Laboratory, Rizhao Key Laboratory of Basic Research on Anesthesia and Respiratory Intensive Care, The People's Hospital of Rizhao, Rizhao, 276826, Shandong, China
| | - Yuzhuo Jiao
- Department of Central Laboratory, Shandong Provincial Key Medical and Health Laboratory, Rizhao Key Laboratory of Basic Research on Anesthesia and Respiratory Intensive Care, The People's Hospital of Rizhao, Rizhao, 276826, Shandong, China
| | - Huashan Sun
- Department of Central Laboratory, Shandong Provincial Key Medical and Health Laboratory, Rizhao Key Laboratory of Basic Research on Anesthesia and Respiratory Intensive Care, The People's Hospital of Rizhao, Rizhao, 276826, Shandong, China
| | - Yinuo Zhao
- Department of Pathology, People's Hospital of Rizhao, Rizhao, 276826, China
| | - Pingping Chen
- Department of Pathology, People's Hospital of Rizhao, Rizhao, 276826, China
| | - Lingxin Meng
- Department of Oncology, People's Hospital of Rizhao, Rizhao, 276826, China.
| | - Tao Zhao
- Department of Central Laboratory, Shandong Provincial Key Medical and Health Laboratory, Rizhao Key Laboratory of Basic Research on Anesthesia and Respiratory Intensive Care, The People's Hospital of Rizhao, Rizhao, 276826, Shandong, China
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von Hessert-Vaudoncourt C, Lelek S, Geisler C, Hartung T, Bröker V, Briest F, Mochmann L, Jost-Brinkmann F, Sedding D, Benecke J, Freitag H, Wolfshöfer S, Lammert H, Nölting S, Hummel M, Schrader J, Grabowski P. Concomitant inhibition of PI3K/mTOR signaling pathways boosts antiproliferative effects of lanreotide in bronchopulmonary neuroendocrine tumor cells. Front Pharmacol 2024; 15:1308686. [PMID: 38375032 PMCID: PMC10875132 DOI: 10.3389/fphar.2024.1308686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/16/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction: Somatostatin analogues (SSAs) are commonly used in the treatment of hormone hypersecretion in neuroendocrine tumors (NETs), however the extent to which they inhibit proliferation is much discussed. Objective: We studied the antiproliferative effects of novel SSA lanreotide in bronchopulmonary NETs (BP-NETs). We focused on assessing whether pretreating cells with inhibitors for phosphatidylinositol 3-kinase (PI3K) and mammalian target for rapamycin (mTOR) could enhance the antiproliferative effects of lanreotide. Methods: BP-NET cell lines NCI-H720 and NCI-H727 were treated with PI3K inhibitor BYL719 (alpelisib), mTOR inhibitor everolimus and SSA lanreotide to determine the effect on NET differentiation markers, cell survival, proliferation and alterations in cancer-associated pathways. NT-3 cells, previously reported to express somatostatin receptors (SSTRs) natively, were used as control for SSTR expression. Results: SSTR2 was upregulated in NCI-H720 and NT-3 cells upon treatment with BYL719. Additionally, combination treatment consisting of BYL719 and everolimus plus lanreotide tested in NCI-H720 and NCI-H727 led to diminished cell proliferation in a dose-dependent manner. Production of proteins activating cell death mechanisms was also induced. Notably, a multiplexed gene expression analysis performed on NCI-H720 revealed that BYL719 plus lanreotide had a stronger effect on the downregulation of mitogens than lanreotide alone. Discussion/Conclusion: We report a widespread analysis of changes in BP-NET cell lines at the genetic/protein expression level in response to combination of lanreotide with pretreatment consisting of BYL719 and everolimus. Interestingly, SSTR expression reinduction could be exploited in therapeutic and diagnostic applications. The overall results of this study support the evaluation of combination-based therapies using lanreotide in preclinical studies to further increase its antiproliferative effect and ultimately facilitate its use in high-grade tumors.
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Affiliation(s)
| | - Sara Lelek
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christina Geisler
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Teresa Hartung
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vanessa Bröker
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Franziska Briest
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Liliana Mochmann
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Jost-Brinkmann
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dagmar Sedding
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joana Benecke
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Helma Freitag
- Institute of Medical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sebastian Wolfshöfer
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hedwig Lammert
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Svenja Nölting
- Department of Endocrinology, Diabetology and Clinical Nutrition, Universitätsspital Zürich, Zurich, Germany
- Department of Internal Medicine II, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Michael Hummel
- Institute of Pathology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jörg Schrader
- I. Department of Medicine, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Patricia Grabowski
- Medical Clinic III, Hematology, Oncology, Tumor Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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6
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Zhou K, Liu Y, Yuan S, Zhou Z, Ji P, Huang Q, Wen F, Li Q. Signalling in pancreatic cancer: from pathways to therapy. J Drug Target 2023; 31:1013-1026. [PMID: 37869884 DOI: 10.1080/1061186x.2023.2274806] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Abstract
Pancreatic cancer (PC) is a common malignant tumour in the digestive system. Due to the lack of sensitive diagnostic markers, strong metastasis ability, and resistance to anti-cancer drugs, the prognosis of PC is inferior. In the past decades, increasing evidence has indicated that the development of PC is closely related to various signalling pathways. With the exploration of RAS-driven, epidermal growth factor receptor, Hedgehog, NF-κB, TGF-β, and NOTCH signalling pathways, breakthroughs have been made to explore the mechanism of pancreatic carcinogenesis, as well as the novel therapies. In this review, we discussed the signalling pathways involved in PC and summarised current targeted agents in the treatment of PC. Furthermore, opportunities and challenges in the exploration of potential therapies targeting signalling pathways were also highlighted.
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Affiliation(s)
- Kexun Zhou
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yingping Liu
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | | | - Ziyu Zhou
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Pengfei Ji
- The Second Clinical Medical College of Lanzhou University, Lanzhou University, Lanzhou, China
| | - Qianhan Huang
- School of Public Health, Xuzhou Medical University, Xuzhou, China
| | - Feng Wen
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
| | - Qiu Li
- Department of Medical Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
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7
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Smith AE, Chan S, Wang Z, McCloskey A, Reilly Q, Wang JZ, Patel HV, Koshizuka K, Soifer HS, Kessler L, Dayoub A, Villaflor V, Adkins DR, Bruce JY, Ho AL, Perez CA, Hanna GJ, Gascó Hernández A, Saunders A, Dale S, Gutkind JS, Burrows F, Malik S. Tipifarnib Potentiates the Antitumor Effects of PI3Kα Inhibition in PIK3CA- and HRAS-Dysregulated HNSCC via Convergent Inhibition of mTOR Activity. Cancer Res 2023; 83:3252-3263. [PMID: 37339176 PMCID: PMC10543974 DOI: 10.1158/0008-5472.can-23-0282] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 05/23/2023] [Accepted: 06/16/2023] [Indexed: 06/22/2023]
Abstract
Outcomes for patients with recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) are poor, with median overall survival (OS) ranging from 6 to 18 months. For those who progress on standard-of-care (chemo)immunotherapy, treatment options are limited, necessitating the development of rational therapeutic strategies. Toward this end, we targeted the key HNSCC drivers PI3K-mTOR and HRAS via the combination of tipifarnib, a farnesyltransferase (FTase) inhibitor, and alpelisib, a PI3Kα inhibitor, in multiple molecularly defined subsets of HNSCC. Tipifarnib synergized with alpelisib at the level of mTOR in PI3Kα- or HRAS-dependent HNSCCs, leading to marked cytotoxicity in vitro and tumor regression in vivo. On the basis of these findings, the KURRENT-HN trial was launched to evaluate the effectiveness of this combination in PIK3CA-mutant/amplified and/or HRAS-overexpressing R/M HNSCC. Preliminary evidence supports the clinical activity of this molecular biomarker-driven combination therapy. Combined alpelisib and tipifarnib has potential to benefit >45% of patients with R/M HNSCC. By blocking feedback reactivation of mTORC1, tipifarnib may prevent adaptive resistance to additional targeted therapies, enhancing their clinical utility. SIGNIFICANCE The mechanistically designed, biomarker-matched strategy of combining alpelisib and tipifarnib is efficacious in PIK3CA- and HRAS-dysregulated head and neck squamous carcinoma and could improve outcomes for many patients with recurrent, metastatic disease. See related commentary by Lee et al., p. 3162.
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Affiliation(s)
| | | | - Zhiyong Wang
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | | | | | | | | | - Keiichi Koshizuka
- Moores Cancer Center, University of California San Diego, La Jolla, California
| | | | | | | | | | | | | | - Alan L. Ho
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cesar A. Perez
- Sarah Cannon Research Institute at Florida Cancer Specialists, Orlando, Florida
| | | | | | | | | | - J. Silvio Gutkind
- Moores Cancer Center, University of California San Diego, La Jolla, California
- Department of Pharmacology, University of California San Diego, La Jolla, California
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8
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Glaviano A, Foo ASC, Lam HY, Yap KCH, Jacot W, Jones RH, Eng H, Nair MG, Makvandi P, Geoerger B, Kulke MH, Baird RD, Prabhu JS, Carbone D, Pecoraro C, Teh DBL, Sethi G, Cavalieri V, Lin KH, Javidi-Sharifi NR, Toska E, Davids MS, Brown JR, Diana P, Stebbing J, Fruman DA, Kumar AP. PI3K/AKT/mTOR signaling transduction pathway and targeted therapies in cancer. Mol Cancer 2023; 22:138. [PMID: 37596643 PMCID: PMC10436543 DOI: 10.1186/s12943-023-01827-6] [Citation(s) in RCA: 114] [Impact Index Per Article: 114.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/18/2023] [Indexed: 08/20/2023] Open
Abstract
The PI3K/AKT/mTOR (PAM) signaling pathway is a highly conserved signal transduction network in eukaryotic cells that promotes cell survival, cell growth, and cell cycle progression. Growth factor signalling to transcription factors in the PAM axis is highly regulated by multiple cross-interactions with several other signaling pathways, and dysregulation of signal transduction can predispose to cancer development. The PAM axis is the most frequently activated signaling pathway in human cancer and is often implicated in resistance to anticancer therapies. Dysfunction of components of this pathway such as hyperactivity of PI3K, loss of function of PTEN, and gain-of-function of AKT, are notorious drivers of treatment resistance and disease progression in cancer. In this review we highlight the major dysregulations in the PAM signaling pathway in cancer, and discuss the results of PI3K, AKT and mTOR inhibitors as monotherapy and in co-administation with other antineoplastic agents in clinical trials as a strategy for overcoming treatment resistance. Finally, the major mechanisms of resistance to PAM signaling targeted therapies, including PAM signaling in immunology and immunotherapies are also discussed.
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Affiliation(s)
- Antonino Glaviano
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Aaron S C Foo
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
| | - Hiu Y Lam
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - Kenneth C H Yap
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
- NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119077, Singapore
| | - William Jacot
- Department of Medical Oncology, Institut du Cancer de Montpellier, Inserm U1194, Montpellier University, Montpellier, France
| | - Robert H Jones
- Cardiff University and Velindre Cancer Centre, Museum Avenue, Cardiff, CF10 3AX, UK
| | - Huiyan Eng
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Madhumathy G Nair
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Pooyan Makvandi
- The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, Zhejiang, China
| | - Birgit Geoerger
- Department of Pediatric and Adolescent Oncology, Gustave Roussy Cancer Center, Inserm U1015, Université Paris-Saclay, Paris, France
| | - Matthew H Kulke
- Section of Hematology and Medical Oncology, Boston University and Boston Medical Center, Boston, MA, USA
| | - Richard D Baird
- Cancer Research UK Cambridge Centre, Hills Road, Cambridge, CB2 0QQ, UK
| | - Jyothi S Prabhu
- Division of Molecular Medicine, St. John's Research Institute, St. John's Medical College, Bangalore, 560034, India
| | - Daniela Carbone
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Camilla Pecoraro
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Daniel B L Teh
- Departments of Ophthalmology and Anatomy, Yong Loo Lin School of Medicine, National University of Singapore, and Neurobiology Programme, National University of Singapore, Singapore, Singapore
| | - Gautam Sethi
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore
| | - Vincenzo Cavalieri
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Kevin H Lin
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | - Eneda Toska
- Department of Biochemistry and Molecular Biology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Matthew S Davids
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jennifer R Brown
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Patrizia Diana
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies, University of Palermo, 90123, Palermo, Italy
| | - Justin Stebbing
- Division of Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0NN, UK
| | - David A Fruman
- Department of Molecular Biology and Biochemistry, University of California, 216 Sprague Hall, Irvine, CA, USA
| | - Alan P Kumar
- Department of Surgery, National University Hospital Singapore, National University of Singapore, Singapore, Singapore.
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.
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9
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Belli C, Repetto M, Anand S, Porta C, Subbiah V, Curigliano G. The emerging role of PI3K inhibitors for solid tumour treatment and beyond. Br J Cancer 2023; 128:2150-2162. [PMID: 36914722 PMCID: PMC10241926 DOI: 10.1038/s41416-023-02221-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/31/2023] [Accepted: 02/24/2023] [Indexed: 03/16/2023] Open
Abstract
Phosphoinositide 3-kinases (PI3Ks) play a central role in tumourigenesis with recurrent activating mutations of its p110α subunit (PIK3CA) identified in several tumours. Although several PI3K inhibitors are approved for haematological malignancies, only alpelisib was approved in solid tumours and for the treatment of PIK3CA-related overgrowth spectrum (PROS) syndrome. Traditional PI3K inhibitors inhibit both wild-type and mutant PI3K with almost equal potency, thus limiting their efficacy due to on-target toxicity. Since the initiation of phase I clinical trials investigating next generation allosteric mutant and isoform selective PIK3CA inhibitors, there has been a surge in interest in PIK3CA targeting in solid tumours. Preclinical characterisation of these compounds showed that maximal mutant protein inhibition fails to elicit metabolic and glucose homoeostasis dysregulation, one of the dose limiting toxicities of both selective and pan PI3K inhibitors. While extreme selectivity can be hypothesised to grant activity and safety advantage to these novel agents, on the other hand reduced benefit can be speculated for patients harbouring multiple or rare PIK3CA mutations. This review summarises the current understanding of PI3K alterations and the state-of-the-art treatment strategies in PI3K driven solid tumours, while also exploring the potential intrinsic and acquired resistance mechanisms to these agents, and the emerging role of mutant selective PIK3CA inhibitors.
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Affiliation(s)
- Carmen Belli
- Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, 20141, Milan, Italy
| | - Matteo Repetto
- Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, 20141, Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy
| | - Santosh Anand
- Department of Informatics, System, and Communications (DISCo), University of Milano-Bicocca, Milan, Italy
| | - Camillo Porta
- Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", 70121, Bari, Italy
| | - Vivek Subbiah
- Department of Investigational Cancer Therapeutics, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- MD Anderson Cancer Network, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapy, European Institute of Oncology, IRCCS, 20141, Milan, Italy.
- Department of Oncology and Hemato-Oncology, University of Milan, 20122, Milan, Italy.
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10
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Boyd DC, Zboril EK, Olex AL, Leftwich TJ, Hairr NS, Byers HA, Valentine AD, Altman JE, Alzubi MA, Grible JM, Turner SA, Ferreira-Gonzalez A, Dozmorov MG, Harrell JC. Discovering Synergistic Compounds with BYL-719 in PI3K Overactivated Basal-like PDXs. Cancers (Basel) 2023; 15:cancers15051582. [PMID: 36900375 PMCID: PMC10001201 DOI: 10.3390/cancers15051582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/23/2023] [Accepted: 03/01/2023] [Indexed: 03/08/2023] Open
Abstract
Basal-like triple-negative breast cancer (TNBC) tumor cells are difficult to eliminate due to resistance mechanisms that promote survival. While this breast cancer subtype has low PIK3CA mutation rates when compared to estrogen receptor-positive (ER+) breast cancers, most basal-like TNBCs have an overactive PI3K pathway due to gene amplification or high gene expression. BYL-719 is a PIK3CA inhibitor that has been found to have low drug-drug interactions, which increases the likelihood that it could be useful for combinatorial therapy. Alpelisib (BYL-719) with fulvestrant was recently approved for treating ER+ breast cancer patients whose cancer had developed resistance to ER-targeting therapy. In these studies, a set of basal-like patient-derived xenograft (PDX) models was transcriptionally defined with bulk and single-cell RNA-sequencing and clinically actionable mutation profiles defined with Oncomine mutational profiling. This information was overlaid onto therapeutic drug screening results. BYL-719-based, synergistic two-drug combinations were identified with 20 different compounds, including everolimus, afatinib, and dronedarone, which were also found to be effective at minimizing tumor growth. These data support the use of these drug combinations towards cancers with activating PIK3CA mutations/gene amplifications or PTEN deficient/PI3K overactive pathways.
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Affiliation(s)
- David C. Boyd
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
- Integrative Life Sciences Program, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Emily K. Zboril
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Amy L. Olex
- C. Kenneth and Dianne Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Tess J. Leftwich
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Nicole S. Hairr
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Holly A. Byers
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Aaron D. Valentine
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Julia E. Altman
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Mohammad A. Alzubi
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
- Integrative Life Sciences Program, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Jacqueline M. Grible
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Scott A. Turner
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
| | | | - Mikhail G. Dozmorov
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA 23219, USA
| | - J. Chuck Harrell
- Department of Pathology, Virginia Commonwealth University, Richmond, VA 23298, USA
- Massey Cancer Center, Virginia Commonwealth University, Richmond, VA 23298, USA
- Correspondence:
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11
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Ye Y, Huang Z, Zhang M, Li J, Zhang Y, Lou C. Synergistic therapeutic potential of alpelisib in cancers (excluding breast cancer): Preclinical and clinical evidences. Biomed Pharmacother 2023; 159:114183. [PMID: 36641927 DOI: 10.1016/j.biopha.2022.114183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/15/2023] Open
Abstract
The phosphoinositide 3-kinase (PI3K) signaling pathway is well-known for its important role in cancer growth, proliferation and migration. The activation of PI3K pathway is always connected with endocrine resistance and poor prognosis in cancers. Alpelisib, a selective inhibitor of PI3K, has been demonstrated to be effective in combination with endocrine therapy in HR+ PIK3CA-mutated advanced breast cancer in preclinical and clinical trials. Recently, the synergistic effects of alpelisib combined with targeted agents have been widely reported in PIK3CA-mutated cancer cells, such as breast, head and neck squamous cell carcinoma (HNSCC), cervical, liver, pancreatic and lung cancer. However, previous reviews mainly focused on the pharmacological activities of alpelisib in breast cancer. The synergistic therapeutic potential of alpelisib in other cancers has not yet been well reviewed. In this review, an extensive study of related literatures (published until December 20, 2022) regarding the anti-cancer functions and synergistic effects of alpelisib was carried out through the databases. Useful information was extracted. We summarized the preclinical and clinical studies of alpelisib in combination with targeted anti-cancer agents in cancer treatment (excluding breast cancer). The combinations of alpelisib and other targeted agents significantly improved the therapeutic efficacy both in preclinical and clinical studies. Unfortunately, synergistic therapies still could not effectively avoid the possible toxicities and adverse events during treatment. Finally, some prospects for the combination studies in cancer treatment were provided in the paper. Taken together, this review provided valuable information for alpelisib in preclinical and clinical applications.
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Affiliation(s)
- Yuhao Ye
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Zhiyu Huang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Maoqing Zhang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Jiayue Li
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Yiqiong Zhang
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
| | - Chenghua Lou
- School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China.
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12
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Bertucci A, Bertucci F, Gonçalves A. Phosphoinositide 3-Kinase (PI3K) Inhibitors and Breast Cancer: An Overview of Current Achievements. Cancers (Basel) 2023; 15:cancers15051416. [PMID: 36900211 PMCID: PMC10001361 DOI: 10.3390/cancers15051416] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
The phosphatidylinositol 3-kinase (PI3K) pathway is one of the most altered pathways in human cancers, and it plays a central role in cellular growth, survival, metabolism, and cellular mobility, making it a particularly interesting therapeutic target. Recently, pan-inhibitors and then selective p110α subunit inhibitors of PI3K were developed. Breast cancer is the most frequent cancer in women and, despite therapeutic progress in recent years, advanced breast cancers remain incurable and early breast cancers are at risk of relapse. Breast cancer is divided in three molecular subtypes, each with its own molecular biology. However, PI3K mutations are found in all breast cancer subtypes in three main "hotspots". In this review, we report the results of the most recent and main ongoing studies evaluating pan-PI3K inhibitors and selective PI3K inhibitors in each breast cancer subtype. In addition, we discuss the future of their development, the various potential mechanisms of resistance to these inhibitors and the ways to circumvent them.
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13
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Royer B, Kaderbhaï CG, Schmitt A. Pharmacokinetics and Pharmacodynamic of Alpelisib. Clin Pharmacokinet 2023; 62:45-53. [PMID: 36633813 DOI: 10.1007/s40262-022-01195-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 01/13/2023]
Abstract
Advanced breast cancers are frequently hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative. Some of them harbor a mutation in PIK3CA, a gene encoding the PI3K catalytic subunit α of phosphatidyl-inositol 3-kinase (PI3K), which confers resistance to hormone therapy. Alpelisib is the first oral selective p110 [Formula: see text] PI3K inhibitor approved by FDA and EMA, in association with fulvestrant, based on PFS improvement as compared to fulvestrant alone. The aim of this review is to summarize and critically review the key aspects of alpelisib pharmacokinetics (PK) and pharmacodynamics (PD). Preclinical data have shown that alpelisib IC50 was 50 times lower for the α enzyme than for the β, δ and γ PI3K enzymes, leading to a decrease in intra-tumoral AKT phosphorylation. The PK properties of alpelisib are somehow favorable, with a rapid and important absorption, a limited CYP P450-mediated metabolism and a predominant biliary excretion, with a half-life of 17.5 ± 5.9 h. Only limited drug-drug interactions are expected and there is no need for dose adaptation in mild and moderate renal impaired and mild to severe hepatic impaired patients. Pharmacokinetic/pharmacodynamic relationships were evidenced during drug development for exposure/efficacy, but also exposure/safety. Main adverse events are hyperglycemia, rash, and diarrhea. The first, if not fully contra-indicated in (pre-)diabetic patients, warrants a close follow up when treatment is started and a potential dose reduction when needed. Because of its safety profile, alpelisib require stringent patient selection and close follow-up.
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Affiliation(s)
- Bernard Royer
- Univ. Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, Besançon, France.,Laboratoire de Pharmacologie Clinique et Toxicologie, CHU Besançon, Besançon, France
| | | | - Antonin Schmitt
- Pharmacy Department, Centre Georges-François Leclerc, 1 rue Pr Marion, 21079, Dijon Cedex, France. .,INSERM U1231, University of Burgundy Franche-Comté, Dijon, France.
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14
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Mechanisms of Resistance in Gastroenteropancreatic Neuroendocrine Tumors. Cancers (Basel) 2022; 14:cancers14246114. [PMID: 36551599 PMCID: PMC9776394 DOI: 10.3390/cancers14246114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Gastroenteropancreatic neuroendocrine tumors (GEP-NETs), although curable when localized, frequently metastasize and require management with systemic therapies, including somatostatin analogues, peptide receptor radiotherapy, small-molecule targeted therapies, and chemotherapy. Although effective for disease control, these therapies eventually fail as a result of primary or secondary resistance. For small-molecule targeted therapies, the feedback activation of the targeted signaling pathways and activation of alternative pathways are prominent mechanisms, whereas the acquisition of additional genetic alterations only rarely occurs. For somatostatin receptor (SSTR)-targeted therapy, the heterogeneity of tumor SSTR expression and dedifferentiation with a downregulated expression of SSTR likely predominate. Hypoxia in the tumor microenvironment and stromal constituents contribute to resistance to all modalities. Current studies on mechanisms underlying therapeutic resistance and options for management in human GEP-NETs are scant; however, preclinical and early-phase human studies have suggested that combination therapy targeting multiple pathways or novel tyrosine kinase inhibitors with broader kinase inhibition may be promising.
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15
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Vasan N, Cantley LC. At a crossroads: how to translate the roles of PI3K in oncogenic and metabolic signalling into improvements in cancer therapy. Nat Rev Clin Oncol 2022; 19:471-485. [PMID: 35484287 PMCID: PMC11215755 DOI: 10.1038/s41571-022-00633-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2022] [Indexed: 12/14/2022]
Abstract
Numerous agents targeting various phosphatidylinositol 3-kinase (PI3K) pathway components, including PI3K, AKT and mTOR, have been tested in oncology clinical trials, resulting in regulatory approvals for the treatment of selected patients with breast cancer, certain other solid tumours or particular haematological malignancies. However, given the prominence of PI3K signalling in cancer and the crucial role of this pathway in linking cancer growth with metabolism, these clinical results could arguably be improved upon. In this Review, we discuss past and present efforts to overcome the somewhat limited clinical efficacy of PI3Kα pathway inhibitors, including optimization of inhibitor specificity, patient selection and biomarkers across cancer types, with a focus on breast cancer, as well as identification and abrogation of signalling-related and metabolic mechanisms of resistance, and interventions to improve management of prohibitive adverse events. We highlight the advantages and limitations of laboratory-based model systems used to study the PI3K pathway, and propose technologies and experimental inquiries to guide the future clinical deployment of PI3K pathway inhibitors in the treatment of cancer.
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Affiliation(s)
- Neil Vasan
- Department of Medicine, Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, NY, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Lewis C Cantley
- Meyer Cancer Center, Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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16
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Skolariki A, D’Costa J, Little M, Lord S. Role of PI3K/Akt/mTOR pathway in mediating endocrine resistance: concept to clinic. EXPLORATION OF TARGETED ANTI-TUMOR THERAPY 2022; 3:172-199. [PMID: 36046843 PMCID: PMC9400772 DOI: 10.37349/etat.2022.00078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/11/2022] [Indexed: 01/06/2023] Open
Abstract
The majority of breast cancers express the estrogen receptor (ER) and for this group of patients, endocrine therapy is the cornerstone of systemic treatment. However, drug resistance is common and a focus for breast cancer preclinical and clinical research. Over the past 2 decades, the PI3K/Akt/mTOR axis has emerged as an important driver of treatment failure, and inhibitors of mTOR and PI3K are now licensed for the treatment of women with advanced ER-positive breast cancer who have relapsed on first-line hormonal therapy. This review presents the preclinical and clinical data that led to this new treatment paradigm and discusses future directions.
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Affiliation(s)
- Aglaia Skolariki
- Department of Oncology, University of Oxford, Churchill Hospital, OX3 7LE Oxford, UK
| | - Jamie D’Costa
- Department of Oncology, University of Oxford, Churchill Hospital, OX3 7LE Oxford, UK
| | - Martin Little
- Department of Oncology, Churchill Hospital, OX3 7LE Oxford, UK
| | - Simon Lord
- Department of Oncology, University of Oxford, Churchill Hospital, OX3 7LE Oxford, UK
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