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Shan KS, Bonano-Rios A, Theik NWY, Hussein A, Blaya M. Molecular Targeting of the Phosphoinositide-3-Protein Kinase (PI3K) Pathway across Various Cancers. Int J Mol Sci 2024; 25:1973. [PMID: 38396649 PMCID: PMC10888452 DOI: 10.3390/ijms25041973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
The dysregulation of the phosphatidylinositol-3-kinase (PI3K) pathway can lead to uncontrolled cellular growth and tumorigenesis. Targeting PI3K and its downstream substrates has been shown to be effective in preclinical studies and phase III trials with the approval of several PI3K pathway inhibitors by the Food and Drug Administration (FDA) over the past decade. However, the limited clinical efficacy of these inhibitors, intolerable toxicities, and acquired resistances limit the clinical application of PI3K inhibitors. This review discusses the PI3K signaling pathway, alterations in the PI3K pathway causing carcinogenesis, current and novel PI3K pathway inhibitors, adverse effects, resistance mechanisms, challenging issues, and future directions of PI3K pathway inhibitors.
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Affiliation(s)
- Khine S. Shan
- Division of Hematology and Oncology, Memorial Health Care, Pembroke Pines, FL 33028, USA; (A.B.-R.); (A.H.); (M.B.)
| | - Amalia Bonano-Rios
- Division of Hematology and Oncology, Memorial Health Care, Pembroke Pines, FL 33028, USA; (A.B.-R.); (A.H.); (M.B.)
| | - Nyein Wint Yee Theik
- Division of Internal Medicine, Memorial Health Care, Pembroke Pines, FL 33028, USA;
| | - Atif Hussein
- Division of Hematology and Oncology, Memorial Health Care, Pembroke Pines, FL 33028, USA; (A.B.-R.); (A.H.); (M.B.)
| | - Marcelo Blaya
- Division of Hematology and Oncology, Memorial Health Care, Pembroke Pines, FL 33028, USA; (A.B.-R.); (A.H.); (M.B.)
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2
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Bracken AK, Gekko CE, Suss NO, Lueders EE, Cui Q, Fu Q, Lui ACW, Anderson ET, Zhang S, Abbasov ME. Biomimetic Synthesis and Chemical Proteomics Reveal the Mechanism of Action and Functional Targets of Phloroglucinol Meroterpenoids. J Am Chem Soc 2024; 146:2524-2548. [PMID: 38230968 PMCID: PMC11000255 DOI: 10.1021/jacs.3c10741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Natural products perennially serve as prolific sources of drug leads and chemical probes, fueling the development of numerous therapeutics. Despite their scarcity, natural products that modulate protein function through covalent interactions with lysine residues hold immense potential to unlock new therapeutic interventions and advance our understanding of the biological processes governed by these modifications. Phloroglucinol meroterpenoids constitute one of the most expansive classes of natural products, displaying a plethora of biological activities. However, their mechanism of action and cellular targets have, until now, remained elusive. In this study, we detail the concise biomimetic synthesis, computational mechanistic insights, physicochemical attributes, kinetic parameters, molecular mechanism of action, and functional cellular targets of several phloroglucinol meroterpenoids. We harness synthetic clickable analogues of natural products to probe their disparate proteome-wide reactivity and subcellular localization through in-gel fluorescence scanning and cell imaging. By implementing sample multiplexing and a redesigned lysine-targeting probe, we streamline a quantitative activity-based protein profiling, enabling the direct mapping of global reactivity and ligandability of proteinaceous lysines in human cells. Leveraging this framework, we identify numerous lysine-meroterpenoid interactions in breast cancer cells at tractable protein sites across diverse structural and functional classes, including those historically deemed undruggable. We validate that phloroglucinol meroterpenoids perturb biochemical functions through stereoselective and site-specific modification of lysines in proteins vital for breast cancer metabolism, including lipid signaling, mitochondrial respiration, and glycolysis. These findings underscore the broad potential of phloroglucinol meroterpenoids for targeting functional lysines in the human proteome.
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Affiliation(s)
- Amy K Bracken
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, New York 14853, United States
| | - Colby E Gekko
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, New York 14853, United States
| | - Nina O Suss
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, New York 14853, United States
| | - Emma E Lueders
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, New York 14853, United States
| | - Qi Cui
- Department of Chemistry and Chemical Biology, Cornell University, Ithaca, New York 14853, United States
| | - Qin Fu
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York 14853, United States
| | - Andy C W Lui
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York 14853, United States
| | - Elizabeth T Anderson
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York 14853, United States
| | - Sheng Zhang
- Proteomics and Metabolomics Facility, Cornell University, Ithaca, New York 14853, United States
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3
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Huang X, You L, Nepovimova E, Psotka M, Malinak D, Valko M, Sivak L, Korabecny J, Heger Z, Adam V, Wu Q, Kuca K. Inhibitors of phosphoinositide 3-kinase (PI3K) and phosphoinositide 3-kinase-related protein kinase family (PIKK). J Enzyme Inhib Med Chem 2023; 38:2237209. [PMID: 37489050 PMCID: PMC10392309 DOI: 10.1080/14756366.2023.2237209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/11/2023] [Indexed: 02/02/2024] Open
Abstract
Phosphoinositide 3-kinases (PI3K) and phosphoinositide 3-kinase-related protein kinases (PIKK) are two structurally related families of kinases that play vital roles in cell growth and DNA damage repair. Dysfunction of PIKK members and aberrant stimulation of the PI3K/AKT/mTOR signalling pathway are linked to a plethora of diseases including cancer. In recent decades, numerous inhibitors related to the PI3K/AKT/mTOR signalling have made great strides in cancer treatment, like copanlisib and sirolimus. Notably, most of the PIKK inhibitors (such as VX-970 and M3814) related to DNA damage response have also shown good efficacy in clinical trials. However, these drugs still require a suitable combination therapy to overcome drug resistance or improve antitumor activity. Based on the aforementioned facts, we summarised the efficacy of PIKK, PI3K, and AKT inhibitors in the therapy of human malignancies and the resistance mechanisms of targeted therapy, in order to provide deeper insights into cancer treatment.
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Affiliation(s)
- Xueqin Huang
- College of Life Science, Yangtze University, Jingzhou, China
| | - Li You
- College of Physical Education and Health, Chongqing College of International Business and Economics, Chongqing, China
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Czech Republic
| | - Miroslav Psotka
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Czech Republic
- Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - David Malinak
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Czech Republic
- Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Marian Valko
- Faculty of Chemical and Food Technology, Slovak University of Technology in Bratislava, Bratislava, Slovakia
| | - Ladislav Sivak
- Department of Chemistry and Biochemistry, Mendel University in Brno, Brno, Czech Republic
| | - Jan Korabecny
- Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Zbynek Heger
- Department of Chemistry and Biochemistry, Mendel University in Brno, Brno, Czech Republic
| | - Vojtech Adam
- Department of Chemistry and Biochemistry, Mendel University in Brno, Brno, Czech Republic
| | - Qinghua Wu
- College of Life Science, Yangtze University, Jingzhou, China
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Czech Republic
| | - Kamil Kuca
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Czech Republic
- Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
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4
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Wu DN, Yu G, Li GF. Validity of Meta-Analytical Data on Cutaneous Adverse Events With Phosphoinositide 3-Kinase Inhibitors. JAMA Oncol 2023; 9:1462. [PMID: 37651115 DOI: 10.1001/jamaoncol.2023.3384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Dan-Na Wu
- Department of Pharmacy, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Haikou, Hainan, China
| | - Guo Yu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Guo-Fu Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, China
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5
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Jahandideh A, Yarizadeh M, Noei-Khesht Masjedi M, Fatehnejad M, Jahandideh R, Soheili R, Eslami Y, Zokaei M, Ahmadvand A, Ghalamkarpour N, Kumar Pandey R, Nabi Afjadi M, Payandeh Z. Macrophage's role in solid tumors: two edges of a sword. Cancer Cell Int 2023; 23:150. [PMID: 37525217 PMCID: PMC10391843 DOI: 10.1186/s12935-023-02999-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023] Open
Abstract
The tumor microenvironment is overwhelmingly dictated by macrophages, intimately affiliated with tumors, exercising pivotal roles in multiple processes, including angiogenesis, extracellular matrix reconfiguration, cellular proliferation, metastasis, and immunosuppression. They further exhibit resilience to chemotherapy and immunotherapy via meticulous checkpoint blockades. When appropriately stimulated, macrophages can morph into a potent bidirectional component of the immune system, engulfing malignant cells and annihilating them with cytotoxic substances, thus rendering them intriguing candidates for therapeutic targets. As myelomonocytic cells relentlessly amass within tumor tissues, macrophages rise as prime contenders for cell therapy upon the development of chimeric antigen receptor effector cells. Given the significant incidence of macrophage infiltration correlated with an unfavorable prognosis and heightened resistance to chemotherapy in solid tumors, we delve into the intricate role of macrophages in cancer propagation and their promising potential in confronting four formidable cancer variants-namely, melanoma, colon, glioma, and breast cancers.
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Affiliation(s)
- Arian Jahandideh
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
- Usern Office, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahsa Yarizadeh
- Islamic Azad University, Tehran Medical Branch, Tehran, Iran
| | - Maryam Noei-Khesht Masjedi
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Fatehnejad
- Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Romina Jahandideh
- Student Research Committee, Mazandaran University of Medical Sciences, Sari, Iran
| | - Roben Soheili
- Department of Microbiology, Faculty of Advanced Science and Technology, Tehran Medical Science, Islamic Azad University, Tehran, Iran
| | - Yeganeh Eslami
- Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Maryam Zokaei
- Department of Food Science and Technology, Faculty of Nutrition Science, Food Science and Technology/National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ardavan Ahmadvand
- Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Nogol Ghalamkarpour
- Department of Clinical Laboratory Sciences, School of Allied Medicine, Student Research Committee, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Rajan Kumar Pandey
- Department Medical Biochemistry and Biophysics, Division Medical Inflammation Research, Karolinska Institute, Stockholm, Sweden
| | - Mohsen Nabi Afjadi
- Department of Biochemistry, Faculty of Biological Sciences, Tarbiat Modares University, Tehran, Iran.
| | - Zahra Payandeh
- Department Medical Biochemistry and Biophysics, Division Medical Inflammation Research, Karolinska Institute, Stockholm, Sweden.
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6
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Safaroghli-Azar A, Sanaei MJ, Pourbagheri-Sigaroodi A, Bashash D. Phosphoinositide 3-kinase (PI3K) classes: From cell signaling to endocytic recycling and autophagy. Eur J Pharmacol 2023:175827. [PMID: 37269974 DOI: 10.1016/j.ejphar.2023.175827] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/05/2023]
Abstract
Lipid signaling is defined as any biological signaling action in which a lipid messenger binds to a protein target, converting its effects to specific cellular responses. In this complex biological pathway, the family of phosphoinositide 3-kinase (PI3K) represents a pivotal role and affects many aspects of cellular biology from cell survival, proliferation, and migration to endocytosis, intracellular trafficking, metabolism, and autophagy. While yeasts have a single isoform of phosphoinositide 3-kinase (PI3K), mammals possess eight PI3K types divided into three classes. The class I PI3Ks have set the stage to widen research interest in the field of cancer biology. The aberrant activation of class I PI3Ks has been identified in 30-50% of human tumors, and activating mutations in PIK3CA is one of the most frequent oncogenes in human cancer. In addition to indirect participation in cell signaling, class II and III PI3Ks primarily regulate vesicle trafficking. Class III PI3Ks are also responsible for autophagosome formation and autophagy flux. The current review aims to discuss the original data obtained from international research laboratories on the latest discoveries regarding PI3Ks-mediated cell biological processes. Also, we unravel the mechanisms by which pools of the same phosphoinositides (PIs) derived from different PI3K types act differently.
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Affiliation(s)
- Ava Safaroghli-Azar
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad-Javad Sanaei
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Pourbagheri-Sigaroodi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Bashash
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Occhiuzzi MA, Lico G, Ioele G, De Luca M, Garofalo A, Grande F. Recent advances in PI3K/PKB/mTOR inhibitors as new anticancer agents. Eur J Med Chem 2023; 246:114971. [PMID: 36462440 DOI: 10.1016/j.ejmech.2022.114971] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022]
Abstract
The biochemical role of the PI3K/PKB/mTOR signalling pathway in cell-cycle regulation is now well known. During the onset and development of different forms of cancer it becomes overactive reducing apoptosis and allowing cell proliferation. Therefore, this pathway has become an important target for the treatment of various forms of malignant tumors, including breast cancer and follicular lymphoma. Recently, several more or less selective inhibitors targeting these proteins have been identified. In general, drugs that act on multiple targets within the entire pathway are more efficient than single targeting inhibitors. Multiple inhibitors exhibit high potency and limited drug resistance, resulting in promising anticancer agents. In this context, the present survey focuses on small molecule drugs capable of modulating the PI3K/PKB/mTOR signalling pathway, thus representing drugs or drug candidates to be used in the pharmacological treatment of different forms of cancer.
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Affiliation(s)
| | - Gernando Lico
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Giuseppina Ioele
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Michele De Luca
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Antonio Garofalo
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Fedora Grande
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy.
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8
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How CW, Ong YS, Low SS, Pandey A, Show PL, Foo JB. How far have we explored fungi to fight cancer? Semin Cancer Biol 2022; 86:976-989. [PMID: 33737109 DOI: 10.1016/j.semcancer.2021.03.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/21/2021] [Accepted: 03/13/2021] [Indexed: 01/01/2023]
Abstract
The use of fungal cultures have been well documented in human history. Although its used in healthcare, like penicillin and statins, have saved countless of lives, but there is still no fungal products that are specifically indicated for cancers. Research into fungal-derived materials to curb cancers in the recent decades have made a considerable progress in terms of drug delivery vehicles, anticancer active ingredients and cancer immunotherapy. Various parts of the organisms have successfully been exploited to achieve specific tasks. Apart from the identification of novel anticancer compound from fungi, its native capsular structure can also be used as drug cargo to achieve higher oral bioavailability. This review summarises the anticancer potential of fungal-derived materials, highlighting the role of capsular polysaccharides, proteins, and other structures in variety of innovative utilities to fit the current pharmaceutical technology. Many bioactive compounds isolated from fungi have also been formulated into nanoparticles to achieve greater anticancer activity. The progress of fungal compounds and their analogues in clinical trials is also highlighted. In addition, the potential of various fungal species to be developed for anticancer immunotherapy are also discussed.
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Affiliation(s)
- Chee Wun How
- School of Pharmacy, Monash University Malaysia, 47500, Bandar Sunway, Selangor, Malaysia
| | - Yong Sze Ong
- School of Pharmacy, Monash University Malaysia, 47500, Bandar Sunway, Selangor, Malaysia
| | - Sze Shin Low
- Department of Chemical and Environmental Engineering, Faculty of Engineering, University of Nottingham Malaysia Campus, Jalan Broga, 43500 Semenyih, Selangor Darul Ehsan, Malaysia
| | - Ashok Pandey
- Centre for Innovation and Translational Research, CSIR-Indian Institute of Toxicology Research, Lucknow, 226 001, India
| | - Pau Loke Show
- Department of Chemical and Environmental Engineering, Faculty of Engineering, University of Nottingham Malaysia Campus, Jalan Broga, 43500 Semenyih, Selangor Darul Ehsan, Malaysia.
| | - Jhi Biau Foo
- School of Pharmacy, Faculty of Health & Medical Sciences, Taylor's University, 1, Jalan Taylors, 47500, Subang Jaya, Selangor, Malaysia; Centre for Drug Discovery and Molecular Pharmacology (CDDMP), Faculty of Health & Medical Sciences, Taylor's University, 1, Jalan Taylors, 47500, Subang Jaya, Selangor, Malaysia.
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9
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Jfri A, Meltzer R, Mostaghimi A, LeBoeuf N, Guggina L. Incidence of Cutaneous Adverse Events With Phosphoinositide 3-Kinase Inhibitors as Adjuvant Therapy in Patients With Cancer: A Systematic Review and Meta-analysis. JAMA Oncol 2022; 8:2797488. [PMID: 36227613 PMCID: PMC9562095 DOI: 10.1001/jamaoncol.2022.4327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 07/27/2022] [Indexed: 11/14/2022]
Abstract
Importance The phosphoinositide 3-kinase (PI3K) pathway is among the most frequently activated pathways in human cancers. As the use of PI3K inhibitors for cancer treatment grows, there is increasing need for understanding the cutaneous effects associated with these therapies. Objective To systematically review the published literature reporting incidence of cutaneous adverse events with PI3K inhibitors and to provide pooled incidence estimates using meta-analysis. Data Sources This systematic review and meta-analysis was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. The literature search concerned entries through September 2021 in the following sources: PubMed, Cochrane registry, ClinicalTrials.gov, and evidence from the NHS UK and Trip medical database. To analyze PI3K inhibitors' cutaneous adverse events incidence, only randomized clinical trials (RCTs) were considered. The search strategy used the following keywords: (prevalence OR incidence OR epidemiology) and (phosphoinositide 3 kinase inhibitors OR PI3K inhibitors). No language restriction was applied. Analysis was conducted on July 1, 2022. Study Selection Studies included phase 2 and phase 3 RCTs that reported incidence of cutaneous adverse events associated with use of PI3K inhibitors. Data Extraction and Measures Data extracted included sex, medication name and class, sample size, rash incidence, and grade. The bias risk was assessed by the Cochrane tool for risk of bias assessment in RCTs. Main Outcomes and Measures The primary outcome was incidence of PI3K inhibitor cutaneous adverse events (with 95% CIs) among the overall population and among subgroups. Between-study heterogeneity was assessed using the I2 statistic. Results The analysis found the incidence of PI3K inhibitor cutaneous events of any grade to be 29.30% in the intervention group, translating to a pooled odds ratio (OR) for incidence of cutaneous adverse events of any grades of 2.55 (95% CI, 1.74-3.75). Incidence of severe grade (grade ≥3) of rash in the intervention group was estimated to be 6.95%, yielding a pooled Peto OR of 4.64 (95% CI, 2.70-7.97). Subgroup analyses revealed that the incidence of severe cutaneous adverse events (grade ≥3) was higher with the use of Pan-class-1 PI3K inhibitors (OR, 6.67; 95% CI, 4.28-10.38) than isoform-selective PI3K inhibitors (OR, 6.37; 95% CI, 3.25-12.48). Conclusions and Relevance This systematic review and meta-analysis identified an overall incidence of PI3K inhibitor cutaneous adverse events of any grade to be 29.30% with a pooled OR of 2.55; (95% CI, 1.74-3.75). These findings clarify the risk of cutaneous adverse events associated with this important class of anticancer therapies.
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Affiliation(s)
- Abdulhadi Jfri
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Rachel Meltzer
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Arash Mostaghimi
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nicole LeBoeuf
- Harvard Medical School, Boston, Massachusetts
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Cutaneous Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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10
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Wang S, Cheng L, Wu H, Li G. Mechanisms and prospects of circular RNAs and their interacting signaling pathways in colorectal cancer. Front Oncol 2022; 12:949656. [PMID: 35992800 PMCID: PMC9382640 DOI: 10.3389/fonc.2022.949656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Colorectal cancer (CRC) is the leading malignant tumor in terms of morbidity and mortality worldwide, and its pathogenesis involves multiple factors, including environment, lifestyle, and genetics. Continuing evidence suggests that circular RNAs (circRNAs), as a novel non-coding RNA, constitute an important genetic variable in the pathogenesis of CRC. These circRNAs with covalently closed-loop structures exist objectively in organisms. They not only have the biological functions of regulating the expression of target genes, changing the activity of proteins, and translating proteins, but also play a key role in the proliferation, invasion, migration, and apoptosis of tumor cells. CRC is one of the most common cancers in which circRNAs are involved in tumorigenesis, metastasis, and drug resistance, and circRNAs have been demonstrated to function through crosstalk with multiple signaling pathways. Therefore, this review summarizes the biological and carcinogenic functions of circRNAs and their related PI3K/AKT, MAPK, Notch, JAK/STAT, Hippo/YAP, WNT/β-catenin, and VEGF signaling pathways in CRC. We further explore the clinical value of circRNAs and important signaling proteins in the diagnosis, prognosis, and treatment of CRC.
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PI3K Inhibitor Eruptions: an Overview of Diagnostic and Management Strategies for the Inpatient Dermatologist. CURRENT DERMATOLOGY REPORTS 2022. [DOI: 10.1007/s13671-022-00365-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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12
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Drug Resistance in Colorectal Cancer: From Mechanism to Clinic. Cancers (Basel) 2022; 14:cancers14122928. [PMID: 35740594 PMCID: PMC9221177 DOI: 10.3390/cancers14122928] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/03/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022] Open
Abstract
Colorectal cancer (CRC) is one of the leading causes of death worldwide. The 5-year survival rate is 90% for patients with early CRC, 70% for patients with locally advanced CRC, and 15% for patients with metastatic CRC (mCRC). In fact, most CRC patients are at an advanced stage at the time of diagnosis. Although chemotherapy, molecularly targeted therapy and immunotherapy have significantly improved patient survival, some patients are initially insensitive to these drugs or initially sensitive but quickly become insensitive, and the emergence of such primary and secondary drug resistance is a significant clinical challenge. The most direct cause of resistance is the aberrant anti-tumor drug metabolism, transportation or target. With more in-depth research, it is found that cell death pathways, carcinogenic signals, compensation feedback loop signal pathways and tumor immune microenvironment also play essential roles in the drug resistance mechanism. Here, we assess the current major mechanisms of CRC resistance and describe potential therapeutic interventions.
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13
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The HER family as therapeutic targets in colorectal cancer. Crit Rev Oncol Hematol 2022; 174:103681. [PMID: 35462030 DOI: 10.1016/j.critrevonc.2022.103681] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 12/23/2022] Open
Abstract
The human epidermal growth factor receptor (HER, ErbB) family has four members, epidermal growth factor receptor (EGFR), HER2, HER3, and HER4. Although distinct in ligands and functions, all of the HER family members are receptor tyrosine kinases playing important roles in the pathogenesis of cancers. In the era of precision medicine, the HER family is one of the most important and successful cancer therapeutic targets, hallmarked by the approval of anti-EGFR therapies for the treatment of colorectal cancer and non-small cell lung cancer, and anti-HER2 therapies for the treatment of breast cancer and gastric cancer. This review briefly discusses how HER family members were discovered, their functions and roles in cancer, and most importantly, the developmental history and recent updates of therapies targeting HER family members, with colorectal cancer as a focus. We also discussed the patient selection and drug resistance to anti-EGFR therapies in the treatment of colorectal cancer.
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14
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Hon KW, Zainal Abidin SA, Othman I, Naidu R. The Crosstalk Between Signaling Pathways and Cancer Metabolism in Colorectal Cancer. Front Pharmacol 2021; 12:768861. [PMID: 34887764 PMCID: PMC8650587 DOI: 10.3389/fphar.2021.768861] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/05/2021] [Indexed: 12/12/2022] Open
Abstract
Colorectal cancer (CRC) is one of the most frequently diagnosed cancers worldwide. Metabolic reprogramming represents an important cancer hallmark in CRC. Reprogramming core metabolic pathways in cancer cells, such as glycolysis, glutaminolysis, oxidative phosphorylation, and lipid metabolism, is essential to increase energy production and biosynthesis of precursors required to support tumor initiation and progression. Accumulating evidence demonstrates that activation of oncogenes and loss of tumor suppressor genes regulate metabolic reprogramming through the downstream signaling pathways. Protein kinases, such as AKT and c-MYC, are the integral components that facilitate the crosstalk between signaling pathways and metabolic pathways in CRC. This review provides an insight into the crosstalk between signaling pathways and metabolic reprogramming in CRC. Targeting CRC metabolism could open a new avenue for developing CRC therapy by discovering metabolic inhibitors and repurposing protein kinase inhibitors/monoclonal antibodies.
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Affiliation(s)
| | | | | | - Rakesh Naidu
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia
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15
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Zhou J, Ji Q, Li Q. Resistance to anti-EGFR therapies in metastatic colorectal cancer: underlying mechanisms and reversal strategies. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2021; 40:328. [PMID: 34663410 PMCID: PMC8522158 DOI: 10.1186/s13046-021-02130-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/22/2021] [Indexed: 12/28/2022]
Abstract
Cetuximab and panitumumab are monoclonal antibodies (mAbs) against epidermal growth factor receptor (EGFR) that are effective agents for metastatic colorectal cancer (mCRC). Cetuximab can prolong survival by 8.2 months in RAS wild-type (WT) mCRC patients. Unfortunately, resistance to targeted therapy impairs clinical use and efficiency. The mechanisms of resistance refer to intrinsic and extrinsic alterations of tumours. Multiple therapeutic strategies have been investigated extensively to overcome resistance to anti-EGFR mAbs. The intrinsic mechanisms include EGFR ligand overexpression, EGFR alteration, RAS/RAF/PI3K gene mutations, ERBB2/MET/IGF-1R activation, metabolic remodelling, microsatellite instability and autophagy. For intrinsic mechanisms, therapies mainly cover the following: new EGFR-targeted inhibitors, a combination of multitargeted inhibitors, and metabolic regulators. In addition, new cytotoxic drugs and small molecule compounds increase the efficiency of cetuximab. Extrinsic alterations mainly disrupt the tumour microenvironment, specifically immune cells, cancer-associated fibroblasts (CAFs) and angiogenesis. The directions include the modification or activation of immune cells and suppression of CAFs and anti-VEGFR agents. In this review, we focus on the mechanisms of resistance to anti-EGFR monoclonal antibodies (anti-EGFR mAbs) and discuss diverse approaches to reverse resistance to this therapy in hopes of identifying more mCRC treatment possibilities.
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Affiliation(s)
- Jing Zhou
- Department of Medical Oncology and Cancer Institute, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Qing Ji
- Department of Medical Oncology and Cancer Institute, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
| | - Qi Li
- Department of Medical Oncology and Cancer Institute, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China. .,Academy of Integrative Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
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Georgiou A, Stewart A, Vlachogiannis G, Pickard L, Valeri N, Cunningham D, Whittaker SR, Banerji U. A phospho-proteomic study of cetuximab resistance in KRAS/NRAS/BRAF V600 wild-type colorectal cancer. Cell Oncol (Dordr) 2021; 44:1197-1206. [PMID: 34462871 PMCID: PMC8516765 DOI: 10.1007/s13402-021-00628-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE We hypothesised that plasticity in signal transduction may be a mechanism of drug resistance and tested this hypothesis in the setting of cetuximab resistance in patients with KRAS/NRAS/BRAFV600 wild-type colorectal cancer (CRC). METHODS A multiplex antibody-based platform was used to study simultaneous changes in signal transduction of 55 phospho-proteins in 12 KRAS/NRAS/BRAFV600 wild-type CRC cell lines (6 cetuximab sensitive versus 6 cetuximab resistant) following 1 and 4 h in vitro cetuximab exposure. We validated our results in CRC patient samples (n = 4) using ex vivo exposure to cetuximab in KRAS/NRAS/BRAFV600 cells that were immunomagnetically separated from the serous effusions of patients with known cetuximab resistance. RESULTS Differences in levels of phospho-proteins in cetuximab sensitive and resistant cell lines included reductions in phospho-RPS6 and phospho-PRAS40 in cetuximab sensitive, but not cetuximab resistant cell lines at 1 and 4 h, respectively. In addition, phospho-AKT levels were found to be elevated in 3/4 patient samples following ex vivo incubation with cetuximab for 1 h. We further explored these findings by studying the effects of combinations of cetuximab and two PI3K pathway inhibitors in 3 cetuximab resistant cell lines. The addition of PI3K pathway inhibitors to cetuximab led to a significantly higher reduction in colony formation capacity compared to cetuximab alone. CONCLUSION Our findings suggest activation of the PI3K pathway as a mechanism of cetuximab resistance in KRAS/NRAS/BRAFV600 wild-type CRC.
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Affiliation(s)
- Alexandros Georgiou
- Division of Cancer Therapeutics, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK.
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sycamore House, Downs Road, London, SM2 5PT, UK.
| | - Adam Stewart
- Division of Cancer Therapeutics, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - Georgios Vlachogiannis
- Division of Molecular Pathology, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - Lisa Pickard
- Division of Cancer Therapeutics, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - Nicola Valeri
- Division of Molecular Pathology, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - David Cunningham
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - Steven R Whittaker
- Division of Cancer Therapeutics, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK
| | - Udai Banerji
- Division of Cancer Therapeutics, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK.
- Division of Clinical Studies, The Institute of Cancer Research, Sycamore House, Downs Road, London, SM2 5PT, UK.
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Zhou X, Feng X, Wang D, Chen D, Wu G, Yan Z, Lyu X, Wang H, Yang JM, Zhao Y. Synthesis and bioactivity studies of covalent inhibitors derived from (-)-Chaetominine. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2021.130694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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18
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Teo MYM, Fong JY, Lim WM, In LLA. Current Advances and Trends in KRAS Targeted Therapies for Colorectal Cancer. Mol Cancer Res 2021; 20:30-44. [PMID: 34462329 DOI: 10.1158/1541-7786.mcr-21-0248] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/25/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
Kirsten Rat Sarcoma (KRAS) gene somatic point mutations is one of the most prominently mutated proto-oncogenes known to date, and accounts for approximately 60% of all colorectal cancer cases. One of the most exciting drug development areas against colorectal cancer is the targeting of undruggable kinases and kinase-substrate molecules, although whether and how they can be integrated with other therapies remains a question. Current clinical trial data have provided supporting evidence on the use of combination treatment involving MEK inhibitors and either one of the PI3K inhibitors for patients with metastatic colorectal cancer to avoid the development of resistance and provide effective therapeutic outcome rather than using a single agent alone. Many clinical trials are also ongoing to evaluate different combinations of these pathway inhibitors in combination with immunotherapy for patients with colorectal cancer whose current palliative treatment options are limited. Nevertheless, continued assessment of these targeted cancer therapies will eventually allow patients with colorectal cancer to be treated using a personalized medicine approach. In this review, the most recent scientific approaches and clinical trials targeting KRAS mutations directly or indirectly for the management of colorectal cancer are discussed.
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Affiliation(s)
- Michelle Yee Mun Teo
- Department of Biotechnology, Faculty of Applied Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Jung Yin Fong
- Department of Biotechnology, Faculty of Applied Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Wan Ming Lim
- Department of Biotechnology, Faculty of Applied Sciences, UCSI University, Kuala Lumpur, Malaysia
| | - Lionel Lian Aun In
- Department of Biotechnology, Faculty of Applied Sciences, UCSI University, Kuala Lumpur, Malaysia.
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Lenze N, Chera B, Sheth S. An evaluation of buparlisib for the treatment of head and neck squamous cell carcinoma. Expert Opin Pharmacother 2020; 22:135-144. [PMID: 33121281 DOI: 10.1080/14656566.2020.1825684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Five-year overall survival for head and neck squamous cell carcinoma (HNSCC) is relatively poor at around 50-66%, and there has been little improvement over the past several decades. PIK3CA alterations are common in HNSCC and offer a promising therapeutic target. AREAS COVERED The authors discuss the PIK3 pathway and the use of PIK3 inhibitors in cancer, with a particular focus on HNSCC. A summary of the safety and efficacy of buparlisib, a class I pan-PI3K inhibitor, from several phase I and phase II HNSCC trials is provided. EXPERT OPINION With a maximum tolerated dose of 100 mg/day and an acceptable toxicity profile, buparlisib may be effective in HNSCC, irrespective of PIK3CA mutational status. On-going clinical trials will help determine the developmental strategy of buparlisib while novel combinatory strategies including combination with immune checkpoint inhibitors should be considered. Importantly, biomarker strategies, including wider use of tumor sequencing and circulating tumor DNA, should be utilized to improve patient selection.
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Affiliation(s)
- Nicholas Lenze
- Department of Otolaryngology-Head and Neck Surgery, The University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Bhisham Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
| | - Siddharth Sheth
- Division of Medical Oncology, Department of Medicine, The University of North Carolina at Chapel Hill , Chapel Hill, NC, USA
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20
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Zhang M, Jang H, Nussinov R. PI3K inhibitors: review and new strategies. Chem Sci 2020; 11:5855-5865. [PMID: 32953006 PMCID: PMC7472334 DOI: 10.1039/d0sc01676d] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/18/2020] [Indexed: 12/16/2022] Open
Abstract
The search is on for effective specific inhibitors for PI3Kα mutants. PI3Kα, a critical lipid kinase, has two subunits, catalytic and inhibitory. PIK3CA, the gene that encodes the p110α catalytic subunit is a highly mutated protein in cancer. Dysregulation of PI3Kα signalling is commonly associated with tumorigenesis and drug resistance. Despite its vast importance, only recently the FDA approved the first drug (alpelisib by Novartis) for breast cancer. A second (GDC0077), classified as PI3Kα isoform-specific, is undergoing clinical trials. Not surprisingly, these ATP-competitive drugs commonly elicit severe concentration-dependent side effects. Here we briefly review PI3Kα mutations, focus on PI3K drug repertoire and propose new, to-date unexplored PI3Kα therapeutic strategies. These include (1) an allosteric and orthosteric inhibitor combination and (2) taking advantage of allosteric rescue mutations to guide drug discovery.
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Affiliation(s)
- Mingzhen Zhang
- Computational Structural Biology Section , Frederick National Laboratory for Cancer Research , National Cancer Institute at Frederick , Frederick , MD 21702 , USA . ; Tel: +1-301-846-5579
| | - Hyunbum Jang
- Computational Structural Biology Section , Frederick National Laboratory for Cancer Research , National Cancer Institute at Frederick , Frederick , MD 21702 , USA . ; Tel: +1-301-846-5579
| | - Ruth Nussinov
- Computational Structural Biology Section , Frederick National Laboratory for Cancer Research , National Cancer Institute at Frederick , Frederick , MD 21702 , USA . ; Tel: +1-301-846-5579
- Department of Human Molecular Genetics and Biochemistry , Sackler School of Medicine , Tel Aviv University , Tel Aviv 69978 , Israel
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21
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Arafeh R, Samuels Y. PIK3CA in cancer: The past 30 years. Semin Cancer Biol 2019; 59:36-49. [DOI: 10.1016/j.semcancer.2019.02.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/08/2019] [Accepted: 02/07/2019] [Indexed: 02/07/2023]
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22
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Curigliano G, Shah RR. Safety and Tolerability of Phosphatidylinositol-3-Kinase (PI3K) Inhibitors in Oncology. Drug Saf 2019; 42:247-262. [PMID: 30649751 DOI: 10.1007/s40264-018-0778-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Activation of phosphatidylinositol-3-kinase (PI3K) and downstream signalling by AKT/mammalian target of rapamycin (mTOR) modulates cellular processes such as increased cell growth, cell proliferation and increased cell migration as well as deregulated apoptosis and oncogenesis. The PI3K/AKT/mTOR pathway (particularly Class I PI3K isoforms) is frequently activated in a variety of solid tumours and haematological malignancies, making PI3K an attractive therapeutic target in oncology. Inhibitors of PI3K also have the potential to restore sensitivity to other modalities of treatments when administered as part of combination regimens. Although many PI3K inhibitors have reached different stages of clinical development, only two (idelalisib and copanlisib) have been currently approved for use in the treatment of B cell lymphoma and leukaemias. While these two agents are effective clinically, their use is associated with a number of serious class-related as well as drug-specific adverse effects. Some of these are immune-mediated and include cutaneous reactions, severe diarrhoea with or without colitis, hepatotoxicity and pneumonitis. They also induce various metabolic abnormalities such as hyperglycaemia and hypertriglyceridaemia. Not surprisingly, therefore, many new PI3K inhibitors with a varying degree of target selectivity have been synthesised in expectations of improved safety and efficacy, and are currently under clinical investigations for use in a variety of solid tumours as well as haematological malignancies. However, evidence from early clinical trials, reviewed herein, suggests that these newer agents are also associated not only with class-related but also other serious and unexpected adverse effects. Their risk/benefit evaluations have resulted in a number of them being discontinued from further development. Cumulative experience with the use of PI3K inhibitors under development suggests that, compared with their use as monotherapy, combining them with other anticancer therapies may be a more effective strategy in improving current standard-of-care and clinical outcomes in cancers beyond haematological cancers. For example, combination of alpelisib with fulvestrant has recently demonstrated unexpectedly superior efficacy compared to fulvestrant alone. Furthermore, the immunomodulatory activity of PI3Kδ and PI3Kγ inhibitors also provides unexpected opportunities for their use in cancer immunotherapy, as is currently being tested in several clinical trials.
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Affiliation(s)
- Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapy, IEO, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Haematology (DIPO), University of Milan, Milan, Italy
| | - Rashmi R Shah
- Pharmaceutical Consultant, 8 Birchdale, Gerrards Cross, Buckinghamshire, SL9 7JA, UK.
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Thierauf J, Ramamurthy N, Jo VY, Robinson H, Frazier RP, Gonzalez J, Pacula M, Dominguez Meneses E, Nose V, Nardi V, Dias-Santagata D, Le LP, Lin DT, Faquin WC, Wirth LJ, Hess J, Iafrate AJ, Lennerz JK. Clinically Integrated Molecular Diagnostics in Adenoid Cystic Carcinoma. Oncologist 2019; 24:1356-1367. [PMID: 30926674 PMCID: PMC6795155 DOI: 10.1634/theoncologist.2018-0515] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/27/2019] [Indexed: 01/29/2023] Open
Abstract
Adenoid cystic carcinoma is a rare but aggressive type of salivary gland malignancy. This article addresses the need for more effective, biomarker‐informed therapies in rare cancers, focusing on clinical utility and financial sustainability of integrated next‐generation sequencing in routine practice. Background. Adenoid cystic carcinoma (ACC) is an aggressive salivary gland malignancy without effective systemic therapies. Delineation of molecular profiles in ACC has led to an increased number of biomarker‐stratified clinical trials; however, the clinical utility and U.S.‐centric financial sustainability of integrated next‐generation sequencing (NGS) in routine practice has, to our knowledge, not been assessed. Materials and Methods. In our practice, NGS genotyping was implemented at the discretion of the primary clinician. We combined NGS‐based mutation and fusion detection, with MYB break‐apart fluorescent in situ hybridization (FISH) and MYB immunohistochemistry. Utility was defined as the fraction of patients with tumors harboring alterations that are potentially amenable to targeted therapies. Financial sustainability was assessed using the fraction of global reimbursement. Results. Among 181 consecutive ACC cases (2011–2018), prospective genotyping was performed in 11% (n = 20/181; n = 8 nonresectable). Testing identified 5/20 (25%) NOTCH1 aberrations, 6/20 (30%) MYB‐NFIB fusions (all confirmed by FISH), and 2/20 (10%) MYBL1‐NFIB fusions. Overall, these three alterations (MYB/MYBL1/NOTCH1) made up 65% of patients, and this subset had a more aggressive course with significantly shorter progression‐free survival. In 75% (n = 6/8) of nonresectable patients, we detected potentially actionable alterations. Financial analysis of the global charges, including NGS codes, indicated 63% reimbursement, which is in line with national (U.S.‐based) and international levels of reimbursement. Conclusion. Prospective routine clinical genotyping in ACC can identify clinically relevant subsets of patients and is approaching financial sustainability. Demonstrating clinical utility and financial sustainability in an orphan disease (ACC) requires a multiyear and multidimensional program. Implications for Practice. Delineation of molecular profiles in adenoid cystic carcinoma (ACC) has been accomplished in the research setting; however, the ability to identify relevant patient subsets in clinical practice has not been assessed. This work presents an approach to perform integrated molecular genotyping of patients with ACC with nonresectable, recurrent, or systemic disease. It was determined that 75% of nonresectable patients harbor potentially actionable alterations and that 63% of charges are reimbursed. This report outlines that orphan diseases such as ACC require a multiyear, multidimensional program to demonstrate utility in clinical practice.
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Affiliation(s)
- Julia Thierauf
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
- Department of Otorhinolaryngology, Head and Neck Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Nisha Ramamurthy
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Vickie Y Jo
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Hayley Robinson
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan P Frazier
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Gonzalez
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Maciej Pacula
- Department of Pathology, Computational Pathology, Boston, Massachusetts, USA
| | | | - Vania Nose
- Department of Pathology, Head and Neck Pathology, Boston, Massachusetts, USA
- Department of Pathology, Surgical Pathology, Boston, Massachusetts, USA
| | - Valentina Nardi
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Dora Dias-Santagata
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Long P Le
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Computational Pathology, Boston, Massachusetts, USA
| | - Derrick T Lin
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - William C Faquin
- Department of Pathology, Surgical Pathology, Boston, Massachusetts, USA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Lori J Wirth
- Cancer Center, Massachusetts General Hospital, Boston, Massachusetts, USA
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Jochen Hess
- Department of Otorhinolaryngology, Head and Neck Surgery, Heidelberg University Hospital, Heidelberg, Germany
- Research Group Molecular Mechanisms of Head and Neck Tumors, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - A John Iafrate
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
| | - Jochen K Lennerz
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
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Interest to consider re-challenging by cetuximab and platinum containing regimen in recurrent Head and Neck Cancer. Oncotarget 2018; 9:37581-37588. [PMID: 30680071 PMCID: PMC6331031 DOI: 10.18632/oncotarget.26506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 12/13/2018] [Indexed: 12/31/2022] Open
Abstract
Background The EXTREME protocol is the standard of care for recurrent or metastatic head and neck squamous-cell carcinoma (R/M HNSCC) in first line. Beyond the first-line except immunotherapy, poor efficacy was reported by second-line chemotherapy. Re-challenge strategies based on a repetition of the first line with platinum and cetuximab regimens might have been an option to consider. Methods We performed a retrospective study in order to assess the efficacy of the cetuximab plus platinum doublet-based chemotherapy regimen in patients with R/M HNSCC progressing after at least 3 months of cetuximab maintenance (EXTREME protocol). We complete a retrospective review of all medical records from R/M HNSCC patients treated after 16 weeks with the EXTREME regimen and treated with a re-challenge strategy between January 2010 and December 2014 in our institution (Centre Paul Strauss, Strasbourg, France). Results 33 patients were identified. The re-challenged strategy provided an ORR in 33.3% of cases and a DCR of 69.6% of cases. The median OS and PFS observed from the second line were 11.2 months and 6.5 months for the subset re-challenged by EXTREME or PCC regimens respectively. The response rate between patients with a platin free interval within 3 and 6 months and greater than 6 months were equal. Drugs dose intensity were better with the PCC protocol than the EXTREME regimen used as a rechallenge. Conclusions This study suggest re-challenging strategy by these regimens could be considered beyond the first line as an option when the platin free interval is greater than 3 months.
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Janku F, Yap TA, Meric-Bernstam F. Targeting the PI3K pathway in cancer: are we making headway? Nat Rev Clin Oncol 2018; 15:273-291. [PMID: 29508857 DOI: 10.1038/nrclinonc.2018.28] [Citation(s) in RCA: 673] [Impact Index Per Article: 112.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The PI3K-AKT-mTOR pathway is one of the most frequently dysregulated pathways in cancer and, consequently, more than 40 compounds that target key components of this signalling network have been tested in clinical trials involving patients with a range of different cancers. The clinical development of many of these agents, however, has not advanced to late-phase randomized trials, and the antitumour activity of those that have been evaluated in comparative prospective studies has typically been limited, or toxicities were found to be prohibitive. Nevertheless, the mTOR inhibitors temsirolimus and everolimus and the PI3K inhibitors idelalisib and copanlisib have been approved by the FDA for clinical use in the treatment of a number of different cancers. Novel compounds with greater potency and selectivity, as well as improved therapeutic indices owing to reduced risks of toxicity, are clearly required. In addition, biomarkers that are predictive of a response, such as PIK3CA mutations for inhibitors of the PI3K catalytic subunit α isoform, must be identified and analytically and clinically validated. Finally, considering that oncogenic activation of the PI3K-AKT-mTOR pathway often occurs alongside pro-tumorigenic aberrations in other signalling networks, rational combinations are also needed to optimize the effectiveness of treatment. Herein, we review the current experience with anticancer therapies that target the PI3K-AKT-mTOR pathway.
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Affiliation(s)
- Filip Janku
- Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy A Yap
- Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Funda Meric-Bernstam
- Department of Investigational Cancer Therapeutics (Phase I Clinical Trials Program), The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Efficacy of PI3K/AKT/mTOR pathway inhibitors for the treatment of advanced solid cancers: A literature-based meta-analysis of 46 randomised control trials. PLoS One 2018; 13:e0192464. [PMID: 29408858 PMCID: PMC5800666 DOI: 10.1371/journal.pone.0192464] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 01/23/2018] [Indexed: 01/05/2023] Open
Abstract
Background The phosphatidylinositol-3- kinase (PI3K)/AKT/mammalian target of rapamycin (mTOR) pathway (PI3K/AKT/mTOR pathway) plays a key role in cancer. We performed this meta-analysis to assess the clinical effect of using PI3K/AKT/mTOR pathway inhibitors on advanced solid tumours. Methods All the randomised controlled trials (RCT) that compared the therapy with PI3K/AKT/mTOR pathway inhibitors with other therapies were included. The main end-point was progression-free survival (PFS); other end-points included overall survival (OS) and objective response rate (ORR). A subgroup analysis was performed mainly for PFS. Results In total, 46 eligible RCT were included. The pooled results showed that PI3K/AKT/mTOR pathway inhibitor-based regimens significantly improved the PFS of patients with advanced solid tumours (hazard ratios (HR) = 0.79; 95% confidence intervals (CI): 0.71–0.88) and PI3K pathway mutations (HR = 0.69; 95% CI: 0.56–0.85). All single PI3K/AKT/mTOR pathway inhibitor therapies were compared with other targeted therapies (HR = 0.99; 95% CI: 0.93–1.06) and dual targeted therapies, including PI3K/AKT/mTOR pathway inhibitors and other targeted therapies (HR = 1.04; 95% CI: 0.62–1.74), which showed no significant differences in the PFS. Additional PI3K/AKT/mTOR pathway inhibitors showed no advantage with respect to the OS (HR = 0.98; 95% CI: 0.90–1.07) or ORR (risk ratio (RR) = 1.02; 95% CI: 0.87–1.20). Conclusion Our meta-analysis results suggest that the addition of the PI3K pathway inhibitors to the therapy regiment for advanced solid tumours significantly improves PFS. The way that patients are selected to receive the PI3K pathway inhibitors might be more meaningful in the future.
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Chaikuad A, Koch P, Laufer SA, Knapp S. The Cysteinome of Protein Kinases as a Target in Drug Development. Angew Chem Int Ed Engl 2018; 57:4372-4385. [DOI: 10.1002/anie.201707875] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 09/20/2017] [Indexed: 01/04/2023]
Affiliation(s)
- Apirat Chaikuad
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; University of Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ UK
- Institute for Pharmaceutical Chemistry; Goethe-University; Max-von-Laue-Strasse 9 60438 Frankfurt am Main Germany
| | - Pierre Koch
- Department of Pharmaceutical/Medicinal Chemistry; Eberhard-Karls-University Tübingen; Auf der Morgenstelle 8 72076 Tübingen Germany
| | - Stefan A. Laufer
- Department of Pharmaceutical/Medicinal Chemistry; Eberhard-Karls-University Tübingen; Auf der Morgenstelle 8 72076 Tübingen Germany
- German Cancer Consortium DKTK, Standort Tübingen; Germany
| | - Stefan Knapp
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; University of Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ UK
- German Cancer Consortium DKTK, Standort Frankfurt/Mainz; Germany
- Institute for Pharmaceutical Chemistry; Goethe-University; Max-von-Laue-Strasse 9 60438 Frankfurt am Main Germany
- Structural Genomics Consortium and Buchmann Institute for Molecular Life Sciences; Johann Wolfgang Goethe-University; Max-von-Laue-Strasse 15 60438 Frankfurt am Main Germany
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Chaikuad A, Koch P, Laufer SA, Knapp S. Das Cysteinom der Proteinkinasen als Zielstruktur in der Arzneistoffentwicklung. Angew Chem Int Ed Engl 2018. [DOI: 10.1002/ange.201707875] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Apirat Chaikuad
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; Universität Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ Großbritannien
- Institut für pharmazeutische Chemie; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 9 60438 Frankfurt am Main Deutschland
| | - Pierre Koch
- Institut für pharmazeutische und medizinische Chemie; Eberhard-Karls-Universität Tübingen; Auf der Morgenstelle 8 72076 Tübingen Deutschland
| | - Stefan A. Laufer
- Institut für pharmazeutische und medizinische Chemie; Eberhard-Karls-Universität Tübingen; Auf der Morgenstelle 8 72076 Tübingen Deutschland
- Deutsches Zentrum für translationale Krebsforschung, Standort; Tübingen Deutschland
| | - Stefan Knapp
- Nuffield Department of Clinical Medicine; Structural Genomics Consortium and Target Discovery Institute; Universität Oxford, Old Road Campus Research Building; Roosevelt Drive Oxford OX3 7DQ Großbritannien
- Deutsches Zentrum für translationale Krebsforschung, Standort Frankfurt/Mainz; Deutschland
- Institut für pharmazeutische Chemie; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 9 60438 Frankfurt am Main Deutschland
- Structural Genomics Consortium and Buchmann Institute for Molecular Life Sciences; Johann Wolfgang Goethe-Universität; Max-von-Laue-Straße 15 60438 Frankfurt am Main Deutschland
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Fernandes MS, Sanches JM, Seruca R. Targeting the PI3K Signalling as a Therapeutic Strategy in Colorectal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1110:35-53. [PMID: 30623365 DOI: 10.1007/978-3-030-02771-1_4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Colorectal cancer (CRC) remains one of the leading causes of cancer mortality worldwide. Regarded as a heterogeneous disease, a number of biomarkers have been proposed to help in the stratification of CRC patients and to enable the selection of the best therapy for each patient towards personalized therapy. However, although the molecular mechanisms underlying the development of CRC have been elucidated, the therapeutic strategies available for these patients are still quite limited. Thus, over the last few years, a multitude of novel targets and therapeutic strategies have emerged focusing on deregulated molecules and pathways that are implicated in cell growth and survival. Particularly relevant in CRC are the activating mutations in the oncogene PIK3CA that frequently occur in concomitancy with KRAS and BRAF mutations and that lead to deregulation of the major signalling pathways PI3K and MAPK, downstream of EGFR. This review focus on the importance of the PI3K signalling in CRC development, on the current knowledge of PI3K inhibition as a therapeutic approach in CRC and on the implications PI3K signalling molecules may have as potential biomarkers and as new targets for directed therapies in CRC patients.
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Affiliation(s)
- Maria Sofia Fernandes
- Institute for Systems and Robotics (ISR), Instituto Superior Técnico (IST), Lisboa, Portugal
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
| | - João Miguel Sanches
- Institute for Systems and Robotics (ISR), Instituto Superior Técnico (IST), Lisboa, Portugal
| | - Raquel Seruca
- Instituto de Investigação e Inovação em Saúde (i3S), University of Porto, Porto, Portugal.
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal.
- Faculty of Medicine, University of Porto, Porto, Portugal.
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Zhao HF, Wang J, Shao W, Wu CP, Chen ZP, To SST, Li WP. Recent advances in the use of PI3K inhibitors for glioblastoma multiforme: current preclinical and clinical development. Mol Cancer 2017; 16:100. [PMID: 28592260 PMCID: PMC5463420 DOI: 10.1186/s12943-017-0670-3] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 05/26/2017] [Indexed: 02/08/2023] Open
Abstract
Glioblastoma multiforme (GBM) is the most common and aggressive malignant primary tumor in the central nervous system. One of the most widely used chemotherapeutic drugs for GBM is temozolomide, which is a DNA-alkylating agent and its efficacy is dependent on MGMT methylation status. Little progress in improving the prognosis of GBM patients has been made in the past ten years, urging the development of more effective molecular targeted therapies. Hyper-activation of the phosphatidylinositol 3-kinase (PI3K)/Akt pathway is frequently found in a variety of cancers including GBM, and it plays a central role in the regulation of tumor cell survival, growth, motility, angiogenesis and metabolism. Numerous PI3K inhibitors including pan-PI3K, isoform-selective and dual PI3K/mammalian target of rapamycin (mTOR) inhibitors have exhibited favorable preclinical results and entered clinical trials in a range of hematologic malignancies and solid tumors. Furthermore, combination of inhibitors targeting PI3K and other related pathways may exert synergism on suppressing tumor growth and improving patients' prognosis. Currently, only a handful of PI3K inhibitors are in phase I/II clinical trials for GBM treatment. In this review, we focus on the importance of PI3K/Akt pathway in GBM, and summarize the current development of PI3K inhibitors alone or in combination with other inhibitors for GBM treatment from preclinical to clinical studies.
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Affiliation(s)
- Hua-fu Zhao
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Jing Wang
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Wei Shao
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Chang-peng Wu
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
- College of Clinical Medicine, Anhui Medical University, Hefei, 230032 China
| | - Zhong-ping Chen
- Department of Neurosurgery/Neuro-oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060 China
| | - Shing-shun Tony To
- Department of Health Technology and Informatics, The Hong Kong Polytechnic University, Hong Kong, China
| | - Wei-ping Li
- Department of Neurosurgery & Shenzhen Key Laboratory of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People’s Hospital, Shenzhen, 518035 China
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Sobani ZA, Sawant A, Jafri M, Correa AK, Sahin IH. Oncogenic fingerprint of epidermal growth factor receptor pathway and emerging epidermal growth factor receptor blockade resistance in colorectal cancer. World J Clin Oncol 2016; 7:340-351. [PMID: 27777877 PMCID: PMC5056326 DOI: 10.5306/wjco.v7.i5.340] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/14/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
Epidermal growth factor receptor (EGFR) has been an attractive target for treatment of epithelial cancers, including colorectal cancer (CRC). Evidence from clinical trials indicates that cetuximab and panitumumab (anti-EGFR monoclonal antibodies) have clinical activity in patients with metastatic CRC. The discovery of intrinsic EGFR blockade resistance in Kirsten RAS (KRAS)-mutant patients led to the restriction of anti-EGFR antibodies to KRAS wild-type patients by Food and Drug Administration and European Medicine Agency. Studies have since focused on the evaluation of biomarkers to identify appropriate patient populations that may benefit from EGFR blockade. Accumulating evidence suggests that patients with mutations in EGFR downstream signaling pathways including KRAS, BRAF, PIK3CA and PTEN could be intrinsically resistant to EGFR blockade. Recent whole genome studies also suggest that dynamic alterations in signaling pathways downstream of EGFR leads to distinct oncogenic signatures and subclones which might have some impact on emerging resistance in KRAS wild-type patients. While anti-EGFR monoclonal antibodies have a clear potential in the management of a subset of patients with metastatic CRC, further studies are warranted to uncover exact mechanisms related to acquired resistance to EGFR blockade.
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