First discovered by Lewis Cantley and colleagues, the phosphoinositide 3-kinase (PI3K) signaling is one of the pathways controlling cell survival, proliferation, and apoptosis. PI3Ks are a large family of lipid enzymes that phosphorylate the 3’-OH group of phosphatidylinositols (PI) at the plasma membrane. This leads to the recruitment of the protein Ser/Thr-kinase, AKT, to the cell membrane where it becomes activated. PI3K catalyzes the production of phosphatidylinositol-3,4,5-triphosphate (PIP3) at the cell membrane. PIP3 in turn serves as a second messenger that helps to activate Akt. Once active, AKT can control key cellular processes by phosphorylating substrates involved in apoptosis, protein synthesis, metabolism, and cell cycle. Human cells express three classes of PI3K enzymes: class I PI3Ks, class II PI3Ks and class III PI3Ks.

The knowledge accumulated during the past three decades of lipid kinase research indicates that the PI3K family members participate in an extraordinarily broad range of cellular regulatory processes, including cell growth and proliferation, metabolism, migration, and secretion. Moreover, aberrations in PI3K signaling contribute to an equally broad spectrum of human diseases, such as cancer, immunological disorders, neurological disorders, diabetes, localized tissue overgrowth, and cardiovascular disease. For example, Somatic mutations in PIK3CA, the gene encoding the p110α catalytic subunit, have been identified in a variety of solid tumors. This plethora of functions and implications in different diseases promoted a great effort in the development of compounds targeting the PI3K signaling pathway.

The ubiquitous nature of PI3K pathway activation in cancer suggests that PI3K, AKT, and other components of this pathway may be attractive targets for cancer therapy, and multiple PI3K pathway inhibitors are now under active drug and clinical development. Wortmannin was the first PI3K inhibitor developed. In 1987, this compound was found to have an inhibitory effect on respiratory burst in neutrophils, and it was eventually shown that its mechanism of action was through irreversible inhibition of PI3K. However, wortmannin is a nonspecific inhibitor that cross-reacts with other PI3K-related proteins such as mTOR, DNA-PKCs, ATM, ATR, and PI4K. It is also unstable and toxic in animals. The first synthetic inhibitor of PI3K is LY294002 which is less potent than wortmannin and is a reversible inhibitor. However, its poor pharmacological properties, such as limited stability, have precluded the clinical development of this molecule.

A structural analog of wortmannin, PX-866, potently and irreversibly inhibits PI3K signaling. PX 866 exhibits single agent in vivo anti-tumor activity and increases the anti-tumor effects of cisplatin and radiation treatment. In cancer cells grown in three-dimensional cultures, PX 866 reduces cell growth and motility without causing cytotoxicity. One LY294002-like compound that has been developed is SF1126. SF1126 contains a peptide-based targeting group to help increase the localization of the drug in the neovascular component supporting tumor growth. It selectively inhibits all PI3K class IA isoforms and other key members of the PI3K superfamily, including DNA-PK and mTOR. SF1126 has been evaluated in numerous animal tumor models showing good tumor inhibition or tumor regression.

Additional classes of inhibitors that are chemically unrelated to wortmannin and LY294002 and more highly selective for Class I PI3K have also been reported. For example, XL147 inhibits class I PI3K isoforms in an ATP-competitive manner. In HER2-overexpressing breast cancer cells, cotreatment with the HER2 inhibitors trastuzumab or lapatinib is reported to sensitize tumor cells to the growth inhibitory effect of XL147.

Early work and clinical trials demonstrated that constant inhibition of mTOR led to a reactivation of PI3K signaling. Many of the PI3K inhibitors that are under development are actually active against several proteins that are structurally related to PI3K, including mTOR. PI-103 is a chemically distinct PI3K inhibitor that also inhibits mTOR kinase activity in mTORC1 and mTORC2. PI-103 exhibits antiproliferative activity against a panel of glioma cell lines in vitro. It also inhibits the growth of established human glioma tumor xenografts in vivo with no observable toxicity. There are several other examples of dual PI3K-mTOR inhibitors in clinical trials. For example, NVP-BEZ235 inhibits PI3K isoforms and mutants with low nanomolar IC50 values, leading to growth arrest in the G1 phase. Through its effects on PI3K, NVP-BEZ235 inhibits VEGF-induced angiogenesis. Another one is XL-765 which decreases EGF-induced production of PIP3, a product of PI3K-mediated PIP2 metabolism. XL-765 also reduces phosphorylation of the PI3K and mTORC targets Akt and ribosomal protein S6 (S6RP) in the same model.

Other PI3K inhibitors that were clinically studied in several clinical trials: ACP-319, BYL719, and Serabelisib were synthesized towards inhibiting PIK3CA (PI3Kα). PIK3CB inhibitors include GSK2636711 and SAR260301. Dual inhibitors of PIK3CA/B includes BAY1082439 PIK3CB/D inhibitors include AZD8186 and KA2237, PIK3CD/G includes Duvelisib and the PIK3CA/D/G inhibitors include Taselisib. Currently, many clinical trials are on the way to using a combination of two inhibitors. In addition, combination therapy using inhibitors of different signal transduction pathways such as UCN-01, ASN003, and ONC201 to target parallel pathways are clinically being studied. Among them, ASN003 (BRAF and PI3K inhibitor) was used to treat melanoma, colorectal neoplasm, and non-small cell lung carcinoma (NSCLC) in phase I clinical trial but was terminated for reformulation.

As of today, three PI3K inhibitors have been approved for cancer treatment. Idelalisib was approved in 2014. Idelalisib is a PI3Kδ inhibitor which is approved for relapsed or refractory chronic lymphocytic leukemia (CLL) in combination with rituximab. Copanlisib, an inhibitor of PI3K which predominantly works against the isoforms PI3K-α and PI3K-δ, was approved in 2017 for the treatment of adult patients with relapsed follicular lymphoma. Duvelisib is a dual inhibitor of PI3Kδ and PI3Kγ which was approved in 2018 for the treatment of adult patients with relapsed or refractory chronic lymphocytic leukemia (CLL) and also for small lymphocytic lymphoma (SLL).

Although many PI3K inhibitors were clinically developed, most of them did not reach the clinic. Importantly, the use of the PI3K inhibitors as monotherapies alone has not resulted in a fruitful experience and mostly ended with a poor clinical response to these PI3K inhibitors. Major reasons for the poor efficacy of monotherapy were due to response to therapy with a sub-optimal level of the drug. Secondly, resistance to pathway inhibition includes activation of the parallel-signals or reactivation of the PI3K pathway.

More than 30 years of discoveries acknowledged a fundamental role for the PI3Ks axis in several cellular processes including inflammation, metabolism, motility, cell proliferation, and survival. Currently, dual inhibition of PI3K and mTOR pathway, inhibition of the parallel pathway, and targeted and non-targeted combinations are being clinically studied and the results are promising.