The importance of the PI3K/Akt pathway in cancer was first established by identification of the tumor-suppressor phosphatase PTEN, which dephosphorylates the 3′-position of the inositide ring to eliminate the lipid second messenger PIP
3 and terminate signalling through this pathway [
26,
27]. Firmly establishing the activation of this pathway as an essential node in tumorigenesis was the discovery of activating mutations in
PIK3CA [
15], the gene encoding the p110α PI3K catalytic subunit, which result in constitutive activation of this pathway [
28]. In addition, mutations in other upstream activators, such as EGF receptor (EGFR) and K-RAS, and AKT1 itself can drive activation of this pathway in many different cancers [
29]. Recent studies have highlighted new ways for cancer cells to promote signalling through this pathway [
30], and it is estimated activation of this pathway is likely to be crucial for a majority of cancers (upwards of 70% of primary breast tumors, for example) [
31]. Mutations in various components of this pathway such as LOF mutations in PTEN, GOF mutations in PI3K, or GOF mutations in AKT itself all result in the common endpoint of increased AKT activation suggesting that AKT inhibitors could be used to treat patients with mutations in any of these respective enzymes. However, it is possible that patients with mutations in AKT1 will respond better to an AKT1 specific inhibitor, and patients with PI3K mutations will respond better to a PI3K specific inhibitor.
One novel mechanism that decreases PTEN expression involves the loss of expression of the pseudogene PTENP1, whose transcripts can act as a decoy for microRNAs targeting PTEN mRNA. Loss of PTENP1 leads to increased PTEN microRNA targeting and decreased PTEN expression, and subsequently leads to the activation of the PI3K/Akt pathway. In consequence, it is not surprising that the
PTENP1 gene is lost in various cancers () [
30].
Downstream of PI3K is its primary target, AKT, which requires the lipid second messenger PIP
3 for activation [
24]. Binding of PIP
3 to AKT’s PH domain allows constitutively bound PDK-1 to phosphorylate AKT at the activation loop site, Thr308 (Akt1) [
32]. AKT is also phosphorylated at the hydrophobic motif, Ser473 (AKT1), by the mTORC2 kinase complex, which enhances AKT activation and its subsequent phosphorylation of downstream substrates, especially, Forkhead Box O (FOXO) family of transcription factors [
33,
34]. The mTORC2 kinase complex can interact with DEPTOR, which suppress the activity of this kinase complex and decreases hydrophobic motif phosphorylation of Akt [
35]. Depletion of DEPTOR results in an increase in Akt phosphorylation (and an increase in S6K phosphorylation because DEPTOR also inhibits mTORC1) and loss of DEPTOR is a common event in multiple myelomas [
35]. Consistent with the importance of increased Ser473 phosphorylation in tumorigenesis is the observation that the PHLPP phosphatases have decreased expression or activity in colon, prostate, breast, and pancreatic cancers, as well as CML [
36–
40]. These phosphatases modulate the amplitude of AKT signalling by regulating phosphorylation of specific Akt isoforms at Ser473 [
41,
42]. Additional posttranslational modifications of AKT have emerged as another quality control mechanism to regulate its activation. Specifically, TRAF6 promotes polyubiquitiylation of AKT, generating Lys63-branched chains, which enhance membrane recruitment of AKT and subsequent activation (polyubiquitiylation also contributes to hyperactivation of the cancer mutant Akt – E17K) [
43]. Consistent with the role of TRAF6 in promoting the activation of Akt, mice lacking TRAF6 have decreased tumorigeneic potential [
43]. The existence of these multifaceted quality control mechanisms that ensure proper regulation of the PI3K/Akt pathway provide multiple sites for aberrant regulation of this pathway and indicate that tight regulation of the pathway is essential to prevent inappropriate proliferation, survival, and cell growth (). These factors must be taken into consideration when targeting various components of this pathway, since feedback loops are used to temper signalling through this pathway [
44–
46]. Therefore, inhibitors of the mTORC1 complex, such as rapamycin, can have the unintended consequence of activating the PI3K/Akt pathway, and may need to be used in combination with other inhibitors, such as a PI-3 kinase inhibitor, or a more promiscuous inhibitor that would target both PI3K and mTOR [
47,
48].