Gastric malignant neoplastic disease remains one of the most common types of malignant neoplastic disease worldwide, and most patients present with advanced disease. Sixty per centum of these patients finally relapse after healing surgical resection, and combination chemotherapy regimens merely provide limited survival benefits. Mammalian mark of rapamycin ( mTOR ) is a new mark of malignant neoplastic disease therapies. Preclinical information suggest that the suppression of the mTOR tract inhibits the patterned advance of stomachic malignant neoplastic disease in vitro and in carnal theoretical accounts. In clinical tests, the mTOR inhibitor, everolimus, was good tolerated in stage I/II surveies on patients with metastatic stomachic malignant neoplastic disease. The efficaciousness of everolimus was assuring in a stage II clinical test, but in a late published stage III clinical test everolimus monotherapy do non significantly better the overall endurance of patients with advanced stomachic malignant neoplastic disease who had been antecedently treated with one or two lines of systemic chemotherapy. Phosphoinositide 3-kinase/mTOR double inhibitors have non yet entered early-stage clinical tests in patients with advanced stomachic malignant neoplastic disease. Further surveies are needed to set up the function of mTOR inhibitors for the intervention of stomachic malignant neoplastic disease.
Cardinal words: Gastric malignant neoplastic disease ; mTOR inhibitors ; everolimus
Gastric malignant neoplastic disease is one of the most common types of malignant neoplastic disease around the universe. A sum of 989,600 new instances of tummy malignant neoplastic disease and 738,000 deceases are estimated to hold occurred in 2008, accounting for 8 % of the entire instances of malignant neoplastic disease and 10 % of the entire malignant neoplastic disease deceases [ 1 ] . The highest incidence rates are found in Eastern Asia, Eastern Europe, and South America. In China, the age-standardized incidence rates were 41.9 ( per 100,000 ) for males and 19.5 for females in 2000 and 37.1 for males and 17.4 for females in 2005. The age-standardized mortality rates were 32.7 ( per 100,000 ) for males and 15.0 for females in 2000 and 28.8 for males and 13.3 for females in 2005. In 2005, 300,000 deceases and 400,000 new instances of stomachic malignant neoplastic disease were reported, doing stomachic malignant neoplastic disease the 3rd most common malignant neoplastic disease [ ] .
Surgery is the prinicpal intervention for stomachic malignant neoplastic disease. Gastric malignant neoplastic disease, when detected early, has first-class forecast after surgical intervention, with a 5-year endurance rate that is & gt ; 90 % [ ] ; nevertheless, most patients present with advanced disease and the long-run endurance is hapless for these instances. These instances do non show a survival advantage even when an extended lymphadenectomy is performed [ ] . Sixty per centum of patients who present with advanced disease finally relapse after healing surgical resection [ 8 ] . Systemic chemotherapy has been extensively evaluated in patients with resectable and unresectable stomachic malignant neoplastic disease. At present, the most common agents are fluorouracil ( FU ) and its derived functions, including taxanes, irinotecan, and Pt derived functions. Combination chemotherapy regimens have been shown to protract the average overall endurance ( OS ) , but by and large survival is less than 1 twelvemonth [ 9-12 ] . The hapless long-run result of patients with stomachic malignant neoplastic disease suggests a demand for novel targeted agents, which may better the clinical forecast [ 13 ] . This reappraisal focuses on the relevancy of the mammalian mark of rapamycin ( mTOR ) tract in stomachic malignant neoplastic disease and the clinical consequences of utilizing mTOR inhibitors to handle patients with stomachic malignant neoplastic disease.
Mechanistic action of mTOR inhibitors
Inhibition of the mTOR tract is a new therapy for the intervention of assorted human malignant neoplastic diseases. mTOR is a critical regulator of cell proliferation, metamorphosis, and protein synthesis via the phosphoinositide 3-kinase ( PI3K ) -Akt tract. Signals from growing factor receptors activate PI3K, ensuing in Akt activation and, finally, activation of the constituents of mTOR that are centrally located downstream. Mutants in the upstream constituents of the mTOR signaling pathway consequence in inappropriate mTOR activation [ 14 ] , therefore advancing tumour patterned advance. In a familial analysis of patients with esophageal malignant neoplastic disease, Akt mutants were associated with an increased hazard of return after chemotherapy, and mutants to the phosphatase and tensin homolog ( PTEN ) , a negative regulator of PI3K/Akt, were associated with a reduced hazard of return, perchance due to increased PTEN look [ 15 ] . Mutants to PI3K hold besides been noted [ 16 ] . Regardless of the mechanism of deviant mTOR activation, presymptomatic surveies suggest that tumours with mutants in the mTOR tract are unambiguously susceptible to mTOR inhibitor therapy [ ] . It has been demonstrated that Akt, mTOR, and S6K1 are phosphorylated ( i.e. , activated ) in most types of malignant neoplastic disease. Activation of PI3K/Akt/mTOR is indispensable for the proliferation and endurance of malignances. The suppression of mTOR signaling can abrogate the cellular response to the activation of growing factor receptors. The mTOR tract has often been shown to be dysregulated in many types of malignant neoplastic diseases, including stomachic malignant neoplastic diseases [ 19 ] .
Preclinical informations on mTOR suppression in human stomachic malignant neoplastic disease
Samples from stomachic malignant neoplastic disease patients demonstrate mTOR look and activation, and phosphorylated mTOR ( p-mTOR ) is positively correlated with tumour patterned advance and hapless endurance in patients with stomachic malignant neoplastic disease. In 1072 stomachic malignant neoplastic disease specimens, the entire look degrees of mTOR and p-mTOR were analyzed utilizing immunohistochemistry and confirmed by Western smudge analysis. It was found that p-mTOR overexpression is correlated with entire mTOR overexpression and p-mTOR overexpression was indicated as an independent predictive factor [ 20 ] . In pT2b stomachic malignant neoplastic disease, p-mTOR look is associated with extended lymph node metastasis and hapless disease-free endurance [ 21 ] . In 109 patients with stomachic glandular cancer, the look degrees of p-mTOR and phosphorylated Akt ( p-Akt ) in the cytol and karyon were analyzed, and cytoplasmatic p-mTOR look was associated with significantly poorer relapse-free endurance and OS [ 22 ] .
Preclinical surveies performed utilizing stomachic malignant neoplastic disease mouse theoretical accounts besides suggest that mTOR is a possible curative mark. Everolimus reduced peritoneal airing in a stomachic malignant neoplastic disease cell line in a mouse theoretical account [ 23 ] . In combination with cyclophosphamide, everolimus exhibited interactive antitumor activity in stomachic malignant neoplastic disease heterografts [ 24 ] .A Rapamycin has besides been shown to heighten the cytotoxic effects of 5-FU, docetaxel, and cisplatin in presymptomatic theoretical accounts [ 25 ] .
Clinical tests on the efficaciousness of everolimus in patients with metastatic gastric malignant neoplastic disease
Everolimus is the lone mTOR inhibitor that has been investigated in clinical tests utilizing patients with stomachic malignant neoplastic disease. In a stage I dose-escalation trail [ 26 ] , RAD001 was continuously administered one time daily over the class of a 28-day rhythm. Nine Nipponese patients were recruited in a 3 A- 3 design survey, where three consecutive cohorts were treated with RAD001 at a dosage of 2.5, 5.0, or 10.0 mg/day, severally. Of seven patients whose tumour response was assessed, tumour shrinking was observed in two patients treated with 10.0 mg/day RAD001. The most common inauspicious effects ( AEs ) , irrespective of class, included thrombopenia ( 56 % ) , leucopenia ( 33 % ) , anorexia ( 44 % ) , and roseola ( 44 % ) . Grade 3 and 4 toxicities were merely noted at the dosage of 10 mg/day ; toxicity was non noted in the first rhythm but did non measure up as DLTs. One patient with advanced esophageal carcinoma developed rate 3 weariness and stomatitis. One patient with colorectal malignant neoplastic disease developed rate 3 hyperglycaemia.
The efficaciousness of everolimus is supported by the consequences of a stage II clinical test. This was an open-label, single-arm, multicenter, proof-of-concept survey that enrolled patients with advanced stomachic glandular cancer who had received one or two anterior chemotherapy regimens [ 27 ] . All patients were treated with 10 mg/day unwritten everolimus that was administered over the class of a uninterrupted 28-day rhythm. The primary survey end point was the disease control rate ( DCR ) . Among 53 evaluated patients, no complete or partial response was observed, but a lessening in tumour size from baseline was observed in 45 % of patients. DCR was 56.0 % , and the average PFS was 2.7 months. After a average follow-up clip of 9.6 months, the average OS was 10.1 months. The major AEs of everolimus were largely grade 1 or 2 in badness. The most common AEs included stomatitis ( 73.6 % ) , anorexia ( 52.8 % ) , weariness ( 50.9 % ) , roseola ( 45.3 % ) , sickness ( 32.1 % ) , peripheral hydrops ( 22.6 % ) , diarrhoea ( 20.8 % ) , and pruritus ( 18.9 % ) . Grade 3 AEs presented in 20 patients ( 37.7 % ) , including anaemia ( 11.3 % ) , hyponatremia ( 9.4 % ) , increased I?-glutamyltransferase ( 7.5 % ) , lymphocytopenia ( 7.5 % ) , weariness ( 5.7 % ) , stomatitis ( 5.7 % ) , anorexia ( 5.7 % ) , unnatural hepatic map ( 5.7 % ) , hyperglycaemia ( 3.8 % ) , hypophosphatemia ( 3.8 % ) , and intestinal obstruction ( 3.8 % ) . Grade 4 AEs were suspected as being intervention related and were reported in four patients ; one patient presented with tumour bleeding, increased I?-glutamyltransferase, lymphocytopenia, and intellectual infarction, severally. This clinical test indicates that everolimus monotherapy is a promising intervention for patients with antecedently treated advanced stomachic malignant neoplastic disease.
Phase III clinical test informations on the effectivity of everolimus for the intervention of stomachic malignant neoplastic disease are now available. The consequences were presented at the 2012 ASCO GI meeting, including the consequences of GRANITE-1, a randomized, double-blind, multicenter, stage III survey [ 28 ] . Patients with confirmed advanced gastric malignant neoplastic disease and disease patterned advance after one or two lines of systemic chemotherapy were randomized ( in a 2:1 ratio ) and received 10 mg/day unwritten everolimus plus best supportive attention ( BSC ) or placebo ( PBO ) plus BSC. A sum of 656 patients from 23 states were enrolled from July 2009 through December 2010 ; 439 patients received everolimus and 217 received PBO. The bulk of these patients were work forces ( 73.6 % ) in Asia ( 55.3 % ) , and 47.7 % had received one old line of chemotherapy and 50.6 % had undergone a gastrectomy. The average OS was 5.39 months for everolimus versus 4.34 months for PBO. The Median PFS, as assessed by the local research worker, was 1.68 months for everolimus versus 1.41 months for PBO. The 6-month PFS estimations were 12.0 % for EVE and 4.3 % for PBO. The OS and PFS consequences were consistent across the assorted subgroups. The nonsubjective response rate ( ORR ) was 4.5 % for everolimus versus 2.1 % for PBO. The most common class 3/4 AEs included anaemia ( 16.0 % for everolimus vs. 12.6 % for PBO ) , decreased appetency ( 11.0 % vs. 5.6 % ) , and weariness ( 7.8 % vs. 5.1 % ) . These consequences indicate that everolimus monotherapy does non significantly better OS in patients with advanced stomachic malignant neoplastic disease who have been antecedently treated with one or two lines of systemic chemotherapy.
mTOR/PI3K double inhibitors
It is now recognized that mTOR inhibitors do non sufficiently accomplish robust anticancer effects, at least when these agents are employed in monotherapy regimens, nevertheless mTOR/PI3K double inhibitors ( TPdIs ) have been developed. Two presymptomatic research surveies have evaluated the in vivo antitumor activities of mTOR/PI3K inhibitors against stomachic malignant neoplastic disease cells. In heterograft mouse theoretical accounts, BEZ235 merely showed a important dose-dependent antitumor response in NCI-N87 xenografts. BEZ235 did non impair tumour growing despite mTOR/PI3K target ordinance in other heterograft mouse theoretical accounts [ 29 ] . PI103-enhanced 5-FU sensitiveness was identified in three out of five gastric cell lines, and PIK3CA mutants were identified as potentially utile biomarkers for foretelling synergy [ 30 ] .
Everolimus has demonstrated promising consequences in stage II clinical tests, but the consequences were a small dissatisfactory in the GRANITE-1 test for handling patients with advanced stomachic malignant neoplastic disease. It is necessary to place which patients may profit from mTOR inhibitor therapy in order to better clinical results. Future surveies are needed to set up elaborate molecular profiles that can foretell sensitiveness to mTOR inhibitor therapy. Patient choice based on molecular events known to be associated with mTOR activation, such as the overexpression of PI3K/Akt and assorted growing factor receptors such as HER2 and insulin-like growing factor receptors, every bit good as mutants to PI3K and mutations/amplifications of Akt or the downregulation of PTEN, may stand for an appropriate manner to place populations that are more likely to show important clinical benefits from mTOR inhibitors.
Another manner to better the efficaciousness of mTOR inhibitors is to unite them with other cytotoxic agents. In mouse theoretical accounts, mTOR inhibitors are able to sensitise malignant neoplastic disease cells to chemotherapy. Ongoing clinical surveies are presently measuring everolimus in combination with cytotoxic agents in patients with stomachic malignant neoplastic disease ( Table 1 ; besides, delight see http: //www.clinicaltrials.gov ) .
Presently, the NCT01248403 ( AIO-STO-0111 RADPAC ) test is measuring the usage of paclitaxel monotherapy ( with or without everolimus ) for the intervention of progressive advanced gastric malignant neoplastic disease after one or two anterior chemotherapy regimens. This survey is being conducted by the German Arbeitsgemeinschaft Internistische Onkologie with a mark registration of 480 patients and OS as the primary end point. This on-going test will measure the efficaciousness of combination mTOR inhibitors with chemotherapy.
In order to more efficaciously suppress the mTOR tract, it is of import to better understand the function of mTOR-dependent webs in the patterned advance of stomachic malignant neoplastic disease. This cognition will supply the foundation for bring forthing fresh schemes that will better the curative success rate. Second-generation mTOR inhibitors that target both mTORC1 and mTORC2 ( TORKinhibs ) have demonstrated improved efficaciousness in early surveies and appear to hold the possible to besiege the rapalog opposition that is present in some types of malignant neoplastic diseases [ 31 ] . Future surveies that set up the optimum mTOR inhibitor-based drug combinations that target the indispensable opposition mechanisms are assuring and will hopefully interpret into direct patient benefits.
This survey was supported by National Key Technology R & A ; D Program ( 2011BAZ03191 ) , and National “ Twelfth Five-Year ” particular scientific discipline and engineering major undertakings ( 2011ZX09307-001-05 ) .
Table 1. Ongoing clinical tests measuring everolimus in combination with cytotoxic agents in patients with stomachic malignant neoplastic disease.
Primary end point
Key eligibility standards
Treatment arm ( s )
Progressive advanced stomachic malignant neoplastic disease after two anterior chemotherapy regimens
Everolimus + capecitabine
stomachic malignant neoplastic disease
Everolimus + cisplatin + 5-FU + leucovorin
stomachic malignant neoplastic disease
Everolimus + paclitaxel + carboplatin
Progressive advanced stomachic malignant neoplastic disease progressing after one or two anterior chemotherapy regimens
Everolimus + paclitaxel vs. paclitaxel + placebo
Abbreviations: BSC, best supportive attention ; FU, fluorouracil ; MTD, upper limit tolerated dose ; ORR, nonsubjective response rate ; OS, overall endurance.