<title>Introduction</title> <p>The phosphatidylinositol 3-kinase (PI3K) enzyme family plays key roles in the transduction of metabolic, proliferative and survival signals induced by insulin and other growth factors ##REF##12040186##[1]##. Activated PI3K generates phosphatidylinositol 3,4,5-triphosphate (PIP3), which binds to the pleckstrin-homology domain (PH-domain) of multiple proteins and thus regulates their activity. PI3K signaling is activated by growth factor receptors and regulated and terminated by multiple factors including dephosphorylation of the 3′phosphate of PIP3 by the phosphatase PTEN ##REF##9861013##[2]##. Deregulation of the PI3K signaling pathway is a hallmark of human cancer, perhaps occurring in a majority of tumors ##REF##12094235##[3]##. Mutation, amplification or overexpression of receptor tyrosine kinases occurs in many cancers ##REF##15864276##[4]##, ##REF##15118125##[5]## and activation of PI3K has been shown to be necessary for their ability to induce transformation. Activating mutations of the gene that encodes the catalytic subunit of class 1A PI3K (<italic>PIK3CA</italic>) have been identified in significant numbers of breast, colorectal and other tumors ##REF##15016963##[6]##, ##REF##15254419##[7]##. <italic>PTEN</italic> is a tumor suppressor gene that is mutationally inactivated in many tumors and inhibited by post-translational modification or decreased expression in others ##REF##9072974##[8]##, ##REF##15287024##[9]##, ##REF##17218260##[10]##.</p> <p>The mechanisms through which activated PI3K mediates the transformed phenotype are incompletely understood and probably involve multiple targets. The most well-characterized are the three members of the Akt protein kinase family. Akt subserves many of the metabolic and proliferative effects of RTK-PI3K signaling. It phosphorylates several transcription factors, including members of the Foxo family and inhibits their functions. Akt family members also affect proliferation and survival by phosphorylating a variety of other substrates that regulate Cap-dependent translation, apoptosis and other processes ##REF##17604717##[11]##. Uncontrolled activation of Akt is common in tumor cells with PI3K activation and is thought to play an important role in maintaining their proliferation, preventing apoptosis, and supporting processes required for the metastatic phenotype ##REF##12094235##[3]##.</p> <p>In breast cancer, Akt is activated by a variety of mechanisms that correlate with specific biologic subsets of the disease. Thus, activating mutations of <italic>PIK3CA</italic> are common in breast cancers that express estrogen receptor ##REF##15805248##[12]##. <italic>HER2</italic> amplification defines a second subtype of breast cancer in which PI3K/Akt signaling is driven by active HER2/HER3 heterodimers ##REF##9677338##[13]##, ##REF##12853564##[14]##. In a third subset, ‘triple negative’ cancers that express neither hormone receptors nor high levels of HER2, <italic>PTEN</italic> is mutated rarely, but a transcriptional profile associated with decreased PTEN function is commonly expressed ##REF##17452630##[15]##.</p> <p>Akt is a retroviral oncogene and has oncogenic properties in model systems ##REF##12799464##[16]##. <italic>Akt</italic> amplification has been demonstrated in human ovarian cancer ##REF##1409633##[17]## and, recently, <italic>Akt1</italic> mutations were identified in human cancers ##REF##17611497##[18]##. These findings suggest that Akt could be an important therapeutic target for human cancer. Many attempts have been made to develop ATP-competitive inhibitors of Akt kinase. Thus far, it has been difficult to generate compounds with sufficient specificity, potency and in vivo activity ##REF##17667591##[19]##, ##REF##18288939##[20]##. Some classes of compounds have had what has been felt to be unacceptable toxicity ##REF##17667591##[19]##, ##REF##18288939##[20]##, perhaps unsurprising for inhibitors of a protein with such pleiotypic and central regulatory functions.</p> <p>An alternative approach for achieving selectivity in kinase inhibitors is the development of antagonists that act allosterically at sites distant from the catalytic domain ##REF##18288939##[20]##. Such inhibitors could be more specific and potentially less toxic as a result of fewer off-target activities. A family of Akt inhibitors that selectively depend on the PH-domain of Akt for their inhibitory activity has been developed ##REF##18479914##[21]##. We have now used one of these, a potent and specific inhibitor of Akt1 and Akt2 (AKTi-1/2), to study the role of Akt activation in breast cancers and to explore whether Akt inhibition is feasible as a therapeutic strategy.</p> <p>Our data shows that tumors with <italic>HER2</italic> amplification or <italic>PIK3CA</italic> mutation are selectively dependent on Akt signaling compared to tumors in which the pathway is not mutationally activated. Moreover, the allosteric Akt inhibitor effectively inhibits Akt signaling in tumors in vivo and completely suppresses their growth, without gross toxicity to the host. The results show that Akt inhibition represents a promising strategy for the treatment of the breast cancers that are dependent on this pathway.</p>
<title>Materials and Methods</title> <title>Cell culture and reagents</title> <p>Human breast cancer cell lines were obtained from the American Type Culture Collection (Manassas, VA) and maintained in a 1∶1 mixture of DME:F12 medium supplemented with 4 mM glutamine, 100 units/ml each of penicillin and streptomycin, and 10% heat-inactivated fetal bovine serum, and incubated at 37°C in 5% CO<sub>2</sub>. HCC1143, HCC1419, HCC1428, HCC1500 and HCC1806 were grown in RPMI 1640 with similar supplements. The Herceptin-resistant breast cancer cell line BT474-EII and the Fo5 tumors were obtained from Genentech (South San Francisco, CA). The AKTi-1/2 ##REF##18479914##[21]## was obtained from Merck (Whitehouse Station, NJ).</p> <title>Cell proliferation assay</title> <p>The effect of the drug on cell proliferation was determined using a CellTiter-Glo Luminescent Cell Viability Assay kit (Promega, Madison, WI), which is based on quantification of the cellular ATP level. Cells were plated in 96-well plates at a density of 2,000–5,000 cells in triplicates. The following day, cells were treated with a range of drug concentrations prepared by serial dilution. After 3–5 days of treatment, 100 µl of prepared reagent was added to each well. The contents of the wells were mixed on a plate shaker for 2 h, and then luminescence was measured by an Analyst AD (Molecular Devices, Sunnyvale, CA).</p> <title>Analysis of cell cycle and apoptosis</title> <p>Cells were plated in 10 cm dishes and the following day cells were treated with drug or vehicle (DMSO) for the indicated times. Both adherent and floating cells were harvested, and the cell nuclei were prepared by the method of Nusse ##REF##2272246##[39]##, and cell cycle distribution (G1, S, and G2/M) and proportion of apoptotic cells (sub-G1) were determined by flow cytometric analysis of DNA content using red fluorescence of 488 nm excited ethidium bromide-stained nuclei. The cell cycle distribution and the fraction of apoptotic cells were gated differently and determined separately in order to more easily achieve accurate quantitation of each parameter.</p> <title>Western blot analysis</title> <p>Cells were washed with PBS once, disrupted on ice for 30 min in NP-40 or RIPA lysis buffer as described ##REF##16226704##[28]## and cleared by centrifugation. Protein concentration was determined with BCA reagent (Pierce, Rockford, IL). Equal amounts of protein (10–50 µg) in cell lysates were separated by SDS-PAGE, transferred to membranes, immunoblotted with specific primary and secondary antibodies and detected by chemiluminescence with the ECL detection reagents (Amersham Biosciences, Piscataway, NJ). Antibodies for p-Akt(S473), p-Akt(T308), p-GSK3α(S21), p-GSK3β(S9), p-FOXO1(T24)/FOXO3(T32), p-p70S6K(T389), p-S6(S235/236), p-S6(S240/244), p-4EBP1(T37/46), p-4EBP1(S65), p-4EBP1(T70), Akt1, Akt2, pan-Akt, p-Rb(S780), p27, activated (cleaved) caspase-3 and cleaved PARP were from Cell Signaling Technology (Beverly, MA). Akt3 antibody was from Upstate Biotechnology (Waltham, MA). PTEN, Cyclin D1, Cyclin D2 and Cyclin D3 antibodies were from Santa Cruz Biotechnology (Santa Cruz, CA). The HER2 (Ab-15) antibody was from Neomarkers (Fremont, CA); EGFR antibody was from BD Biosciences (San Jose, CA) and β-actin antibody was from Sigma (St. Louis, MO).</p> <title>Animal studies</title> <p>Six-week-old nu/nu athymic female mice (NCI-Frederick Cancer Center) were maintained in pressurized ventilated cages. Experiments were carried out under an IACUC approved protocol and institutional guidelines for the proper and humane use of animals in research were followed. Tumors were generated by transplanting 0.5–1.0×10<sup>7</sup> tumor cells in a 1∶1 mixture of media and Matrigel (BD Biosciences) into the right flank (200 µl/mouse). For the BT474 and MCF7 models, 17β-estradiol pellets (0.72 mg/pellet) (Innovative Research of America, Sarasota, FL) were inserted subcutaneously 3 days before tumor cell inoculation. For the Fo5 tumor model, tumors were serially passaged in nude mice and the tumors with 2×2 mm size were implanted subcutaneously. Prior to initiation of treatment, mice were randomized to receive the AKTi-1/2 at a dose of 50 and 100 mg/kg or vehicle only as control. The AKTi-1/2 was formulated in 25% hydroxypropyl β-cyclodextrin (pH 4–5), and administered subcutaneously. Mice were killed by CO<sub>2</sub> euthanasia. The average tumor diameter (two perpendicular axes of the tumor were measured) was measured in control and treated groups using a caliper. The data are expressed as the increase or decrease in tumor volume in mm<sup>3</sup> (mm<sup>3</sup> = π/6×(larger diameter)×(smaller diameter)<sup>2</sup>). To prepare lysates, tumor tissue was homogenized in 2% SDS lysis buffer and then processed for Western blotting as described above. For immunohistochemical studies, xenograft tumors were fixed overnight in paraformaldehyde followed by dehydration in graded ethanol and embedding in paraffin. 8 µm sections of tissue were prepared for hematoxylin and eosin (H&amp;E), Ki-67 and p-Akt(S473) staining. TUNEL assay was performed using the In Situ Cell Death Detection Kit (Roche Applied Science, Indianapolis, IN) according to the manufacturer's instructions.</p> <title>Statistical analysis</title> <p>Results are mean values±standard error. <italic>P</italic>-values are given in the figure legends, and values of <italic>P</italic> &gt; 0.05 were considered not to be significant. Statistical analyses were performed by an unpaired, two-tailed Student <italic>t</italic>-test.</p>
<title>Results</title> <title>AKTi-1/2 is a potent and selective inhibitor of Akt1 and Akt2</title> <p>A potent and selective inhibitor of Akt1 and Akt2 (AKTi-1/2; naphthyridinone) was prepared through optimization of leads identified by a high-throughput screen for inhibitors of purified activated Akt1, Akt2 and Akt3 kinases ##REF##18479914##[21]##. As is the case for the previously described compounds in this class ##REF##15456405##[22]##, ##REF##15713898##[23]##, AKTi-1/2 is not competitive with ATP and its inhibitory activity requires the presence of the PH domain ##REF##18479914##[21]##. The compound selectively inhibited Akt1 and Akt2 with EC<sub>50</sub> values of 3.5 nM and 42.1 nM, respectively. It was 45-fold less active against Akt3 (EC<sub>50</sub> 1.9 µM) and was essentially inactive against closely related AGC family kinases (PKA, PKC, SGK, GSK, PDK1) at concentrations as high as 10 µM ##REF##18479914##[21]##. In screens against total of 169 unique kinases, only 7 enzymes were inhibited more than 50% at 10 µM, none of which are members of the PI3K/Akt/mTOR signaling cascade (unpublished data). Thus, in vitro assays suggest that this compound is a very specific inhibitor of Akt1 and Akt2.</p> <title>Breast cancer cells with <italic>HER2</italic> amplification or <italic>PI3K</italic> mutation are sensitive to Akt inhibition</title> <p>In a panel of breast cancer cell lines, those with <italic>PIK3CA</italic> mutation ##REF##15805248##[12]##, <italic>HER2</italic> amplification ##REF##14758095##[24]## or undetectable levels of PTEN expression ##REF##9072974##[8]##, ##REF##10582703##[25]## all displayed Akt activation as assessed by elevated levels of Akt phosphorylation on threonine 308 and serine 473 (##FIG##0##Figure 1A##). In contrast, in five cell lines in which PTEN was expressed, HER2 levels were low, and <italic>PIK3CA</italic> was wild-type, levels of Akt phosphorylation were low (##FIG##0##Figure 1A## and ##SUPPL##0##Figure S1##). Akt1 and Akt2 proteins were expressed in all of the cell lines at varying levels; Akt3, which is preferentially expressed in brain and skin ##REF##15930105##[26]##, ##REF##15986137##[27]##, was expressed only in two cell lines (MDA-MB-468 and MDA-MB-231) in the panel. AKTi-1/2 effectively and completely inhibited Akt phosphorylation at 0.5–1 µM in each of the cell lines in tissue culture except MDA-MB-468, in which phosphorylation was inhibited 60% at 0.5 µM, but 5–10 µM was required for maximal inhibition (##FIG##0##Figure 1B##).</p> <p>The breast cancer cell lines with <italic>PI3KCA</italic> mutation or <italic>HER2</italic> amplification were uniformly sensitive to AKTi-1/2 with IC<sub>50</sub> of 0.1–0.88 µM (##FIG##0##Figure 1A## and ##SUPPL##0##Figure S1##). In contrast, the five cell lines without aberrant activation of PI3K signaling were all insensitive to the drug, even at concentrations greater than 10 µM, far exceeding those required for inhibition of Akt phosphorylation. Thus, tumor cells in which a transforming event dysregulates Akt signaling are hypersensitive, or ‘addicted’, to Akt inhibition compared to tumor cells in which regulation of the pathway is not impaired.</p> <p>The situation in tumors with PTEN-deficiency is more complex. ZR-75-1, a PTEN-deficient cell, is also sensitive to the inhibitor (IC<sub>50</sub> of 0.1 µM). In contrast, MDA-MB-468, a PTEN-deficient cell with high levels of EGFR, is not (##FIG##0##Figure 1A##). This may be explained by the high level expression of Akt3 in this tumor cell. However, we have previously shown that PTEN-negative tumors with elevated EGFR/MEK/ERK signaling are refractory to inhibition of PI3K/Akt signaling alone, but sensitive to combined inhibition of both pathways ##REF##16226704##[28]##.</p> <title>AKTi-1/2 inhibits Akt signaling and causes G1 arrest and apoptosis</title> <p>The marked sensitivity of <italic>PIK3CA</italic>-mutated and/or HER2-overexpressing breast cancer cells to AKTi-1/2 allowed us to examine the functional consequences of Akt blockade in these cells. The effects of AKTi-1/2 on Akt signaling were compared in T47D, a tumor cell with the <italic>PIK3CA</italic> H1047R mutation and in HCC1806, a tumor cell with normal AKT signaling that is insensitive to the drug (##FIG##1##Figure 2A##). In both cells, 1 µM AKTi-1/2 effectively inhibited Akt phosphorylation and the phosphorylation of the Akt substrate Foxo3a and GSK3β as well as phosphorylation of the downstream target of Akt-TORC1 signaling, p70S6K. In T47D, the phosphorylation of other downstream targets of Akt signaling, S6 and 4EBP1 were also inhibited. Similar results were obtained in BT474 and MDA-MB-453 cell lines with coexistent HER2 overexpression and <italic>PIK3CA</italic> mutations (##FIG##2##Figure 3A##).</p> <p>Inhibition of Akt signaling in T47D was associated with loss of D-cyclin expression, induction of p27 and loss of Rb phosphorylation. In contrast, in HCC1806, inhibition of Akt signaling resulted in inhibition of neither both S6 and 4EBP1 phosphorylation nor in changes in D-cyclin or p27 expression and Rb phosphorylation <bold>(</bold>
##FIG##1##Figure 2A##
<bold>).</bold> It is likely that in this cell, in which Akt signaling is not activated by mutation, other pathways are responsible for S6 and 4EBP1 phosphorylation and deregulation of growth. As expected from these data, T47D cells treated with 1 µM AKTi-1/2 accumulated in the G1 phase of the cell cycle with concomitant loss of the fraction in S-phase, while Akt inhibition had no effect on the cell cycle of HCC1806 (##FIG##1##Figure 2B##).</p> <p>The data support the conclusion that activation of PI3K/Akt signaling by HER2/HER3 signaling plays a key role in mediating the transformed phenotype in breast cancers with <italic>HER2</italic> amplification ##REF##9677338##[13]##, ##REF##12853564##[14]##. Furthermore, these tumors often harbor coexistent <italic>PIK3CA</italic> mutations ##REF##15805248##[12]##, further suggesting the importance of the pathway. In ##FIG##2##Figure 3##, the effects of inhibition of Akt activity with AKTi-1/2 were examined in more detail in tumors with HER2-overexpression. In a panel of five cell lines, Akt phosphorylation, phosphorylation of Akt substrates such as GSK3α and members of the Foxo family, and phosphorylation of downstream components of the pathway were inhibited (##FIG##2##Figure 3A## and unpublished data). All of these cell lines underwent G1 arrest which was maximal at 24 after exposure to the compound (##FIG##2##Figure 3B## and unpublished data). G1 arrest was followed by marked induction of apoptosis at 48–72 hours as assessed by increased sub-G1 fraction or by increased levels of cleaved PARP in cell lines with <italic>HER2</italic> amplification with or without coexistent <italic>PIK3CA</italic> mutation (SKBr3, MDA-MB-453, UACC-893, MDA-MB-361 and BT474) (##FIG##2##Figure 3A and 3C## and unpublished data). Thus, these cells are dependent on Akt signaling for both proliferation and survival.</p> <title>AKTi-1/2 effectively inhibits Akt signaling in vivo and has profound anti-tumor activity</title> <p>The in vitro data support the ideas that the dysregulation of PI3K/Akt that is commonly found in human tumors is likely to be essential for maintenance of the transformed phenotype and that the pathway is therefore an appealing therapeutic target. However, because PI3K/Akt signaling has many important functions, including the maintenance of glucose homeostasis, it is not clear that its inhibition would be tolerated in vivo. To determine whether tolerable doses of AKTi-1/2 could effectively inhibit Akt signaling in tumors in vivo and inhibit their growth, mice harboring BT474 xenografts were treated with the drug. Unlike UACC-893, MDA-MB-453 and MDA-MB-361, BT474 cells are highly tumorigenic when injected into nude mice. BT474 breast cancer cells overexpress HER2, harbor <italic>PIK3CA</italic> K111N mutation ##REF##15805248##[12]##, and respond to AKTi-1/2 in tissue culture in a fashion similar to the three <italic>PIK3CA</italic>-mutated and HER2-overexpressing breast cancer cells (##FIG##0##Figures 1## and ##FIG##2##3##).</p> <p>Akt is a key downstream mediator of the metabolic effects of insulin and hyperglycemia is a known side-effect of Akt inhibitors ##REF##11387480##[29]##. AKTi-1/2 treatment of mice at a dose of 100 mg/kg caused transient hyperglycemia that peaked 2 hours after drug administration and that was associated with a transient hyperinsulinemia, both of which resolved by 6–8 hours (manuscript in preparation). Mice treated with 100 mg/kg AKTi-1/2 for 5 consecutive days each week for 4–6 weeks demonstrated no gross toxicity or weight loss (##SUPPL##1##Figure S2## and unpublished data). At this dose, Akt phosphorylation fell rapidly within 1 hour of drug administration and remained depressed for at least 12 hours (##FIG##3##Figure 4A and 4C##). Furthermore, inhibition of Akt was accompanied by marked dephosphorylation of Akt substrates and its downstream signaling targets (GSK3, Foxo, p70S6K, S6 and 4EBP1) (##FIG##3##Figure 4A##). Chronic treatment with AKTi-1/2 caused a dose-dependent inhibition of the growth of BT474 xenografts (##FIG##3##Figure 4B##); 100 mg/kg completely suppressed the growth of the tumor with modest tumor regression, whereas 50 mg/kg only delayed tumor growth (##FIG##3##Figure 4B##; <italic>P</italic>&lt;0.005 for 50 versus 100 mg/kg, and 50 and 100 mg/kg versus control). Growth suppression in vivo was associated with loss of D-cyclin expression, hypophosphorylation of Rb, a profound decrease in cell proliferation as measured by Ki67, and induction of apoptosis as measured by TUNEL and cleaved PARP (##FIG##3##Figure 4A and 4C##). Similarly, AKTi-1/2 also effectively suppressed the growth of <italic>PIK3CA</italic>(E545K)-mutated MCF7 xenografts (##FIG##3##Figure 4D##). Together, these data show that chronic inhibition of Akt1 and Akt2 kinase can be achieved in mice, at levels sufficient to recapitulate the Akt-dependence of breast cancer cells with <italic>HER2</italic> amplification or <italic>PIK3CA</italic> mutation seen <italic>in vitro</italic>.</p> <title>Herceptin-resistant breast cancer models are sensitive to Akt inhibition</title> <p>The anti-HER2 antibody Herceptin is effective for the treatment of breast tumors with <italic>HER2</italic> amplification ##REF##11248153##[30]##, but patients with metastatic disease invariably develop resistance to the antibody ##REF##10561337##[31]##, ##REF##11821453##[32]##. The molecular mechanisms underlying resistance in patients are not well understood, but the anti-tumor activity of the HER kinase inhibitor lapatinib in this setting suggests that a significant proportion of Herceptin-resistant tumors remain HER2-dependent ##REF##18212337##[33]##. To test the hypothesis that these tumors might also remain dependent on Akt signaling, we used two experimental models of Herceptin-resistant breast cancer: the BT474-EII cell line model and the Fo5 xenograft model. BT474-EII was derived from estrogen independent BT474 xenograft tumors that were found to also be insensitive to Herceptin (Gail Phillips, Genentech, personal communication). Herceptin and AKTi-1/2 both significantly inhibited growth of HER2-overexpressing BT474 cells when compared with untreated controls (<italic>P</italic>&lt;0.001), with the latter being somewhat more effective (##FIG##4##Figure 5A##). In contrast, Herceptin had no effect on the growth of the resistant BT474:EII cell line (##FIG##4##Figure 5A##; <italic>P</italic> = 0.35), but the AKTi-1/2 was equally effective in the sensitive and resistant model (##FIG##4##Figure 5A##; <italic>P</italic>&lt;0.001 for AKTi-1/2 versus control). The Fo5 model was derived from a transgenic MMTV-human HER2-driven mouse after tumors maintained by serial transplantation progressed during continuous Herceptin treatment ##REF##15073130##[34]##. HER2 continues to be highly expressed in this tumor and binds to Herceptin (Gail Phillips, Genentech, personal communication). Fo5 tumors were resistant to the anti-tumor effects of Herceptin in vivo (##FIG##4##Figure 5B##; <italic>P</italic> = 0.31). Treatment with AKTi-1/2 at dose of 100 mg/kg effectively inhibited phosphorylation of Akt and its downstream targets (GSK3, Foxo, p70S6K, S6 and 4E-BP1) in the Fo5 tumors for at least 12 hours (##FIG##4##Figure 5D##). Daily treatment with AKTi-1/2 at this dose level for 4 weeks effectively inhibited growth of the Fo5 xenografts (##FIG##4##Figure 5C##; <italic>P</italic>&lt;0.001 for AKTi-1/2 versus control). Growth inhibition was associated with loss of D-cyclin expression, induction of p27 and activation of caspase-3 (##FIG##4##Figure 5D##). These results suggest that HER2-dependent tumor models with resistance to Herceptin remain dependent on Akt signaling and that Akt inhibitors may be useful in treating Herceptin-resistant breast cancer.</p>
<title>Discussion</title> <p>The PI3K/Akt signaling pathway is deregulated in the majority of human cancers and almost certainly plays an important pathogenic role in carcinogenesis and progression. Data from model systems suggest that inhibition of the pathway would both arrest growth and induce apoptosis or sensitize the cell to proapoptotic stimuli ##REF##12094235##[3]##. Thus, much effort has focused on developing novel anti-tumor agents that target this pathway. Up to now, however, it has been unclear whether the degree of pathway inhibition required for significant anti-tumor activity could be achieved without unacceptable toxicity. The PI3K/Akt pathway is an important regulator of many key physiologic processes and the development of several classes of Akt inhibitors has been halted because of toxicity ##REF##17667591##[19]##, ##REF##18288939##[20]##.</p> <p>We now show that a selective and potent allosteric inhibitor of Akt1 and Akt2 effectively inhibits Akt signaling in tumor bearing mice without gross toxicity or weight loss even when administered chronically (##FIG##3##Figures 4## and ##FIG##4##5## and S2). The drug potently inhibits Akt phosphorylation in breast cancers and inhibits the proliferation of breast tumors with <italic>PI3K</italic> mutation and/or <italic>HER2</italic> amplification but is ineffective in tumors in which <italic>PI3K</italic> and <italic>PTEN</italic> are wild-type and HER2 is expressed at normal levels. Considering that the drug treatment is well tolerated and that tumors in which the PI3K/Akt pathway is not mutationally activated are insensitive to the drug, the hypersensitivity of tumors with <italic>PI3K</italic> mutation or <italic>HER2</italic> amplification suggests that these tumors are ‘addicted’ to PI3K/Akt signaling.</p> <p>Oncogene addiction is a term given for the observation that inhibition of oncoprotein function in transformed cells often has much more profound effects than inhibition of the corresponding wild-type protein in the untransformed parental cell ##REF##12098689##[35]##. This phenomenon has been noted in many systems and may be a general property of oncoprotein-transformed cells, but the underlying mechanism is not clear ##REF##18079171##[36]##. One possibility is that survival of oncoprotein-transformed cells requires second mutations that prevent senescence or apoptosis. In the context of these other mutations, loss of function of the activated oncoprotein may be selectively toxic ##REF##18079171##[36]##. A second possibility is that the complex signaling network in normal cells is robust and relatively insensitive to loss of any single component of the network. Constitutive activation of the oncoprotein may feedback inhibit redundant pathways in the network and cause the cell to become hyperdependent on the single oncoprotein. This idea is consistent with the observation in ##FIG##1##Figures 2A## and ##FIG##2##3A##, which show that Akt inhibition is sufficient to inhibit key downstream signaling targets in tumors with <italic>PI3K</italic> mutation or <italic>HER2</italic> amplification, but not in those tumors with wild-type <italic>PI3K</italic> and normal HER2 expression.</p> <p>Akt (especially Akt2) is a key downstream mediator of the metabolic effects of insulin and hyperglycemia is a known side-effect of both PI3K and Akt inhibition ##REF##11387480##[29]##, ##REF##11916922##[37]##. The Akt1/Akt2 inhibitor caused transient and moderate hyperglycemia in mice that is associated with a transient hyperinsulinemia (manuscript in preparation). Why the drug is so effective at concentrations that cause only transient hyperglycemia, but no gross toxicity, is not entirely clear. It is possible that this is a manifestation of oncogene addiction; the levels of pathway inhibition achieved are sufficient to inhibit tumor growth, but without significant deleterious impact on normal physiology. The inhibitor is equipotent against human and mouse Akt in vitro and in vivo, ruling out selective inhibition of the Akt in the xenograft tumor (unpublished data). The greater selectivity of an allosteric inhibitor as compared to ATP-competitive inhibitors may also play a role: off-target effects are less likely. It is also possible that the relative sparing of Akt3 activity is responsible, although genetic models suggest that Akt2 is most responsible for maintaining glucose homeostasis ##REF##11387480##[29]##. The finding that the Akt1/Akt2 inhibitor can be given chronically to animals for months without weight loss suggests that the drug does not cause severe metabolic toxicity under these conditions, at least in mice. Whereas the physiological function of Akt3 is unclear at present, the avoidance of Akt3 inhibition may allow a greater therapeutic window for Akt1 and Akt2 inhibition.</p> <p>Whereas breast tumors with PI3K or HER2 deregulation may be addicted to Akt signaling, the situation is less clear for tumors with PTEN loss. ZR-75-1 (PTEN-negative, low EGFR) is extremely sensitive to AKTi-1/2, but MDA-MB-468 (PTEN-negative, high EGFR) is not. This could be due to a variety of factors, including residual Akt3 activity in the latter cell line (##FIG##0##Figure 1##). However, this is unlikely, since we have previously shown that MDA-MB-468 cells are not effectively inhibited when AKT activity is completely inhibited in response to induction of the expression of wild type PTEN ##REF##16226704##[28]##. Triple negative breast tumors often have evidence for decreased <italic>PTEN</italic> function together with elevated EGFR expression ##REF##17452630##[15]##. In MDA-MB-468 cells, inhibition of either EGFR/MEK/ERK or PI3K/Akt signaling alone has only modest effects on growth or survival ##REF##16226704##[28]##. These and other data suggest that, in the context of EGFR activation, the proliferation and survival of PTEN-negative cells are not dependent on PI3K/Akt signaling alone. However, inhibition of both pathways causes synergistic apoptosis and tumor regression in vivo ##REF##16226704##[28]##. These data suggest that combined inhibition of Akt and EGFR signaling may be a useful strategy for the treatment of the triple-negative basal subset of breast cancers.</p> <p>The results suggest that G1 progression and the survival of breast tumors with <italic>PI3K</italic> mutation and/or <italic>HER2</italic> amplification are dependent on Akt activation. Moreover, HER2-dependent tumor models selected for resistance to the anti-HER2 antibody Herceptin retain Akt-dependence and their sensitivity to the drug. These findings and the absence of gross toxicity in vivo suggest that Akt inhibition is a feasible therapeutic strategy for breast cancers in which PI3K/Akt signaling is dysregulated by mutation. Up to now, effective inhibition of Akt signaling in tumors could only be achieved with inhibitors of growth factor receptors (such as HER2) known to drive the pathway in particular tumors. No agent is currently available to directly and specifically inhibit Akt signaling in breast and other cancers with <italic>PI3K</italic> mutation or PTEN loss. Allosteric inhibition of Akt may be useful as a single modality in the treatment of these tumors, including those that have become resistant to HER2 inhibitors. Furthermore, it would be expected to sensitize tumors to induction of apoptosis by cytotoxic agents and, perhaps, in combination with EGFR inhibitors in triple-negative breast cancer and with drugs such as rapamycin that cause the feedback activation of PI3K/Akt signaling ##REF##16452206##[38]##.</p>
<p>Conceived and designed the experiments: QBS NR. Performed the experiments: QBS SC QY JL. Analyzed the data: QBS SC QY JL DDJ HEH NR. Contributed reagents/materials/analysis tools: KMH KRL DDJ HEH. Wrote the paper: QBS NR.</p> <title>Background</title> <p>Dysregulated PI3K/Akt signaling occurs commonly in breast cancers and is due to <italic>HER2</italic> amplification, <italic>PI3K</italic> mutation or PTEN inactivation. The objective of this study was to determine the role of Akt activation in breast cancer as a function of mechanism of activation and whether inhibition of Akt signaling is a feasible approach to therapy.</p> <title>Methodology/Principal Findings</title> <p>A selective allosteric inhibitor of Akt kinase was used to interrogate a panel of breast cancer cell lines characterized for genetic lesions that activate PI3K/Akt signaling: <italic>HER2</italic> amplification or <italic>PI3K</italic> or <italic>PTEN</italic> mutations in order to determine the biochemical and biologic consequences of inhibition of this pathway. A variety of molecular techniques and tissue culture and in vivo xenograft models revealed that tumors with mutational activation of Akt signaling were selectively dependent on the pathway. In sensitive cells, pathway inhibition resulted in D-cyclin loss, G1 arrest and induction of apoptosis, whereas cells without pathway activation were unaffected. Most importantly, the drug effectively inhibited Akt kinase and its downstream effectors in vivo and caused complete suppression of the growth of breast cancer xenografts with <italic>PI3K</italic> mutation or <italic>HER2</italic> amplification, including models of the latter selected for resistance to Herceptin. Furthermore, chronic administration of the drug was well-tolerated, causing only transient hyperglycemia without gross toxicity to the host despite the pleiotropic normal functions of Akt.</p> <title>Conclusions/Significance</title> <p>These data demonstrate that breast cancers with <italic>PI3K</italic> mutation or <italic>HER2</italic> amplification are selectively dependent on Akt signaling, and that effective inhibition of Akt in tumors is feasible and effective in vivo. These findings suggest that direct inhibition of Akt may represent a therapeutic strategy for breast and other cancers that are addicted to the pathway including tumors with resistant to Herceptin.</p>
<title>Supporting Information</title>
<p>We thank C. Cherrin and A. Watkins for providing dosing information for AKTi-1/2 mouse studies; M. Bilodeau and P. Sanderson for providing AKTi-1/2; M. Sliwkowski and G. Phillips for providing BT474-EII cells and Fo5 tumors for this study; D. Domingo for assistance with FACS and H. Zhao, W. Wong, J. Qiu and E. DeStanchina for assistance with nude mouse studies.</p>
<fig id="pone-0003065-g001" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0003065.g001</object-id><label>Figure 1</label><caption><title>PIK3CA-mutated or HER2-overexpressing breast cancer cells are highly sensitive to AKTi-1/2.</title><p>(A) Half-maximal growth inhibitory concentration (IC<sub>50</sub>) of AKTi-1/2 to a panel of breast cancer cell lines with wild-type (wt) and mutant (mut) <italic>PIK3CA</italic>, <italic>PTEN</italic> loss, <italic>HER2</italic> and <italic>EGFR</italic> amplification (amp). Growth inhibition assays and Western blot analysis for expression of EGFR, HER2, Akt1, Akt2, Akt3, pan-Akt, PTEN, β-actin and phosphorylated Akt at Ser473 and Thr308 were performed as described in <xref ref-type="sec" rid="s4">Materials and Methods</xref>. (B) Western blot analysis of Ser473 phosphorylated Akt and pan-Akt in cell lysates of the indicated breast cancer cells after treatment with various concentrations of AKTi-1/2 for 24 h.</p></caption></fig> <fig id="pone-0003065-g002" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0003065.g002</object-id><label>Figure 2</label><caption><title>AKTi-1/2 inhibits Akt signaling and causes G1 arrest in <italic>PIK3CA</italic>-mutant but not in <italic>PIK3CA</italic>-WT breast cancer cells.</title><p>(A) HCC1806 and T47D cells were treated with 1 µM AKTi-1/2 for the indicated times and cell lysates were immunoblotted with the indicated antibodies. (B) HCC1806 and T47D cells were treated with 1 µM AKTi-1/2 or DMSO for 24 h. The fractions of cells in G1, S and G2/M were determined by flow cytometry.</p></caption></fig> <fig id="pone-0003065-g003" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0003065.g003</object-id><label>Figure 3</label><caption><title>Akt inhibition induces G1 arrest and apoptosis in HER2-overexpressing with or without <italic>PIK3CA-</italic>mutated breast cancer cells.</title><p>(A) Akt inhibition causes dephosphorylation of its downstream targets (Foxo1, GSK3α, p70S6K, S6 and 4EBP1), loss of D-cyclin expression, and induction of p27 and PARP cleavage in BT474 and MDA-MB-453 cells treated with 1 µM AKTi-1/2. (B–C) Cells were analyzed by flow cytometry and gated differently to determine fractions of G1, S and G2/M (B) and the fraction of apoptotic cells (sub-G1) (C). (B) Cells were treated with 1 µM AKTi-1/2 or DMSO for 24 h. (C) Cells were treated with the indicated concentrations of AKTi-1/2 for 24 h, 48 h and 72 h. All error bars indicate standard error.</p></caption></fig> <fig id="pone-0003065-g004" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0003065.g004</object-id><label>Figure 4</label><caption><title>AKTi-1/2 effectively suppresses HER2-overexpressing and <italic>PIK3CA</italic>-mutated tumor growth in vivo.</title><p>(A) AKTi-1/2 inhibits Akt followed by dephosphorylation of its downstream targets (GSK3, Foxo, p70S6K, S6 and 4EBP1), loss of D-cyclin expression, Rb hypophosphrylation and induction of PARP cleavage in BT474 xenograft tumors. Mice with established BT474 xenografts were treated with AKTi-1/2 100 mg/kg for the indicated times. Tumor lysates were immunoblotted with the indicated antibodies. (B) Mice with established BT474 xenografts were treated with AKTi-1/2 50 and 100 mg/kg/day×5 days/week or vehicle only as control. The results represent the mean tumor volume±standard error (n = 5 mice per group) from two independent experiments. *, <italic>P</italic>&lt;0.005, 50 versus 100 mg/kg AKTi-1/2, and 50 and 100 mg/kg AKTi-1/2 versus control. (C) Representative immunohistochemistry fields of BT474 tumors from mice euthanized 6 h after the final treatment of AKTi-1/2 as in (B). Tumors were excised, and H&amp;E, phosphorylated Akt, Ki67 and TUNEL were assessed by immunohistochemic statining. (D) Mice with established MCF7 xenografts were treated with AKTi-1/2 50 and 100 mg/kg/day×5 days/week or vehicle only as control. The results represent the mean tumor volume±standard error (n = 5 mice per group) from two independent experiments. *, <italic>P</italic>&lt;0.005, 50 versus 100 mg/kg AKTi-1/2, and 50 and 100 mg/kg AKTi-1/2 versus control.</p></caption></fig> <fig id="pone-0003065-g005" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0003065.g005</object-id><label>Figure 5</label><caption><title>Herceptin-resistant HER2-overexpressing breast cancer cells retain Akt dependence.</title><p>(A) Both Herceptin-sensitive (BT474) and Herceptin-resistant (BT474:EII) HRE2-overexpressing breast cancer cells are sensitive to AKTi-1/2. Growth inhibition assays were performed as described in ##FIG##0##Figure 1A##. All error bars indicate standard error. *, <italic>P</italic>&lt;0.001, Herceptin and AKTi-1/2 versus control in BT474 cells. **, <italic>P</italic> = 0.35, Herceptin versus control in BT474:EII cells. ***, <italic>P</italic>&lt;0.001, AKTi-1/2 versus Herceptin and control in BT474:EII cells. (B) Herceptin has no anti-tumor effects on the Fo5 xenograft model. Mice with established Fo5 tumors were treated with Herceptin 20 mg/kg/day×2 days (Tue/Fri)/week or vehicle only as control. The results represent the mean tumor volume±standard error (n = 5 mice per group) from two independent experiments. *, <italic>P</italic> = 0.31, Herceptin versus control. (C) AKTi-1/2 demonstrates anti-tumor activity against the Herceptin-resistant Fo5 xenograft model. Mice with established Fo5 tumors were treated with AKTi-1/2 100 mg/kg/day×5 days/week or vehicle only as control. The results represent the mean tumor volume±standard error (n = 5 mice per group) from two independent experiments. *, <italic>P</italic>&lt;0.001, AKTi-1/2 versus control. (D) Mice with established Fo5 tumors were treated with AKTi-1/2 100 mg/kg for the indicated times. Tumor lysates were immunoblotted with the indicated antibodies.</p></caption></fig>
<supplementary-material content-type="local-data" id="pone.0003065.s001"><label>Figure S1</label><caption><p>Sensitivity of additional breast cancer cell lines with <italic>HER2</italic> amplification or wild-type <italic>PIK3CA</italic> and <italic>PTEN</italic> to AKTi-1/2. (A) Half-maximal growth inhibitory concentration (IC<sub>50</sub>) of AKTi-1/2 to HCC1143, HCC1428 and HCC1419 breast cancer cell lines. Growth inhibition assays were performed as described in ##FIG##0##Figure 1A##. (B) Western blot analysis for expression of EGFR, HER2, Akt1, Akt2, Akt3, total Akt, PTEN, β-actin and phosphorylated Akt at Ser473 and Thr308 in cell lysates of the indicated breast cancer cells. (C) Western blot analysis of Ser473 phosphorylated Akt and total Akt in cell lysates of the indicated breast cancer cells after treatment with various concentrations of AKTi-1/2 for 24 h.</p><p>(0.63 MB TIF)</p></caption></supplementary-material> <supplementary-material content-type="local-data" id="pone.0003065.s002"><label>Figure S2</label><caption><p>Chronic treatment with AKTi-1/2 does not cause weight loss in mice. Mice with established BT474 (A) and Fo5 (B) xenografts were treated with AKTi-1/2 50 and 100 mg/kg/day×5 days/week or vehicle only as control as described in ##FIG##3##Figures 4B## and ##FIG##4##5C##, respectively. The mouse body weight was measured in control and treated groups using a weighing scale. The results represent the mean body weight±standard error (n = 5 mice per group) from two independent experiments.</p><p>(0.14 MB TIF)</p></caption></supplementary-material>
<fn-group><fn fn-type="COI-statement"><p><bold>Competing Interests: </bold>KMH, KRL and HEH are employees of Merck &amp; Co. Inc. DDJ is an employee of GlaxoSmithKline Co. KMH, KRL, DDJ and HEH own Merck stock and stock options. KMH, DDJ and HEH are inventors on a patent application related to Akt inhibitors. All other authors have declared that no competing interests exist.</p></fn><fn fn-type="financial-disclosure"><p><bold>Funding: </bold>This work was supported by the NIH P01CA94060 (NR), the Breast Cancer Research Foundation (NR), and the Taub Foundation (NR). The funders played no role in the study design, execution, analysis or preparation of the paper.</p></fn></fn-group>
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PLoS One. 2008 Aug 26; 3(8):e3065