PI3K/Akt/mTOR pathway inhibitors enhance radiosensitivity in radioresistant prostate cancer cells through inducing apoptosis,reducing autophagy,suppressing NHEJ and HR repair pathways

The PI3K/Akt/mTOR pathway has a central role in cancer metastasis and radiotherapy. To develop effective therapeutics to improve radiosensitivity, understanding the possible pathways of radioresistance involved and the effects of a combination of the PI3K/Akt/mTOR inhibitors with radiotherapy on prostate cancer (CaP) radioresistant cells is needed. We found that compared with parent CaP cells, CaP-radioresistant cells demonstrated G0/G1 and S phase arrest, activation of cell cycle check point, autophagy and DNA repair pathway proteins, and inactivation of apoptotic proteins. We also demonstrated that compared with combination of single PI3K or mTOR inhibitors (BKM120 or Rapamycin) and radiation, low-dose of dual PI3K/mTOR inhibitors (BEZ235 or PI103) combined with radiation greatly improved treatment efficacy by repressing colony formation, inducing more apoptosis, leading to the arrest of the G2/M phase, increased double-strand break levels and less inactivation of cell cycle check point, autophagy and non-homologous end joining (NHEJ)/homologous recombination (HR) repair pathway proteins in CaP-radioresistant cells. This study describes the possible pathways associated with CaP radioresistance and demonstrates the putative mechanisms of the radiosensitization effect in CaP-resistant cells in the combination treatment. The findings from this study suggest that the combination of dual PI3K/Akt/mTOR inhibitors (BEZ235 or PI103) with radiotherapy is a promising modality for the treatment of CaP to overcome radioresistance.Radiotherapy (RT) is an important treatment option for prostate cancer (CaP) patients detected at early-stage or advanced-stage disease. Despite appropriate RT, up to 30% of treated high-risk CaP patients often experience local relapse and progression to metastatic disease.¹ One main reason for these failures following RT is because of radioresistance of a subpopulation of CaP clones within tumor. Therefore, radioresistance is a major challenge for the current CaP RT. RT dose escalation techniques have been used to counteract radioresistance. However, further dose escalations to 82 Gy in a phase II trial yielded significant acute and late morbidity.² Although three-dimensional conformal RT, intensity-modulated radiation therapy and image guided radiation therapy can increase the dose to local CaP and improve control rate,³ the clinical outcomes indicate that these advanced approaches cannot completely overcome radioresistance in CaP.⁴ Thus, modalities for improving the therapeutic efficacy of RT for locally confined or locally advanced CaP are warranted to increase sensitivity of radiation treatment in optimizing radiation effect and minimizing radioresistance influence.The PI3K/Akt/mTOR pathway is an important intracellular signaling pathway in regulating cell growth, survival, adhesion and migration, particularly during cancer progression, metastasis and radioresistance,^{5, 6, 7, 8} and is frequently activated in cancer cells. PI3K activates a number of downstream targets including the serine/threonine kinase Akt that activates mTOR. Many valuable inhibitors targeting one protein (single inhibitor) or two proteins at the same time (dual inhibitor) in the pathway have been developed in recent years.BKM120 is a single PI3K inhibitor by inhibiting p110α/β/δ/γ and often results in tumor suppression,⁹ and Rapamycin is a single mTOR inhibitor and has been used in clinical trials against various cancer types.¹⁰ NVP-BEZ235 (BEZ235) is a potent dual pan-class I PI3K and mTOR inhibitor that inhibits PI3K and mTOR kinase activity and has been used in preclinical studies in many cancers to demonstrate excellent anticancer effects.¹¹ In addition, this inhibitor was the first PI3K/mTOR dual inhibitor to enter clinical trials in 2006.¹² PI103 is another potent dual pan-class I PI3K and mTOR inhibitor and selectively targets DNA-PK, PI3K (p110α) and mTOR.¹³ No reports have been published to test them in CaP-radioresistant (RR) cells as radiosensitizers to improve radiosensitivity so far. The mechanisms of these inhibitors in combination with RT in the treatment of CaP are unclear.Under a low-dose radiation treatment, we have recently developed three CaP-RR cell lines with increased colony formation, invasion ability, sphere formation capability and enhanced epithelial–mesenchymal transition (EMT) and cancer stem cell (CSC) phenotypes and the activation of the PI3K/Akt/mTOR signaling pathway.⁷ In addition, we also found that the PI3K/Akt/mTOR pathway is closely linked with EMT and CSCs.⁷ Therefore, these CaP-RR cells, representative of the source of CaP recurrence after RT, may provide a very good model to mimic a clinical radioresistance condition as well as to examine the efficacy of these single and dual PI3K/Akt/mTOR inhibitors for their radiosensitization effects.Here, we investigated (1) whether cell cycle distribution, cell cycle check point proteins, apoptosis, autophagy and DNA repair pathways are involved in CaP radioresistance; (2) the link between radiosensitization effects and cell cycle distribution after treatment with a combination of dual inhibitors (BEZ235 and PI103) and single inhibitors (BKM120 and Rapamycin) with RT in CaP-RR cells in vitro; (3) whether cell death pathways (apoptosis and autophagy), DNA repair pathways (non-homologous end joining (NHEJ) and homologous recombination (HR)) are associated with CaP radiosensitivity after treatment with combination of dual or single inhibitors with RT.