Corrigendum: Targeting the PI3K/AKT/mTOR Pathway in Lung Cancer: Mechanisms and Therapeutic Targeting

Min Qiang ^1,2* Zhe Chen ¹ Hongyang Liu ^2* Junxue Dong ³ Kejian Gong ¹ Xinjun Zhang ^1* Peng Huo ⁴ Jingjun Zhu ⁵ Yifeng Shao ^6,7 Jinazun Ma ¹ Bowei Zhang ¹ Wei Liu ¹ Mingbo Tang ¹

• ¹ Department of Thoracic Surgery, First Affiliated Hospital of Jilin University, Changchun, Hebei Province, China
• ² College of Clinical Medicine, Jilin University, Changchun, Jilin Province, China
• ³ Department of Molecular Biology, Max Planck Institute for Infection Biology, Berlin, Baden-Württemberg, Germany
• ⁴ Laboratory of Infection Oncology, Institute of Clinical Molecular Biology, Christian-Albrechts-Universität zu Kiel and University Hospital Schleswig-Holstein,, Kiel, Schleswig-Holstein, Germany
• ⁵ Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine,, Seoul, Republic of Korea
• ⁶ Department of General Surgery, Beijing Children’s Hospital, Capital Medical University, Beijing, China
• ⁷ Peking Union Medical College Hospital (CAMS), Beijing, Beijing Municipality, China

The International Agency for Research on Cancer (IARC) predicts that in 2022, lung cancer (LC) will have the highest global rates of incidence at 12.4% and mortality at 18.7% (1). The 2022 report from the China National Cancer Center indicated that the number of LC cases in China will increase to 1,060,600, with 733,300 deaths. LC remains the leading cause of both incidence and mortality (Figure 1) (2). Smoking is the most significant risk factor that markedly increases the incidence of LC. In China, smoking is responsible for approximately 44.7% of reported LC deaths in males and 6.4% in females (3). Based on the morphological characteristics of LC cells, LC is classified into small-cell lung cancer (SCLC, approximately 15%) and non-small-cell lung cancer (NSCLC, approximately 85%) (4). SCLC, with its small cellular morphology, is distinguished by its rapid proliferative kinetics and propensity for swift metastasis to organs, such as the liver and brain, through lymphatic and hematogenous routes. Consequently, the prognosis of SCLC is poor, with a 5-year survival rate less than 7% (5). In contrast, the two predominant histological subtypes of NSCLC are adenocarcinoma (ADC; approximately 50%) and squamous cell carcinoma (SCC; approximately 40%) (6).The high incidence and mortality rates of LC pose significant global health challenges. Therefore, understanding these factors is essential to improve patient outcomes. The incidence of LC largely mirrors smoking rates with a latency period of several decades. Consequently, smoking cessation is considered the most effective strategy to reduce the risk of LC. Other important risk factors include environmental exposure to radon, occupational carcinogens, and preexisting nonmalignant lung diseases. Addressing this challenge requires a comprehensive approach to the various treatment modalities available for managing the complexities of LC.Therapeutic strategies for LC can be classified into five main categories: surgery, chemotherapy, radiotherapy, immunotherapy, and targeted therapy. Multimodal treatment approaches have been used to improve patient survival. However, owing to the challenges of early diagnosis, the overall 5-year survival (OS) rate of LC remains low at only 19%, and therapeutic outcomes are unsatisfactory (1). In recent years, targeted therapy for LC has undergone rapid evolution with significant advancements. Given the high mutation rates in LC, progress in genetic and biomarker detection has made personalized, targeted therapies for individual patients increasingly feasible (7). As the treatment landscape evolves, personalized approaches driven by molecular and genetic insights have become pivotal in improving patient outcomes. Advances in molecular biology hold promise for developing chemopreventive agents that prevent the onset of LC (8). Notably, the phosphatidylinositol-3-kinase (PI3K)/ protein kinase B (AKT)/ mammalian target of rapamycin (mTOR) signaling (PAM) pathway has emerged as a key target for the development of effective therapies.The PAM signaling pathway is a key driver of carcinogenesis and drug resistance in patients with solid tumors. Abnormalities in the PAM signaling pathway are present in approximately 50% of tumors, making it the most frequently activated signaling pathway in human cancers (9). This pathway is regulated by various upstream signaling proteins and plays a crucial role in modulating downstream effectors through interactions with compensatory signaling pathways, particularly the RAF/MEK/ERK pathway. The limited clinical success of targeted therapeutic agents highlights the importance of addressing alterations in the PAM signaling pathway when designing effective personalized treatment strategies (10). The use of inhibitors targeting key molecules within the PAM signaling pathway has garnered significant interest in targeted LC therapy. Indeed, several studies have developed promising inhibitors of this pathway, particularly for NSCLC (11). Several targeted therapies aimed at the PAM signaling pathway, including buparlisib (a PI3K inhibitor), MK2206 (an AKT inhibitor), sirolimus (an mTOR inhibitor), and perifosine (a dual PI3K/AKT inhibitor), are currently undergoing clinical trials for the treatment of LC (12)(13)(14)(15). Furthermore, several preclinical studies on natural compounds have garnered interest, with findings highlighting their potent inhibitory effects on the PAM signaling pathway (16)(17)(18). The high incidence and mortality rates of LC highlight the need for further research and treatment development.In this review, we explored the role of the PAM signaling pathway in tumorigenesis and disease progression and reviewed recent advancements in preclinical studies and clinical trials targeting the PAM signaling pathway, focusing on the potential of natural products as therapeutic agents.PI3K, an enzyme comprising a large family of lipid and serine/threonine kinases (19), is a heterodimeric protein comprising a p110 catalytic subunit and a p85 regulatory subunit (Figure 2) (20). P110 catalytic subunits (p110α, p110β, p110δ, and p110γ) are encoded by PIK3CA, PIK3CB, PIK3CD, and PIK3CG, respectively (21). All p85 regulatory subunits (p85α, p85β, p55α, p55γ, p50α) are encoded by PIKR1 (22). Three types of PI3K (classes I, II, and III) have been identified in mammals. Class I PI3K is further divided into two subtypes: class 1A (p110α, p110β, p110δ) and 1B (p110γ), the most common type of cancer, is normally activated by RTKs, such as Epidermal Growth Factor Receptor (EGFR), insulin-like growth factor receptor (IGF1-R), and human epidermal growth factor receptor 2 (HER2/neu) (23). Conversely, Class IB consists of one of the two regulatory subunits, p101 or p87, and the PIK3CG-encoded isoform, p110γ (22). Class II PI3K comprises three distinct enzymes: PI3K-C2α, PI3K-C2β, and PI3K-C2γ. In contrast, class III PI3K has only one known member, Vacuolar Protein Sorting 34 (Vps34, also known as PI3K-C3), the sole PI3 kinase expressed in all eukaryotes (9). PI3K signaling is one of the most commonly dysregulated pathways in cancer, promoting cell growth, proliferation, and survival (19).Activation of the receptor tyrosine kinase recruits PI3Kα to the plasma membrane, where it phosphorylates phosphatidylinositol 4,5-bisphosphate (PIP2) to phosphatidylinositol 3,4,5 triphosphate (PIP3). As a second messenger, PIP3 binds to and recruits various lipid-binding domains of downstream targets, such as the pleckstrin homology (PH), FYVE, phox (PX), C1, and C2 domains, to the cell membrane (24). The PIK3CA mutation, which activates PI3K α, is one of the most common PI3K/AKT activation mechanisms in cancer. Distortion of NF1, MET, ERBB2, and RIT1 can also activate the PI3K signaling pathway (25).The AKT/mTOR signaling pathway is initiated by PI3K activation. AKT, also known as PKB, is a 57-kDa serine/threonine kinase that is a key mediator of growth factor-nduced cell survival. In the mammalian genome, three AKT isoforms have been identified: AKT1, AKT2, and AKT3. AKT1 is the primary subtype crucial in regulating cell apoptosis (26). AKT1 binds to PIP3 and facilitates the activation of 3-phosphoinositide-dependent protein kinase 1 (PDK1) and mTOR complex 2 (mTORC2). PI3K activation leads to the phosphorylation of two critical residues in AKT1: threonine 308 (T308) in the activation loop and serine 473 (S473) in the C-terminal hydrophobic motif (27). The phosphorylation of these two residues is a critical step in the maximal activation of AKT1. The corresponding residues in AKT2 (T309 and S474) and AKT3 (T305 and S472) regulated this activation process. PDK1 plays a key role in AKT activation by phosphorylating AKT1 at T308 (28,29). Maximal activation of AKT requires phosphorylation at S473 in the hydrophobic motif, and mTORC2 is the primary kinase responsible for this phosphorylation (30). Although AKT retained some activity without S473 phosphorylation, its activity was significantly reduced. Phosphorylation of S473 stabilizes T308 phosphorylation and maintains AKT in its fully active state (27,31).EGFR-Y1068 self phosphorylates to provide a docking site for SH2 containing adaptor proteins, directly activating the PI3K/AKT pathway to maintain cell survival (32).Phosphorylation of EGFR at Y992, Y1148, and Y1173 sites leads to recruitment of SHC to activate the MAPK/ERK pathway, thereby promoting cell proliferation (33). IGF1R promotes cancer cell proliferation and differentiation by inducing phosphorylation of PI3K and AKT (34). mTOR is a serine/threonine protein kinase that is the primary catalytic subunit of two protein complexes, mTOR complex 1 (mTORC1) and mTORC2. mTOR was originally discovered as a cellular target of rapamycin and is involved in the checkpoint regulation of cell cycle regulation and regulates various biological processes, including cell proliferation, survival, autophagy, metabolism, and immunity (35,36). Inhibition of mTOR can effectively inhibit the growth, proliferation, cell cycle progression, migration, and invasion of NSCLC cells, while inducing apoptosis activation (37).The mTORC1 complex, which comprises mTOR, mLST8, Raptor, and PRAS40, is highly sensitive to rapamycin, making it a key target for mTOR inhibitors, particularly first-generation inhibitors (38). mTORC1 and mTORC2 are intricately linked. mTORC1 exerts feedback inhibition on mTORC2 through S6K1, one of its substrates. Upon activation by mTORC1, S6K1 phosphorylates Rictor at T1135 and mSin1 at T86 and T398, leading to the disruption of mTORC2 integrity (39)(40)(41). mTORC2 activates the IGF-IR-AKT axis, thereby upregulating mTORC1 (42). Phosphatase and tensin homolog (PTEN) is a negative regulator of mTOR, which inhibits signal transduction via the PI3K/AKT signaling pathway. Other regulatory factors include the tuberous sclerosis complex (TSC) comprising TSC1 (hamartin) and TSC2 (tuberin) (43). AKT inactivates the TSC1-TSC2 complex, thereby promoting the activation of RHEB GTPase, activating mTORC1 (44). Subsequently, active mTORC1 promotes protein synthesis by inactivating the translation inhibitor 4E-BP1 and activating the kinase S6K; (ii) induces lipid biogenesis by activating the transcription factors SREBP1 and PPAR; (iii) inhibits autophagy by blocking ULK1 (45,46). mTORC2 directly activates AKT via phosphorylation at Ser-473 site (47,48).Previous studies have identified non-coding RNA (ncRNA) as an essential regulatory factor in the PAM signaling pathway (49). ncRNAs function as both upstream and downstream effectors in regulating the PI3K pathway and, directly or indirectly, targets multiple key components of this pathway, including PI3K, AKT, and mTOR. However, the precise mechanisms by which ncRNAs exert these effects remain to be fully elucidated (11,50,51).The PAM signaling pathway is a crucial intracellular signaling pathway that regulates various cellular processes, including cell growth, survival, proliferation, metabolism, apoptosis, invasion, and angiogenesis (52), and is one of the most commonly dysregulated pathways in cancers and pivotal in oncogenesis. Activation of the PAM signaling pathway can inhibit autophagy and apoptosis, which are typically associated with pro-survival effects (53,54).Most importantly, the excessive activation of key molecules within this pathway can unjustifiably promote cancer cell survival by inhibiting autophagy and apoptosis (55). The inhibition of this survival pathway induces autophagy and apoptosis in cancer cells (56).The PAM signaling pathway is as a central signal transduction hub in response to extracellular stimuli, including insulin, insulin-like growth factor-1 (IGF-1), fibroblast growth factor (FGF), and epidermal growth factor (EGF) (57). Chemokine receptor 9 (CCR9), inflammation-associated cytokine Toll-like receptor (TLR), and interleukin (IL)-6 are key upstream regulatory factors of the PAM signaling pathway (58)(59)(60). High expression levels of CCR9 are associated with increased tumor proliferation and metastasis (61). IL6 promotes tumor cell survival through PI3K/AKT and cyclin A1 (60). The upregulation of TLR-4 coexists with the downregulation of PI3K, AKT, and mTOR, associated with reduced cell damage (62).Genetic alterations targeting the PAM signaling pathway are closely associated with cancer development. For example, the loss of PTEN in somatic cells represent the second most common oncogenic mutations in the human genome, second only to malignant p53 mutations (63). In recent years, the rising incidence of malignant tumors has been linked to abnormal activation of the PAM signaling pathway (64). Mutations or overexpression of PI3K can result in hyperactivation of this pathway, driving cancer cell proliferation and survival. IL-7 upregulates PI3K expression and promotes AKT and mTOR phosphorylation, activating the PAM signaling pathway (65). Abnormal expression of KIF2A promotes malignant transformation of cell carcinoma. Different analytical approaches focusing on antitumor miRNAs and their specific targeting of oncogenes are of great significance for identifying the molecular mechanisms underlying the pathogenesis of lung squamous cell carcinoma (66).AKT is constitutively active in many cancers, promotes resistance to apoptosis, and enhances tumor survival (67). mTOR is often hyperactivated in cancer, leading to increased protein synthesis, cell growth, and angiogenesis, all essential for tumor progression (68,69).Mutations in PI3K, loss of function of the PTEN tumor suppressor (a negative regulator of the pathway), and amplification or mutation of AKT can result in the constitutive activation of the PAM signaling pathway, driving uncontrolled cell proliferation and survival (70).Owing to its pivotal role in cancer, the PAM signaling pathway is a major target for cancer therapies. Inhibitors targeting PI3K, AKT, and mTOR are undergoing clinical trials for various cancer types. However, drug resistance and feedback loops within the pathway remain major limitations that complicate the treatment strategies.The PAM signaling pathway is involved in metabolic, cardiovascular, and neurodegenerative diseases (71,72). For example, activation of the PAM signaling pathway alleviates ischemia-reperfusion injury in diabetic cardiomyopathy (72). This pathway also regulates insulin signaling and glucose homeostasis, making it a key focus of diabetes research (73).Furthermore, applying plant-derived secondary metabolites in managing and treating various neurological diseases through modulation of the PAM signaling pathway is a promising neuroprotective strategy (74).Understanding the biological complexities of the PAM signaling pathway is essential for elucidating its role in cancer progression and resistance mechanisms. Building on this foundation, the following section discusses therapeutic implications, focusing on how these insights can be applied to develop targeted treatment strategies for LC.The PAM signaling pathway is one of the most frequently dysregulated networks in human cancers and plays a critical role in the proliferation and survival of LC cells. In LC cells, this pathway is often abnormally activated. For example, mutations in the PI3K gene or overexpression of AKT protein are common, which can cause uncontrolled proliferation, inhibited apoptosis, and enhanced migration and invasion ability of LC cells. Consequently, numerous drugs, most of which are small-molecule compounds, targeting these three key kinases---PI3K/AKT/mTOR have been developed and evaluated. Although these advances have contributed to significant progress, the effectiveness and future potential of these therapies require further exploration of specific inhibitors and their clinical applications.In the following sections, we explore inhibitors targeting the PI3K, AKT, and mTOR components of the PAM signaling pathway, analyzing their mechanisms of action, outcomes of current clinical trials, and challenges in optimizing their use for LC therapy (Table 1) (Supplementary pictures 1-3). This in-depth analysis sheds light on how these small-molecule inhibitors shape the future of LC treatments.Within the PAM signaling pathway, PI3K is a primary drug target for cancer treatment since its hyperactivity is strongly associated with tumor progression, enhanced tumor microvascular formation, and increased cancer cell invasiveness (75). Over the past few decades, several pharmaceutical companies have developed PI3K inhibitors to target this key pathway (76,77). Although PI3K inhibitors have demonstrated significant therapeutic efficacy against human cancers, acquired and intrinsic resistance limit their clinical efficacy (78).Buparlisib (BKM120), a 2,6-dimorpholino pyrimidine derivative, is a novel, potent, highly selective inhibitor of class I PI3K with confirmed anticancer effects in various solid tumor models (79). However, it has not been approved by the U.S. Food and Drug Administration (FDA) for the treatment of specific cancer types (80). Experimental studies have shown little correlation between mutations in K-Ras, p53, LKB1, PTEN, EGFR, or CDKN2A and the sensitivity of cells to BKM120. Therefore, BKM120 effectively inhibits the growth of NSCLC cells, regardless of genetic mutations (81). BKM120 has a rapid and effective inhibitory effect on the PAM signaling pathway in human NSCLC cells (81).In SCLC and NSCLC, BKM120 may inhibit tumor cell growth by blocking key enzymes required for cell proliferation. Administering PI3K inhibitors, such as BKM120, in combination with chemotherapeutic agents, such as carboplatin, pemetrexed disodium, cisplatin, and etoposide, may enhance tumor cell killing (NCT01723800, NCT02194049) (82,83). The open-label, two-stage, phase II study BASALT-1 (NCT01820325) evaluated the efficacy of the pan-PI3K inhibitor BKM120 in patients with recurrent NSCLC and PI3K pathway activation (84). These results indicate that although PI3K pathway activation can be detected using circulating tumor DNA (ctDNA), it may not be the primary oncogenic driver in NSCLC. Therefore, combination therapies involving PI3K inhibitors and other agents may be more effective than monotherapy (85).Pictilisib (GDC-0941) is an efficient PI3K selective inhibitor. When combined with trastuzumab (an antitumor drug), pictilisib demonstrated significant therapeutic effects against cancer cells in vitro and on tumors in vivo (86). One study investigated the treatment of patients with advanced NSCLC using pictilisib in combination with paclitaxel and carboplatin (with or without bevacizumab) or pemetrexed and cisplatin (with or without bevacizumab). The authors demonstrated that combining pictilisib with various standard first-line treatment regimens is feasible for NSCLC patients, and preliminary findings have indicated encouraging antitumor activity (NCT00974584) (87,88).Eganelisib (IPI549) is a first-in-class, orally administered, highly selective PI3Kγ inhibitor that has demonstrated anti-tumor activity in preclinical studies, both as a monotherapy and in combination with programmed cell death protein 1/ligand 1 (PD-1/PD-L1) inhibitors.Eganelisib reshapes the tumor immune microenvironment and promotes cytotoxic T cell-mediated tumor regression without directly targeting the cancer cells (89). The IPI-549-01 study was the first-in-human, multicenter, open-label, phase 1/1b dose-escalation trial.The results indicated that eganelisib doses of 30 and 40 mg once daily in combination with PD-1/PD-L1 inhibitors were selected for further evaluation in Phase II trials (NCT02637531) (90,91).TQ-B3525, a novel PI3Kδ/α dual inhibitor developed by Zhengda Tianqing, induces cell apoptosis and inhibits the proliferation of malignant tumor cells by inhibiting the expression of PI3K protein and reducing the phosphorylation level of AKT protein (92). TQ-B3525 selectively inhibits the PI3Kδ and PI3Kα subunits, overcoming drug resistance attributed to the upregulation of PI3Kα activity when PI3Kδ alone is inhibited. An ongoing single-arm, open-label, multi-cohort, multicenter clinical study is currently investigating the safety and efficacy of TQ-B3525 tablets combined with osimertinib for the treatment of patients with advanced NSCLC (NCT05284994) (93).Alpelisib (BYL-719) is a potent, selective, orally active PI3Kα inhibitor with high efficacy in targeting PIK3CA-mutated cancersits anticancer activity against squamous cell LC cells with PIK3CA mutations in vitro and in vivo studies (94). BYL719 enhances the anticancer effects of gefitinib by inhibiting the p-AKT signaling pathway activated by PI3K/AKT in gefitinib-resistant NSCLC cells. The combination of BYL719 and gefitinib produced a synergistic effect on EGFR-mutant NSCLC cells via PI3K/AKT activation. Acquisition of PIK3CA mutations may contribute to cell proliferation and gefitinib resistance in NSCLC cells harboring EGFR mutations. Thus, combination therapy with gefitinib and BYL719 is a promising strategy to overcome EGFR-TKI resistance driven by PI3K/AKT activation (95).Candidate biomarkers for PI3K inhibitors have shown predictive value in preclinical models and exhibit tissue-specific changes in primary tumors (96).Several drugs can specifically inhibit AKT protein, preventing excessive activation of downstream targets in the PAM signaling pathway. Ongoing clinical trials are investigating AKT inhibitors, such as capivasertib and ipatasertib, as monotherapy and in combination with other agents for treating advanced LC. In addition, MK-2206 has been evaluated in advanced solid and hematological malignancies. However, none of these drugs have received FDA approval. Notably, capivasertib is a promising new treatment option for these patients and is expected to gain Food and FDA approval in the near future (97).MK-2206 is a potent, orally active allosteric inhibitor of human AKT1, AKT2, and AKT3, with demonstrated preclinical antitumor activity. A phase I study investigated the combination of MK-2206 and gefitinib in NSCLC patients who failed prior chemotherapy and epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs) (NCT01147211) (98).Ipatasertib (GDC-0068) is an orally effective, highly selective, ATP-competitive pan-AKT inhibitor that activates FoxO3a and NF-κB through AKT inhibition, leading to p53-independent activation of PUMA. Ipatasertib also induces apoptosis in cancer cells and inhibits tumor growth in xenograft mouse models (99,100).Preclinical studies have suggested that ipatasertib enhances the therapeutic efficacy of chemotherapy and immunotherapy by modulating the PI3K-AKT signaling pathway.Consequently, a multicenter phase II study is currently underway to evaluate the combination of ipatasertib and docetaxel for the treatment of patients with metastatic or advanced NSCLC who have failed or are intolerant to first-line immunotherapy (NCT04467801) (101).Capivasertib (AZD5363), a novel pyrrolopyrimidine-derived compound, inhibits all AKT isoforms and is an effective ATP-competitive AKT inhibitor with an IC50 of < 10 nM for all three AKT subtypes. Using a GI50 critical value of < 3 μM, 23% of a large panel of cell lines are sensitive to capivasertib inhibition, with three-quarters of these cell lines harboring PIK3CA mutations, PTEN deletions, or HER2 amplification. KRAS is a negative predictive biomarker of the capivasertib response (102). SAFIR02_Lung is an open-label, multicenter, randomized, phase II trial. Using high-throughput genomic analysis as a tool for treatment decision-making, this trial aims to identify actionable genetic abnormalities in NSCLC (NCT02117167) (103). Cells with dual AKT activation and RAS mutations may inhibit 4E-BP1 even if AKT is inhibited (104).mTOR inhibitors were the first PAM-targeted drugs to enter clinical practice (105). mTORC1 activation promotes the synthesis of proteins, lipids, and nucleotides while inhibiting autophagy, thereby enhancing cell survival, proliferation, and growth. In parallel, mTORC2 activation regulates protein kinases, including AKT, further supporting cell survival and proliferation (30,106). Therefore, the functions of both mTORC1 and mTORC2 offer critical insights into the targeting of mTOR complexes to tumors. However, the effectiveness of some mTOR inhibitors may be limited by compensatory feedback loops that result in AKT activation (107).Sirolimus is an effective and specific inhibitor of mTOR. In tissue culture studies, sirolimus at concentrations as low as 1 ng/ml inhibits mTOR signaling in cells. The first report on combining an mTOR inhibitor with radiotherapy in humans demonstrated that patients tolerated the combination well. Both clinical and animal data indicated that sirolimus can be safely combined with radiotherapy and cisplatin to treat LC (108).Everolimus (RAD001 or Afinitor) is a rapamycin analog that functions similarly by acting as a conformational inhibitor of mTOR. RAD001 is an FDA-approved drug used to treat kidney cancer. This prevents cancer cell proliferation and renders them susceptible to cell death. RAD001 improves progression-free survival in patients with advanced renal cell carcinoma who previously received VEGF-targeted therapies (109). Similar to rapamycin, everolimus induces AKT activation while inhibiting mTOR signaling in human cancer cells, including NSCLC cells, as well as in tumor biopsies (110,111). This Phase II, nonrandomized, open-label, multicenter study evaluated the efficacy of everolimus monotherapy in patients with advanced NSCLC previously undergone no more than two chemotherapy regimens (NCT00124280) (112). Research has demonstrated that when administered at a daily dose of 10 mg, everolimus possesses favorable tolerability and safety within its pharmacological class. Additionally, preclinical evidence suggests that combining EGFRi and mTOR inhibitors can have cumulative or synergistic effects in NSCLC by sensitizing cells to DNA-damaging agents via mTOR inhibition. This indicates that everolimus, when combined with erlotinib and chemotherapy, may be an effective treatment for advanced NSCLC (113).Temsirolimus (CCI-779) is an mTOR kinase inhibitor with antiproliferative and antiangiogenic properties. Temsirolimus activates autophagy and prevents cardiac function deterioration in animal models (114) and is a potential candidate for combination therapy with radiotherapy in NSCLC owing its established anti-proliferative and anti-angiogenic activities in multiple epithelial tumors and its non-overlapping mechanisms with radiotherapy (115). A phase I study evaluating the combination of tacrolimus and chest radiotherapy in patients with NSCLC demonstrated good tolerability of tacrolimus at a dose of 15 mg/week when combined with chest radiotherapy (NCT01396408) (116). Additionally, the 1-year PFS in the itraconazole group was significantly improved, although this was not reflected in the 1-year OS (NCT03664115) (117,118).Aspirin, a nonsteroidal anti-inflammatory drug (NSAID), not only possesses classic anti-inflammatory properties but also exhibits chemopreventive effects against various human cancers, including colon cancer, LC, breast cancer, and leukemia, making it a promising anticancer agent (119). Autophagy occurs frequently during tumorigenesis and cancer chemotherapy, and strategies to stimulate or inhibit autophagy have been proposed as potential cancer therapies (120). In LC cells, combination therapy with aspirin and ABT-737 (a Bcl-2 inhibitor) induces a stronger autophagic response than either drug alone. Autophagy triggered by this combination shifts the role of p38 from cell protection to death promotion, with p38 acting as a switch between two distinct types of cell death: autophagy and apoptosis (121). In an in vivo study using a lung tumor model induced by Dactolisib (NVP-BEZ235) is an orally active, dual pan-class I PI3K and mTOR kinase inhibitor that targets p110α, p110γ, p110δ, p110β, mTORC1, and mTORC2 (130). Dactolisib induces significant antiproliferative effects in transgenic mice with carcinogenic KRAS-induced NSCLC, as well as in NSCLC cell lines expressing carcinogenic KRAS.Although dactolisib therapy alone cannot induce apoptosis, dual PI3K/mTOR blockade effectively sensitizes NSCLC cells expressing oncogenic KRAS to the pro-apoptotic effects of ionizing radiation (IR) in vitro and in vivo. Therefore, combining dual PI3K/mTOR blockade with IR may benefit patients with NSCLC expressing oncogenic KRAS (131). An abnormal vascular structure in the LC leads to hypoxia, which limits the effectiveness of radiotherapy. Dactolisib improves tumor oxygenation and vascular structure, contributing to effective vascular normalization. The significant therapeutic benefit of combining dactolisib and irradiation highlights its potential importance in cancer treatment (132).The combination of BKM120 and RAD001 has shown a synergistic inhibitory effect on LC cell growth in vitro and in vivo (NCT01470209) (80,110,133). This combination not only eliminated RAD001-induced AKT and eIF4E phosphorylation but also enhanced the inhibitory effect on 4EBP1 phosphorylation and p21 induction (81).Although this combination was tolerable when the doses of both drugs were reduced, it remained effective (134). Gefitinib (ZD1839) is a potent, selective, and orally active EGFR tyrosine kinase inhibitor that inhibits EGF-stimulated tumor cell growth by blocking EGF-induced EGFR autophosphorylation in tumor cells. In addition to its inhibitory effects on cell proliferation, gefitinib induces autophagy and apoptosis, making it a valuable agent for cancer research, particularly for LC and breast cancer (136)(137)(138). A Phase Ib trial investigated the combination therapy of gefitinib and the oral class I PI3K inhibitor BKM120 in patients with advanced NSCLC, focusing on those with alterations in PI3K pathway molecules and known overexpression of EGFR (NCT01570296) (139). A randomized Phase II trial compared treatment with either gefitinib alone or combined with simvastatin to treat patients with advanced NSCLC (NCT00452244) (140). The authors demonstrated that, in patients with wild-type EGFR non-adenocarcinoma, the combination of gefitinib and simvastatin results in a higher response rate (RR) and longer progression-free survival (PFS) than gefitinib alone.Therefore, simvastatin may enhance the efficacy of gefitinib in this subgroup of gefitinib-resistant NSCLC patients (141). AZD6244 is an effective, selective, orally administered MEK1/2 inhibitor. The combination of NVP-BEZ235 and AZD6244 enhanced both antitumor and anti-angiogenic effects. Studies have shown that combining selective MEK and PI3K/mTOR inhibitors can effectively inhibit the growth of gefitinib-resistant tumors caused by EGFR T790M mutation, MET amplification, and KRAS/PIK3CA mutations (143). This new treatment strategy may offer a practical approach to treating these patients.Although several drugs targeting the PAM signaling pathway have been developed, research on natural products demonstrated promising potential.The next section explores the application of natural products in targeting the PAM signaling pathway and examines their underlying mechanisms.Recently, drugs isolated and purified from natural products have garnered considerable interest. As a component of traditional Chinese medicine (TCM) used in disease treatment, TCM offers several advantages, including minimal side effects, noninvasiveness, low cost, and broad accessibility to cancer therapy. Numerous studies have demonstrated the antitumor activity of various TCM ingredients, with clear benefits in reducing toxicity and enhancing efficacy when combined with other treatment modalities (Table 2) (144,145).For example, quercetin, kaempferol, and isorhamnetin demonstrated anti-NSCLC effects by targeting AKT1 and EGFR. Among these compounds, isorhamnetin exhibits the strongest binding affinity to EGFR, with a binding energy of -6.79 kcal/mol. The primary interactions between isorhamnetin and EGFR involve carbon-hydrogen bonds and Pi-sigma, Pi-sulfur, and Pi-alkyl interactions. Isorhamnetin inhibits the migration and invasion of A549 cells, induces cell apoptosis and G1 phase arrest, and reduces expression of P-PI3K and P-AKT in A549 cells (146). A drug may play a crucial role through multiple signaling pathways due to its multiple targets. For instance, Lanatoside C induces G2/M cell cycle arrest and inhibits cancer cell growth by weakening the MAPK, Wnt, JAK-STAT, and PI3K/AKT/mTOR signaling pathways (147).Napabucasin is a furanonaphthoquinone compound derived from plants of the Bignoniaceae family, with botanical sources including Tabebuia cassinoides (148), Millettia versicolor Fucoidan is a sulfated polysaccharide extracted from brown seaweed and is primarily composed of L-fucose and sulfate groups with an average molecular weight of approximately 20,000 Da. Fucoid polysaccharides exhibit a range of biological activities, including antibacterial effects (156), antioxidant (157), anti-inflammatory (158), anticoagulant (159), and anti-tumor activities (160). Fucoid polysaccharides significantly inhibited the phosphorylation of PI3K and its downstream target AKT in a concentration-and time-dependent manner and inhibited mTOR phosphorylation in a concentration-dependent manner. In addition, two direct downstream targets of mTOR, 4E-BP1, and p70S6K, which are markers of mTOR activity, were significantly downregulated. In A549 LC cells, fucoid polysaccharides inhibited MMP-2 activity by suppressing the PAM signaling pathway, reducing cancer cell migration and invasion (161).Sophflarine A, a novel alkaloid derived from Sophora flavescens, exhibits significant antiproliferative activity against NSCLC cells both in vitro and in vivo. Euphorbia hirta is an herbaceous plant in the Euphorbiaceae family commonly found worldwide. E. hirta is well-known for its efficacy against various fungal and bacterial infections (163) and contains secondary metabolites, including terpenoids, flavonoids, phenols, and essential oils. Currently, nanobiotechnology and nanomedicine are gaining increasing attention due to advancements in delivering targeted therapies that specifically destroy malignant cells (164). Silver ions can inactivate invading pathogens and cancer cells, making them one of the most extensively studied metals for their activity against microbial pathogens and malignant cells (165,166). Over the past 20 years, silver nanoparticles (AgNPs) have garnered significant attention for their potent antiviral, antibacterial, antifungal, antiangiogenic, and anticancer properties, making them valuable for various biomedical applications (167). Additionally, AgNPs selectively destroy malignant cells while protecting normal cells through the controlled release of Ag ions (168). In addition, some studies have shown that silver AgNPs selectively destroy malignant cells while protecting normal cells by releasing silver ions (169). This demonstrates that the application of Eh-AgNPs significantly reduces the phosphorylation of p-PI3K, p-AKT, p-mTOR, and p70S6K. The administration of Eh AgNPs specifically decreased the expression of PI3Kγ, without affecting other PI3K subtypes such as PI3Kα, β, and δ. These findings suggest that Eh AgNPs induce cell apoptosis by downregulating PI3Kγ, disrupting the PAM/p70S6K signaling pathway (170).Emodin (1,3,8-trihydroxy-6-methylanthraquinone) is a naturally occurring anthraquinone derivative isolated from the roots and bark of many plants, fungi, and lichens, including shown for the first time that treatment with emodin leads to blocking the binding of Her2/neu to Hsp90, intracellular redistribution, and enhanced ubiquitination, thereby promoting the proteasomal degradation of Her2/neu. This may represent a new approach for targeted therapy of Her2/neu overexpressing cancer (173).The PAM signaling pathway plays a pivotal role in the maturation, differentiation, recruitment, and survival of immune cells. The regulation of the immune system via the PAM signaling pathway is finely tuned, enabling the precise mobilization or inhibition of specific immune cell subsets through tightly controlled signaling mechanisms.The tumor immune microenvironment (TIM), a critical site for tumor growth, invasion, and immune evasion, comprises various immune cells, tumor-associated cells, and signaling molecules. The PAM signaling pathway plays a pivotal role in mediating the interactions between tumor cells and their surrounding microenvironment, particularly affecting immune cells and influences immune response, cell survival, and dysfunction (Figure 3).The following outlines the interactions between key cells in the TIM and PAM signaling pathways: Tumor-associated macrophages (TAMs) are among the most abundant cellular components in the tumor microenvironment and typically exhibit an M2-type immunosuppressive phenotype (174). TAMs are a significant source of angiogenic factors that promote vascular growth, and subsequently accelerate tumor invasion and metastasis.TAMs contribute to angiogenesis by activating and releasing these factors, and TAM-derived VEGFA plays a crucial role in driving tumor-associated angiogenesis (175). Therefore, TAM-mediated angiogenesis is a potential therapeutic target for malignant tumors. The PAM signaling pathway plays a key role in regulating the differentiation, survival, and function of TAMs. Excessive activation of the PAM signaling pathway drives the transformation of TAMs toward the M2 phenotype, enhancing their pro-tumor activities, such as the secretion of immunosuppressive cytokines like IL-10 and promoting angiogenesis, while simultaneously reducing the expression of M1-associated cytokines like TNF-α (176). Drugs that inhibit the PAM signaling pathway, such as PI3K inhibitors, may alter the phenotype of TAMs, transforming them from the M2 type to the antitumor M1 type, thereby enhancing the tumor immune response.Tumor-infiltrating lymphocytes (TILs) are T cells and other immune cells that infiltrate tumor tissues and are typically associated with better antitumor immune responses. This indicates the parameters of the immune response to tumors (175). Numerous studies have demonstrated that the quantity and composition of TILs are associated with an improved response to ICI therapy in various solid tumors (177). Activation of the PAM signaling pathway in TILs can influence their antitumor capabilities. The regulation of the PAM signaling pathway can enhance the infiltration and antitumor activity of TILs, particularly CD8+ T cells (178). Compared with normal T lymphocytes, tumor-infiltrating T lymphocytes exhibited relatively low levels of miR-26a-5p. Experimental studies have shown that miR-26a-5p can inhibit the PAM signaling pathway, thereby reducing the ability of CD8+ tumor-infiltrating cells to eradicate tumors. Consequently, miR-26a-5p has emerged as a promising target for optimizing the efficacy of TIL therapy (179). For example, PI3Kδ-specific inhibitors can enhance the activity of TILs, thereby improving the immune-mediated clearance of tumors. Some tumor cells induce immunosuppressive signals by activating the PAM signaling pathway, which reduces the function (180). This immune escape mechanism is a key focus of current research, with efforts to restore the antitumor activity of TILs by targeting the PAM signaling pathway. PI3Kδ inhibition (188). Similar to PI3Kδ, the PI3Kγ subtype is active in lymphocytes. PI3Kγ, along with its regulatory subunits PIK3R5 and PIK3R6, is uniquely overexpressed in the bone marrow compartment, where PI3Kγ is the primary catalytic subunit for PI3K activity (189). G protein-coupled receptors (GPCRs) activate p110γ through a Ras/p101-dependent mechanism, while receptor tyrosine kinases (RTKs) and Toll-like/IL-1 receptors (TLR/IL1Rs) activate p110γ via a Ras/p87-dependent mechanism. Once activated, p110γ promotes the inside-out activation of the integrin α4β1, facilitating the invasion of bone marrow cells into tumors. Pharmacological or genetic blockade of p110γ inhibits inflammation, tumor growth, and metastasis in both implanted and spontaneous tumor models (189).AKT expression in most immune cells, both at the baseline and upon activation, underscores its critical role in immunity. AKT is essential for the regulation of both innate and adaptive immunity (190). AKT1 and AKT2, but not AKT3, promote terminal differentiation of CD8+ T cells while impairing the development of central and effector memory CD8+ T cell populations. These findings offer insights into adoptive cell transfer and vaccine-based cancer immunotherapies (191). In addition, AKT plays a critical role in CD4+ T cells by guiding helper T cell (Th) differentiation in a subtype-specific manner. AKT1 promotes antigen-specific Th1/Th17 responses by inhibiting the proliferation of thymes-derived T cells (Tregs). In contrast, AKT2 enhances tTreg proliferation in vitro and in vivo, while suppressing antigen-specific Th1/Th17 responses (192).T cell activation through TCR and CD28 co-stimulation promotes the downstream induction of cytokines IL-2 and IFN-γ, mediated by T helper type 1 (Th1) cells in an AKT-dependent manner. In contrast, the regulation of IL-4 and IL-5 by T helper type 2 (Th2) cells occurs independently of AKT. FOXO is considered a tumor suppressor because they play an important role in inducing cell cycle arrest, DNA damage repair, and ROS clearance (193).Treg-mediated suppression (194). enhancement (195). Modulating the FOXO signaling pathway in Treg cells offers a potential strategy for selectively disrupting tumor immune tolerance (196). Recent studies have demonstrated that Treg-mediated immune suppression is constrained in an AKT-dependent manner by PD-1 inhibition. Reduced signal transduction in the PI3K-AKT pathway is a key mechanism contributing to the enhanced suppressive capacity of PD-1-deficient Treg cells (197).mTOR is the catalytic component of the mTORC1 and mTORC2 complexes, and its activation is essential for the proper activation and differentiation of effector CD4+ T cells (198). These complexes collectively regulate cellular metabolism, the primary mechanism by which mTOR influences the immune system. mTORC1, in particular, plays a key role in regulating the differentiation of memory T cells (199); mTORC1 also partially sustains Treg cell function by inhibiting the mTORC2 pathway, linking immune signals from the TCR and IL-2 to adipogenesis pathways and functional adaptability. This highlights the central role of the Treg inhibitory activity in maintaining immune homeostasis and tolerance (198).mTORC1 influences the effector response of CD8+ T cells, whereas mTORC2 regulates the memory of CD8+ T cells. mTORC2 inhibition leads to metabolic reprogramming driven by FOXO-mediated suppression of IL-15R expression, thereby enhancing the generation of CD8+ memory cells (200). Importantly, mTORC1 and mTORC2 play direct roles in regulating innate immunity. mTOR is a key regulator of memory CD8+ T cell differentiation, and rapamycin, an immunosuppressive drug, has an immunostimulatory effect on the production of memory CD8+ T cells (199). mTORC1 regulates the production of inflammatory cytokines by inhibiting NF-κB, controlling monocyte/macrophage-mediated inflammation (201). mTORC2 complements this by modulating the chemotaxis of mast cells and neutrophils. Additionally, through FOXO1 inhibition, mTORC2 downregulates IL-12 production in dendritic cells and plays a key role in IL-4-dependent selective activation of M2 macrophages (202,203). mTOR regulates the expression of key inflammatory cytokines, including IL-10, IL-12, TGF-β, and TNF (204). mTOR-mediated inflammatory responses can also promote the recruitment of immune cells to TIM, which may exert antitumor effects or contribute to cancer cell growth, progression, and metastasis (205). Activation of tumor-associated PAM signaling also promotes the expression of VEGF, a key mediator of angiogenesis and a chemokine that attracts immunosuppressive MDSCs and Tregs (204,206,207). MDSCs accumulate in most cancer patients, promote tumor progression, suppress antitumor immunity, and impede the effectiveness of many cancer immunotherapies (206).In ) is reshaping cancer treatment strategies. In the context of precision medicine, immuno-oncology is evolving into precision immuno-oncology with an emphasis on identifying predictive biomarkers that can optimize responses to ICIs (208).PI3K inhibition is a key target for antitumor therapy. While several inhibitors, including copanlisib, alpelisib, idelalisib, duvelisib, and umbralisib, have been approved by the FDA, challenges remain regarding drug resistance, identification of sensitivity markers, and toxicity (209).Serious toxicities associated with PI3K inhibitors in clinical practice include hyperglycemia, skin reactions, diarrhea/colitis, pneumonia, and hypertension. Hyperglycemia typically occurs during the first two cycles of PI3K inhibitor treatment (210,211). Hyperglycemia is regarded as an on-target effect of PI3K inhibitors and is linked to the critical role of the PI3K pathway in insulin signaling and glucose homeostasis (212). p110α and p110β regulate insulin-driven PI3K/AKT signaling pathway; inhibiting it can lead to hyperglycemia, rather than p110 δ and p110 γ (213). Additionally, the glucose-insulin feedback triggered by PI3K inhibitors is sufficient to reactivate PI3K signaling, thereby diminishing the effectiveness of the inhibitors (214). Skin reactions, such as rashes or papules, are among the most common toxicities observed with PI3K inhibitors in experimental studies. The PI3K/AKT signaling pathway is crucial in determining whether epidermal keratinocytes undergo differentiation or cell death (215). Inhibition of this pathway suppressed keratinocyte proliferation and migration (216).Additionally, activating the PAM signaling pathway inhibits autophagy and promotes inflammation in keratinocytes (217). Diarrhea and colitis are common side effects of PI3K inhibitors, with severe cases often leading to treatment discontinuation (218). Histological examination via colonoscopy in patients with colitis revealed neutrophil infiltration, increased intraepithelial lymphocytes, and crypt cell apoptosis within the crypt epithelium (219).The increased number of intraepithelial lymphocytes was predominantly CD8+ T cells, likely due to immune dysfunction. PI3Kδ inhibitors may disrupt B cell differentiation through immune dysregulation of Tregs, contributing to intestinal injury (220). Fatal and severe pneumonia are common complications in patients receiving PI3K inhibitor treatments.Non-infectious pneumonia may be linked to the downstream inhibition of PI3K, whereas allergic and organizing pneumonia is more frequently observed in patients treated with mTOR inhibitors (221). Pneumonia is also an immune-mediated disease, with a median increase in Th1-associated cytokines and chemokines observed in patient serum samples, including IFN-γ and IL-6, -7, and -8 (222). Hypertension is one of the most common adverse events associated with acute vasoconstriction (223). The PI3K/AKT signaling pathway plays a key role in regulating classical endothelial functions, including the modulation of vascular tone and recruitment of white blood cells to the vascular wall (224). p110γ is a key factor in regulating blood pressure. p110γ alleviates hypertension and reduces vascular inflammation by lowering peripheral resistance; conversely, it may contribute to developing hypertension and related target organ damage by modulating T cell function (225).Somatic mutations in PIK3CA also display unique patterns with respect to sex-and tissue-specificity (226). Amplification of chromosome regions containing the PIK3CA gene has been identified in several human cancers, including ovarian, cervical, head and neck, and gastric cancers (20,227). PIK3CB undergoes a missense substitution (E633K) that enhances cell proliferation, transformation, and membrane targeting, reducing its dependence on Ras activation (228). Overexpression of p110γ can induce oncogenic transformation in cell cultures, and its increased expression promotes cell proliferation. However, downregulation via siRNA reduces proliferation, underscoring the critical role of p110γ in pancreatic cancer progression (229,230). p110δ is primarily implicated in blood cancers, and somatic mutations in its catalytic subunit (E1021K) are associated with recurrent infections and progressive airway damage (231). High-throughput mutation analysis identified novel somatic mutations affecting p110γ (N66K, D161E, R178L, S348I, K364N, T503M, R542W, E602V, and E740K) and p110δ (V397A) across various tumor types, including breast cancer, LC, ovarian cancer, and prostate cancer (232).The therapeutic efficacy of PAM signaling pathway inhibitors is limited and often accompanied by significant treatment-related toxicity, particularly when used in combination with standard therapies or other targeted drugs. Consequently, most PAM signaling pathway inhibitors are not suitable as mainstream treatments for tumors. Recent trends have shifted toward combining multiple drugs with other treatment modalities, such as surgery, hormone therapy, and additional antitumor agents. Future studies should identify reliable biomarkers for patient stratification based on cancer type and genetic characteristics, allowing for a more effective use of PI3K inhibitors. Since the full mechanism of action of PI3K inhibitors is yet to be fully elucidated, further research is required to better understand their advantages and limitations in the context of personalized cancer treatment.The AKT pathway is crucial for regulating cell proliferation, survival, and metabolism, making AKT inhibition a potentially powerful antitumor strategy. However, dose-limiting toxicities and an incomplete understanding of the different AKT subtypes have hindered the successful pharmacological application of AKT inhibitors.Treatment with AKT inhibitors may also result in adverse reactions, including gastrointestinal discomfort, skin reactions, metabolic disorders, abnormal liver function, hematological abnormalities, cardiac toxicity, and immunosuppression (233). AKT1 amplification has been detected in gastric cancer and is associated with cisplatin resistance (234). Somatic mutations in AKT1 have been identified in breast, colorectal, ovarian, LC, and bladder cancer (235).AKT1 E17K is an activating mutation that causes constitutive localization of the protein to the plasma membrane, leading to hyperphosphorylation of serine-473 and threonine-308 in a growth factor-independent manner (236). AKT2 amplification is frequently detected in various tumors, including ovarian, breast, colorectal, and pancreatic cancers, and is positively correlated with increased invasion and poor prognosis (237)(238)(239). Selective activation of the AKT3 subtype combined with PTEN loss has been observed in 43-60% of sporadic melanomas, indicating elevated levels of active AKT3 in the late stages of the disease (240).The pharmacological markers of AKT inhibitors have demonstrated incomplete targeted regulation. Currently, there are no approved biomarkers that can predict treatment response to specific AKT inhibitors before their use. Consequently, predicting which patients will experience adverse reactions due to AKT inhibition is challenging. However, the AKT E17K mutation is a promising biomarker, as clinical data have shown a correlation between this mutation and the response to the AKT inhibitor capivasertib (241). Mutations that confer resistance to one AKT inhibitor may not necessarily confer resistance to others. For example, the clinically relevant AKT1 Q79K mutation can induce resistance to certain miRNAs but not MK-2206, highlighting the importance of understanding AKT genotypes when selecting appropriate treatments (242). Targeting AKT is a key focus of clinical oncology research, and future studies may improve its clinical efficacy by combining AKT inhibitors with synergistic cytotoxic drugs.Several mTOR inhibitors (mTORis) have been developed; however, only everolimus and temsirolimus have been approved for treating human tumors. Everolimus has shown acceptable safety in patients with neuroendocrine tumors, TSC-associated angiomyolipomas, renal cell carcinomas, and breast cancer. In patients with neuroendocrine tumors receiving everolimus monotherapy, grades 3-4 drug-related adverse events included stomatitis (9%), diarrhea (7%), infection (7%), anemia (4%), fatigue (3%), and hyperglycemia (3%). In renal cell carcinoma patients undergoing combination therapy with everolimus and lenvatinib, the most common grades 3-4 adverse events were constipation (37%) and diarrhea (20%) (243,244). The most common grades 3-4 adverse reactions induced by temsirolimus included hypertriglyceridemia (44%), anemia (20%), hypophosphatemia (18%), lymphopenia (16%), hyperglycemia (16%), fatigue (11%), dyspnea (9%), neutropenia (5%), rash (5%), and pain (5%) (245). Additionally, developing new combination therapies may help to identify the molecular factors responsible for resistance to each drug class and improve patient selection for specific treatments. Optimizing the treatment sequences using different drugs may delay or overcome resistance to mTOR inhibitors.Long non-coding RNAs (lncRNAs), a class of ncRNAs longer than 200 nucleotides that regulate gene expression through various mechanisms, play critical roles in tumorigenesis (246). In recent years, many lncRNAs have been implicated in cancer progression by modulating the PAM signaling pathway. MALAT1, a well-known tumor-promoting lncRNA, competitively binds to microRNAs (miRNAs) such as miRNA-101 to relieve the inhibition of the PAM signaling pathway, thereby promoting tumor cell proliferation and migration (247).Conversely, MEG3 is a tumor suppressor lncRNA that inhibits tumorigenesis by negatively regulating the PAM signaling pathway (248). The relative transcription level of colorectal cancer-related lncRNA colorectal cancer (OECC) was initially significantly upregulated in clinical LC tissues and cultured LC cells. Knocking down OECC in the LC cell line A549 led to a reduction in the mRNA levels of PI3K, phosphoinositide-dependent kinase-1, AKT, MiR-21, a well-known pro-tumor miRNA, directly inhibits PTEN expression, thereby activating the PI3K/AKT pathway and promoting tumor cell proliferation, migration, and survival (253). MiR-29 promotes tumorigenesis by enhancing mTOR signaling through inhibition of the TSC1/TSC2 complex (254). Conversely, miR-126 acts as a tumor suppressor by inhibiting the expression of the PIK3R2 subunit of PI3K, thereby suppressing the PI3K/AKT pathway and reducing cell proliferation (254). Research has demonstrated that the overexpression of microRNA-520a-3p significantly reduces the ratios of p-AKT/AKT, p-PI3K/PI3K, and Bcl-2/Bax, as well as the levels of mTOR, matrix metalloproteinase-2 (MMP-2), and matrix metalloproteinase-9 (MMP-9) in NSCLC. Conversely, inhibition of microRNA-520a-3p expression enhances cell proliferation, migration, and invasion, while suppressing apoptosis (255).Overall, miRNAs and lncRNAs are promising therapeutic targets as regulatory molecules of the PAM signaling pathway. By designing miRNA mimetics or inhibitors or by interfering with lncRNA function, cancer-related signaling pathways can be modulated, offering new strategies for anti-cancer therapy. These approaches will facilitate the development of innovative cancer treatments.Further research focusing on these molecules is expected to yield novel treatment options for cancer patients, and the outlook for LC treatment is optimistic. The PAM signaling pathway has demonstrated significant success in treating various tumors, and breakthroughs in LC therapy are anticipated. As more drugs targeting the PAM signaling pathway emerge, integrating multiple therapeutic approaches will play a crucial role in future treatment models.Multidisciplinary research may uncover increasingly effective strategies to gradually improve the survival rates of patients with LC. Additionally, advances in personalized precision medicine will offer more tailored and effective treatments, contributing to an overall improvement in the outcomes of this malignant disease.In summary, the PAM pathway represents a critical target in the development of therapies for LC. Despite advances in identifying inhibitors and natural products targeting this pathway, challenges such as drug resistance, toxicity, and compensatory mechanisms persist.Addressing these issues requires a comprehensive understanding of the PAM pathway's role in cancer progression and its interaction with other signaling networks. This figure consists of two maps showing the age-standardized incidence (Figure 1A) and mortality rates (Figure 1B) of lung cancer (per 100,000 population) across different regions of the world in 2022. The color gradient in Figure 1A, from light blue to dark blue, represents increasing incidence rates, with darker blue regions indicating higher lung cancer incidence.In Figure 1B, the color gradient from light red to dark red represents increasing mortality rates, with darker red regions indicating higher lung cancer mortality. These complex interactions within the TME collectively create an environment that promotes immune escape, angiogenesis, and tumor progression.Buparlisib: A novel, potent, and highly selective Class I PI3K inhibitor that has demonstrated anticancer efficacy in various solid tumor models. It inhibits the growth of non-small cell lung cancer (NSCLC) cells regardless of specific genetic mutations (e.g., K-Ras, p53, LKB1, PTEN, EGFR, or CDKN2A). Clinical studies, such as NCT01820325, have found that although PI3K pathway activation can be detected via circulating tumor DNA (ctDNA), it may not be a primary oncogenic driver in NSCLC. However, combination therapies involving PI3K inhibitors and other agents may be more effective.