The
mammalian target of rapamycin (mTOR) has emerged as an attractive
cancer therapeutic target. Treatment of metastatic
renal cell carcinoma (mRCC) has improved significantly with the advent of agents targeting the mTOR pathway, such as
temsirolimus and
everolimus. Unfortunately, a number of potential mechanisms that may lead to resistance to
mTOR inhibitors have been proposed. In this paper, we discuss the mechanisms underlying resistance to
mTOR inhibitors, which include the downstream effectors of the
phosphoinositide 3-kinase (PI3K)/AKT/mTOR pathway, the activation of
hypoxia-inducible factor (HIF), the PIM
kinase family, PTEN expression, elevated
superoxide levels, stimulation of autophagy, immune cell response and ERK/MAPK, Notch and Aurora signaling pathways. Moreover, we present an updated analysis of clinical trials available on PubMed Central and www.clinicaltrials.gov, which were pertinent to the resistance to
rapalogs. The new frontier of inhibiting the mTOR pathway is to identify agents targeting the feedback loops and cross talks with other pathways involved in the acquired resistance to
mTOR inhibitors. The true goal will be to identify
biomarkers predictive of sensitivity or resistance to efficiently develop novel agents with the aim to avoid toxicities and to better choose the active drug for the right patient.