Is There a Role for Dual PI3K/mTOR Inhibitors for Patients Affected with Lymphoma?

The activation of the PI3K/AKT/mTOR pathway is a main driver of cell growth, proliferation, survival, and chemoresistance of cancer cells, and, for this reason, represents an attractive target for developing targeted anti-cancer drugs. There are plenty of preclinical data sustaining the anti-tumor activity of dual PI3K/mTOR inhibitors as single agents and in combination in lymphomas. Clinical responses, including complete remissions (especially in follicular lymphoma patients), are also observed in the very few clinical studies performed in patients that are affected by relapsed/refractory lymphomas or chronic lymphocytic leukemia. In this review, we summarize the literature on dual PI3K/mTOR inhibitors focusing on the lymphoma setting, presenting both the three compounds still in clinical development and those with a clinical program stopped or put on hold.


Introduction
The activation of the phosphoinositide 3-kinase (PI3K)/v-akt murine lymphoma viral oncogene homolog (AKT)/mammalian target of rapamycin (mTOR) pathway is a main driver of cell growth, proliferation, survival, and chemoresistance of cancer cells [1][2][3][4][5]. The PI3K/AKT/mTOR pathway has already represented an attractive target for developing targeted anti-cancer drugs for many years, and, indeed, many isoform-specific, pan-inhibitors, or dual PI3K/mTOR inhibitors have already entered the clinical evaluation and also undergone approval by regulatory agencies [1][2][3][4]. The pathway is also important for lymphoma cells and its pharmacological inhibition has shown clinical benefit for patients that are affected by different lymphoproliferative neoplasms [1,2,6].
The present review will focus on dual PI3K/mTOR inhibitors in clinical and pre-clinical development for patients that are affected by hematological malignancies after providing an overview of the pathway in relation with cancer.

The PI3K Signaling Pathway
Human cells express three classes of PI3Ks proteins, according to primary sequence homology, regulation, and in vitro substrate specificity [1,3,4,7,8]. PI3Ks are composed by a catalytic isoform complexed with a regulatory subunit, which regulates the activity, localization, and binding of the dimer. In mammals, class I PI3Ks are divided into IA and IB subclasses that are based on their regulation criteria. Class IA PI3Ks includes heterodimers of p110 catalytic subunit and p85 regulatory subunit. The class IA catalytic subunit isoforms are encoded by the genes PIK3CA, PIK3CB, and PIK3CD (p110α,

PI3K Pathway and Metabolism
PI3K signaling is activated upon grow factor stimulation and grow factor receptors activation, including insulin receptor (INSR), which regulates metabolic homeostasis. Conformational changes of the activated receptors allow autophosphorylation and the activation of INSR, which recruits IRS proteins, which are phosphorylated by INSR and finally create the binding motif for p85 [3,19]. The early insulin-driven PI3K signaling leads to enhanced glucose transporters (GLUT) translocation in the membrane [20] and augmented transcription and translation of genes coding for these transporters [21], increasing the glucose uptake in muscle and fat cells. The isoform p110α mediates glucose homeostasis in muscle, liver, and fat [22]. The regulatory subunit p85 could act both as a positive and negative regulator of insulin signaling. In fact, p85 could also block IRS signaling [23], which causes the inhibition of insulin signaling and formation of insulin resistance. Based on its normal biologic functions, it is obvious that pharmacological targeting the of PI3K/mTOR pathway as cancer treatment is unlikely to be devoid of on-target metabolism-related toxicities. Indeed, drugs that target p110α induce acute insulin resistance, which causes severe hyperglycemia, leading to hyperinsulinemia [3].

Deregulation of the Signaling in Cancer
As already mentioned, a constitutive activation and deregulation of the PI3K/AKT/mTOR pathway is almost a hallmark of cancers cells [1,2,4,24,25]. Somatic mutations in the genes encoding for

PI3K Pathway and Metabolism
PI3K signaling is activated upon grow factor stimulation and grow factor receptors activation, including insulin receptor (INSR), which regulates metabolic homeostasis. Conformational changes of the activated receptors allow autophosphorylation and the activation of INSR, which recruits IRS proteins, which are phosphorylated by INSR and finally create the binding motif for p85 [3,19]. The early insulin-driven PI3K signaling leads to enhanced glucose transporters (GLUT) translocation in the membrane [20] and augmented transcription and translation of genes coding for these transporters [21], increasing the glucose uptake in muscle and fat cells. The isoform p110α mediates glucose homeostasis in muscle, liver, and fat [22]. The regulatory subunit p85 could act both as a positive and negative regulator of insulin signaling. In fact, p85 could also block IRS signaling [23], which causes the inhibition of insulin signaling and formation of insulin resistance. Based on its normal biologic functions, it is obvious that pharmacological targeting the of PI3K/mTOR pathway as cancer treatment is unlikely to be devoid of on-target metabolism-related toxicities. Indeed, drugs that target p110α induce acute insulin resistance, which causes severe hyperglycemia, leading to hyperinsulinemia [3].
Mutations targeting catalytic class I PI3K isoforms are only associated to PIK3CA catalytic isoform, while in the other class I catalytic isoforms PIK3CB, PIK3CD, and PIK3CG tumor associated mutations are very rare [28,29]. Mutations in the PIK3CA are associated with augmented kinase activity and cluster in two 'hotspots', one in the exon 9 (E542K and E545K, in the helical domain), the other in exon 20 (H1047R, in the kinase domain) [28,30,31]. The E542K and E545K mutations disrupt the inhibitory interface with the regulatory subunit p85, while H1047R mutation enhance the interaction of the kinase domain with cell membranes. Nevertheless, proteins p100β, p100δ, and p100γ are also capable of inducing oncogenic transformation in their wild-type form [32], in line with the fact that PIK3CB, PIK3CD, and PIK3CG are generally amplified or overexpressed, but not mutated, in cancer. Genes encoding AKT isoforms, mTOR, and PTEN are targeted by somatic mutations deregulating the PI3K/AKT/mTOR pathway. Mutations in the RTK or RAS genes, RTK receptor overexpression/amplification, autocrine loops involving RTKs, and the ligands are also recurrent events [6].
The regulatory isoforms p85 are also involved in tumorigenesis. Specific PIK3R1 mutations in the region of the protein that interacts with p110 stabilize the p110 isoforms and abrogate the inhibitory action of p85 on p110 [33]. Mutations in other PI3K regulator subunits are rare.
The amplification of AKT1 and AKT2 and activating mutation of AKT1 (in E17K) increase AKT1 binding to the plasma membrane and its phosphorylation in solid tumors [34].

Deregulation of the Signaling in Lymphoma
The PI3K pathway is activated by a large number of mechanisms across B-cell malignancies. In patients, PIK3CA mutations or amplification were found, respectively, in 8% of DLBCL (diffuse large B-cell lymphoma), mainly in the catalytic domain, [35,36], and in 68% of mantle cell lymphoma (MCL) [37,38]. Chronic lymphocytic leukemia (CLL) patients rarely have PIK3CA mutations [39] and amplification of PIK3CA has been reported in 5.6% of the cases [40]. PTEN loss was observed in 15% of MCL patients [37,38], in 37-55% of DLBCL patients [35,41,42], and in 21% of follicular lymphoma (FL) [43]. Low levels of PTEN were observed also in CLL patients [44]. Among DLBCL, the loss of PTEN expression was found in 55% of GCB (germinal center B-cell type) DLBCL patients, and only in 14% of non-GCB DLBCL cases [41]. In GCB DLBCL cell lines and primary patient samples, PTEN status was inversely correlated with the activation of the PI3K/AKT pathway, suggesting that activation of this pathway could give an oncogenic addiction for this subtype of DLBCL. In fact, in GCB DLBCL, deletions of PTEN, and amplification of the MIR17HG (microRNA-17-92 cluster) sustain cell proliferation [45]. Similar deregulation of PTEN and MIR17HG is also in place in Burkitt lymphoma (BL) cells, in which the constitute activation of the MYC oncogene that is due to chromosomal translocation also directly activates PI3K/AKT/mTOR [46][47][48][49].
PI3K pathway activation can also be mediated by B cell receptor (BCR) signaling. The phosphorylation of CD19 by BCR leads to the binding of the regulatory subunit p85, and the recruitment of the p110 catalytic subunit [50]. BTK, which is a downstream protein of BCR, is activated by PI3K (by PIP3) in B cells.
Recurrent mutations in PIK3CD, PIK3R1, and MTOR occur in DLBCL primary tumors [51]. Three cases were characterized by single point mutation T → G in the catalytic domain of PIK3CD, converting Asp (uncharged side chains) in Lys (charged side chains). The mutations in PIK3CD, PIK3R1, and MTOR did not all cluster in a single hot spot of the gene, but they were spread across it. PIK3CD mutations were localized in the catalytic domain (N948K, E1021K), PIK3R1 mutations occurred in the RhoGAP-p85 domain (V172M, A210D), and in the COG4942 domain (Y470D, D560G), MTOR mutations were in the HEAT domain (A835T), close to the FAT and rapamycin binding domains (N1765D, A37T, T182K), and to the FATC domain (V619I). The cell lines with MTOR mutations showed a higher sensitivity to PI3K inhibitor than those that did not harbor MTOR mutations, which suggests that sensitivity to PI3K inhibitors correlates with MTOR mutations.
In GCB DLBCL cell lines, a tonic (antigen-independent) BCR signaling activates AKT, regulates proliferation and size with different magnitudes, and AKT knockout resulted in toxicity [52].
Chronic active BCR signaling is typical of ABC (activated B cell) DLBCL, the subgroup of DLBCL with constitutive activation of NFκB (nuclear factor κB), also regulated by PI3K [53].
The phosphorylation of AKT was detected in 52% of DLBCL [54], and the sensitivity to AKT inhibition correlated to the efficacy of the inhibitor to block phosphorylation of S6K1 and RPS6 [55]. Cell lines expressing AKT-independent S6K1, as activated by upregulation of PIM2 (Pim-2 Proto-Oncogene, Serine/Threonine Kinase) or activation of BCR, are resistant to AKT inhibitors. Combining AKT inhibitor with BTK, PIM2, or S6K1 inhibitors could overcome resistance to AKT inhibition in this subtype of lymphoma.
Finally, the PI3K/AKT/mTOR signaling also plays an important role in the different non-neoplastic cells that are present in the tumor microenvironment, for example regulating the proliferation and migration of endothelial cells, the M1/M2 polarization of macrophages, and the activation and/or differentiation of T cells [56][57][58][59][60][61][62].

Dual PI3K/mTOR Inhibitors in Lymphoma
We can recognize different classes of compounds targeting the PI3K/AKT/mTOR pathway: pan-PI3K inhibitors, isoform specific inhibitors (i.e., idelalisib), dual PI3K/mTOR inhibitors, AKT inhibitors, allosteric mTOR inhibitors (rapalogs) inhibitors, and mTOR kinase inhibitors [1,2,4,14,[63][64][65][66][67][68][69]. An interesting strategy is to target several PI3K isoforms as well as mTOR instead of a single PI3K isoform or only mTOR. In fact, the catalytic isoform of the p110 subunit and mTOR have structural similarities, and targeting two crucial points of the same pathway could lead to higher efficacy, could overcome feedback inhibition coming from mTOR inhibition [70], and the risk of drug resistance that should easily come out in the case of treatment with compounds targeting a single p110 isoform [71][72][73]. Indeed, the dual PI3K/mTOR inhibitors have shown, at least in the preclinical setting, an improved than what achieved targeting individually single PI3K isoforms, all PI3K isoforms or mTOR [74][75][76][77]. Table 1 shows an exhaustive list of the dual class I PI3K and mTOR inhibitors. Table 2 summarizes the clinical data available for patients that are affected by lymphoma enrolled in phase I/II studies with such a class of compounds. The chemical structures, International Union of Pure and Applied Chemistry (IUPAC) names, and molecular weights for all of the compounds are shown in Table 3 or Table S1, depending on their current clinical development stage. Indeed, there are only three dual PI3K/mTOR inhibitors that are still in clinical development for humans: bimiralisib, GDC-0084, and gedatolisib.   [78];ˆˆ, the trial also allowed the addition of rituximab.    GDC-0084 (RG 7666) is orally given and it passes the blood brain barrier (BBB) and it has been specifically developed for patients with brain tumors or with brain metastases from solid tumors [87][88][89]. Gedatolisib (PF05212384/PKI-587) is an intravenous inhibitor of PI3Ks (preferentially of p110α, also acting on the mutant forms) and TORC1/TORC2 with preclinical activity in different solid tumor models [90,91]. There are no data in lymphoma models, while the compound has been extensively tested in lymphoblastic and myeloid leukemia models [92][93][94][95]. No lymphoma patient was treated in the phase I study [96].
Bimiralisib (PQR309) inhibits all of the PI3Ks (p110α, first, followed by p110δ, p110β, and p110γ) and TORC1/TORC2 [97]. It is an oral compound and it is capable of crossing the BBB [97]. When comparing the published data [97,98], bimiralisib has an overlapping inhibition of p110α with voxtalisib, a reduced inhibition of p110δ, p110β, and p110γ, a higher activity on mTOR, and a reduced activity on the off-target DNA-PK [97]. Bimiralisib has in vitro and in vivo anti-lymphoma activity in models that were derived from B and T cell lymphomas [75], and also from canine DLBCL [99]. The pattern of activity is highly correlated to what was achieved by apitolisib, another dual PI3K/mTOR inhibitor (see below), but bimiralisib shows higher IC50 values [75]. Bimiralisib also shows in vitro activity in lymphoma cell lines with primary or secondary resistance to the PI3Kδ inhibitor idelalisib [75]. Analysis of transcriptome and phospho-proteomics of DLBCL cells that were exposed to bimiralisib demonstrates that the compound modulates transcripts and proteins that are involved in fundamental pathways and signaling cascades: BCR signaling, NFκB pathway, PI3K/AKT/mTOR pathway, mRNA processing, apoptosis, cell cycle, MAPK/RAS signaling, Myc pathway, and glycolysis [75]. Moreover, the modulation of these pathways occurs via changes at both the RNA and protein phosphorylation levels. However, while the mTOR pathway and mRNA metabolism are more regulated at the protein level, cell cycle and BCR signaling changes are more driven by expression level changes [75]. Interestingly, the early changes at the RNA level seen after bimiralisib exposure are largely overlapping with what was observed after exposing the same DLBCL cell lines to the p100δ inhibitor idelalisib, the p100δ/ p100γ inhibitor duvelisib, or the BTK inhibitor ibrutinib [75], in accordance with studies that were performed in normal B cells after BTK and PI3K genetic silencing [100]. Importantly, an adaptive mechanism with an early upregulation of genes coding members of the BCR signaling is induced by bimiralisib, idelalisib, duvelisib and ibrutinib, partially explaining the benefit of targeting the BCR signaling with compounds targeting multiple of its members [75]. Bimiralisib as well as other BCR signaling inhibitors, up-regulates CXCR4, which is a possible marker of adaptive resistance [75,101].
Following the completion of a phase 1 study in patients with advanced solid tumors [102], bimiralisib has entered the clinical setting for patients with relapsed/refractory lymphoma (phase I/II: II NCT02249429, NCT03127020), and for patients with relapsed/refractory primary central nervous system lymphomas (NCT02669511). Unfortunately, the only data publicly available refer to the first 15 patients that were enrolled in the phase I (NCT02249429). Reported severe (G3/G4) side effects include hyperglycemia, rhabdomyolysis, anorexia, neutropenia, sepsis, pneumonitis, and fatigue. Clinical responses were seen in 27% of 11 evaluable patients with one complete response (CR) in a FL patient and partial responses (PR) in two patients (DLBCL, MZL) ( Table 2), and stable diseases (SD) in FL (3/4 patients), MCL (1/2 patients), and T-cell lymphoma (1/1 patients) [78]. The pattern of activity, with most of the responses in FL, is similar to what was reported with another dual PI3K/mTOR inhibitor voxtalisib (see below) [79,80].
All of the other dual PI3K/mTOR inhibitors have not reached the clinical development stage or the latter has been permanently or temporarily stopped. Among these, here we will only discuss the two agents with available clinical data, whilst we refer to the Supplementary Material for the other compounds.
Voxtalisib (XL765/SAR245409) preferentially targets p110γ, followed by p110α, p110δ, p110β, and TORC1/TORC2 with activity in a variety of solid tumor models [98]. It is an oral compound and passes the BBB [98]. Voxtalisib also has preclinical anti-tumor activity in models of lymphoma and CLL [103]. The positive laboratory data have led to different clinical trials as single agent and also in combination in patients with hematological cancers [79,80,104].
Sixteen patients with relapsed or refractory lymphoma (MCL, FL, DLBCL, others) received voxtalisib in an expansion cohort [79] of the phase I study for patients with solid tumors (NCT00485719) [105] ( Table 2). The toxicity profile included fatigue, gastrointestinal and cutaneous adverse events, liver enzyme abnormalities, and cytopenia [79]. Three patients achieved a clinical response with one CR in a FL patients and two PR in patients (DLBCL, MCL, one patient each) [79]. Although not reaching the definition of PR, two FL experienced tumor regression and six patients had SD, with one MCL and one FL receiving treatment for four months or longer [79]. Reductions in PI3K/mTOR and ERK pathway activity were seen in the serial tumor biopsies done, which were only successfully performed in one patient (MCL with PR) [79]. There was no evident modulation of chemokine or cytokine levels by drug exposure. Only two of 12 patients that underwent serial measurements presented changes [79]. Although they were both cases with clinical responses (CR and PR), the observed changes were not concordant with no overlapping changes and with the IL16 (interleukin 16) levels behaving in the opposite way [79]. Based on these results, a phase II study with voxtalisib (NCT01403636) enrolled 167 patients with relapsed or refractory disease (FL, MCL, DLBCL, CLL) [80] (Table 2). Clinical responses were seen in all of the subtypes, but especially in FL (41%), followed by MCL and CLL (12 and 11%, respectively) [80]. Only two of the 42 (5%) DLBCL patients responded [80]. Complete responses were observed in FL (11%, 5/47) and MCL (7%, 3/42) [80]. SD was seen in 33% (14/42) of MCL patients, 30% (14/46) of FL, 10% (4/41) of DLBCL, and 66% (23/35) of CLL [80]. The median progression-free survival was 58 weeks for FL patients, 24 for CLL, nine for MCL, and seven for DLBCL [80].
No useful information came from genetic studies done on tumor samples before treatment or from the measurement of cytokines and chemokines in plasma samples in both the phase I [79] and in the phase II [80] voxtalisib studies. In the phase I study, only two of 12 patients that underwent serial measurements presented changes [79]. Although they were both cases with clinical responses (CR and PR), the observed changes were not concordant and the IL16 levels modulated in the opposite way [79].
The combination has also been studied in a phase I clinical trial study (NCT01410513), evaluating voxtalisib in combination with the anti-CD20 monoclonal antibody rituximab plus or minus the chemotherapy agent bendamustine in patients with relapsed or refractory B-cell malignancies [104]. The study enrolled 37 patients, 16 in the rituximab arm (CLL, n. = 11; MCL, n. = 3; FL, n. = 2) and 21 in the triple combination arm (CLL, n. = 12; MCL, n. = 6; FL, n. = 3) [104]. The safety profile (characterized by nausea, fatigue, and vomiting) was acceptable, with no interactions among drugs at the pharmacokinetic level [104]. There was clinical activity: one CR in FL patient and five PRs in the voxtalisib/rituximab; three CRs (one patient with MCL, two with CLL) and eight PRs in the voxtalisib/rituximab/bendamustine arm [104].
The clinical development of voxtalisib has been stopped [106] due to limited clinical anti-tumor activity observed in two phase I studies enrolling 83 (NCT00485719) [105] and 49 (NCT01596270) [106] patients with advanced solid tumors.
The LY294002/SF1101 derivative SF1126 is a multikinase inhibitor, which targets the PI3K isoforms and TORC1/TORC2, but also DNA-PK and the BET Bromodomain proteins [107][108][109]. SF1126 has preclinical anti-tumor activity in B and T cell lymphoma models [110], as well from multiple myeloma [111]. None of the five patients with B cell lymphoid neoplasm that were enrolled in the phase I study (NCT00907205) achieved a CR or PR [81] (Table 2). Two CLL patients (one with no prior therapy) achieved a SD [81].
Different dosing schedules could improve the toxicity profile and provide the best therapeutic window. For example, apitolisib given once weekly [123] has shown better tolerability than once daily [120]. Other approaches include intermittent dosing, dose reductions, and interruptions that are based on side effects [1][2][3].
Alternative modalities to decrease the side effects that have been explored are the delivery of the compounds preferentially to cancer cells (sparse preclinical data with BEZ235 in CaCO(3) nanocrystals [125] or in liposomes [126]) or lowering the doses of the dual PI3K/mTOR inhibitors in the context of combination therapies can help to overcome the toxicity issue. Combinations would also be important for two additional reasons. First, the addition of a second compound can overcome the primary or acquired resistance to the dual PI3K/mTOR inhibitors [3][4][5]. Indeed, resistance to both PI3K and mTOR inhibitors is due to genetic events that maintain the same pathway active or via activation of alternative signaling cascades [3,4,64]. Second, the activation of PI3K/mTOR signaling is a frequent mechanism of resistance to other targeted agents [3,4]. Studies conducted mainly in the solid tumor setting suggest that combinations with other agents can be feasible [104,113,114,127,128], although toxicities can still be an issue [106,127,[129][130][131][132][133].
Preclinical data that were obtained in different lymphoma models indicate that dual PI3K/mTOR inhibitors synergize with both targeted and chemotherapy agents, as presented in Table 4. For few combinations, synergism has been observed in different laboratories and/or obtained with different dual PI3K/mTOR inhibitors, underlying the robustness of the data. Table 4. Combinations based on dual PI3K/mTOR inhibitors with available preclinical data in lymphomas.

Steroids
Dexamethasone [150] Omipalisib [150] T-NHL [150] ABC While also considering the toxicity profile and its already established role in CLL and lymphomas [151], the BCL2 inhibitor venetoclax appears as an interesting drug to be combined with dual PI3K/mTOR inhibitors. Bimiralisib, dactolisib, and omipalisib have all shown synergism when combined with venetoclax [75,[139][140][141]. Combining dactolisib with venetoclax induces the accumulation of pro-apoptotic BAD and BIM and down-regulation of the anti-apoptotic MCL1 [139,140], with the ability to revert secondary resistance to venetoclax [139]. The combination of bimiralisib with venetoclax is much more active than the single agents in GCB and ABC DLBCL xenograft models, as well as causing an increase in cell death in CLL primary cells [75].
Another combination that is sustained by multiple data is with histone deacetylase (HDAC) inhibitors.
Dactolisib, bimiralisib, and omipalisib have been successfully combined with panobinostat [75,145] or Vorinostat [141]. In ABC, GCB and double hit DLBCL, and MCL cell lines, dactolisib had major effect when combined with HDAC inhibitor panobinostat, AKT inactivation, MCL1 downregulation, and BIM upregulation contribute to the effect of the combination of dactolisib with panobinostat [145,147,152].
Combination with the FDA approved BTK inhibitor ibrutinib appears to be another interesting combination, as shown using apitolisib, bimiralisib [75], and dactolisib [143] in ABC DLBCL and MCL models [75,143].
Bimiralisib and other BCR signaling inhibitors induce the increased expression of both PIM1 and PIM2, kinases that are involved in lymphomagenesis and potential therapeutic targets. The combination of bimiralisib with the PIM inhibitor AZD1208 [153] is largely synergistic in both GCB and ABC DLBCL cells with an increased G0/G1 cell cycle arrest [75]. The addition of the PIM inhibitor SGI-1776 to dactolisib is associated with MCL1 downregulation and increased cell death in the ABC DLBCL cell lines [76].
Bimiralisib [75] and PF04691502 [136] have been beneficially combined with the anti-CD20 monoclonal antibody rituximab in the DLBCL and MCL cell lines. The addition of rituximab to a dual PI3K/mTOR inhibitors with rituximab is the only combination that has been clinically evaluated. Indeed, we have already mentioned the voxtalisib phase I trial that has reported some clinical activity [104].
Similar results have been obtained with three dual PI3K/mTOR inhibitors (dactolisib, bimiralisib, and omipalisib) added to proteasome inhibitors (bortezomib or marizomib) [75,141,144,149]. In particular, the addition of dactolisib reverts the resistance to proteasome inhibitors in a bortezomib-resistant MCL cell line decreasing AKT and mTOR signaling [144].
Finally, the effect of this class of agents on the tumor microenvironment and how this indirect activity can be exploited, especially in combination with immuno-oncology drugs, such as the bispecific antibodies, is an open issue [154,155].

Conclusions
Based on the importance of the p110α in different solid tumors, a bigger relevance to this isoform has been given in the design of compounds and in the population of patients that are enrolled in the clinical studies. However, there are plenty of preclinical data sustaining the anti-tumor activity of dual PI3K/mTOR inhibitors as single agents and in combination in lymphomas. Additionally, clinical responses, including CR (especially in the FL setting), are clearly observed in the very few clinical studies that were performed in patients affected by relapsed/refractory lymphomas or CLL. Unfortunately, the vast majority of clinical trials that were performed in patients with solid tumors have been disappointing due to unacceptable toxicity profile and/or to a lack of meaningful clinical activity. Based on these clinical results, the clinical development of all but three dual PI3K/mTOR inhibitors has been stopped, although they could be beneficial for some patients that were affected by lymphoid neoplasms. Different schedules of dual PI3K/mTOR inhibitors given as single agents in specific patients' populations (for example, high risk or relapsed/refractory FL patients) or combination regimens (for example, with venetoclax) appear still worthy of further clinical investigations. The use of tools to identify the responders at an early time-point, possibly paired with still-to-be defined robust biomarkers, will help in optimizing the use of dual PI3K/mTOR inhibitors, avoiding both toxicities to patients that are unlikely to benefit and costs to the health care system.