Pilot Study To Investigate Targetable Metabolic Pathways Sustaining Triple Negative Breast Cancer

One of the recognized hallmarks of cancer cells is deregulated cellular metabolism,
characterized by enhanced metabolic autonomy compare with non-transformed cells. Tumor cells
typically display an overall increase in glucose metabolism, associated with enhanced aerobic
glycolysis and decreased oxidative phosphorylation, accompanied by a requirement for a high
rate of protein, nucleotide, and fatty acid synthesis to provide the raw materials for cell
division. 13C-glucose is a non-radioactive stable isotope tracer that has been widely used in
vitro, in vivo, and in patients in a variety of disease settings to study glucose, amino
acid, and lipid metabolism, at steady state and following intervention. [1,2-13C] glucose can
provide additional information on the activity of the oxidative pentose phosphate pathway
versus glycolysis. Administration of intravenous 13C-glucose is a convenient and affordable
approach to analyzing the metabolomics of human cancers in their native microenvironments.

The metabolic dependencies of the various breast cancer subtypes are poorly understood.
Importantly, in depth analyses of the in situ metabolic processes utilized by triple-negative
breast cancers (TNBCs) using state-of-the-art in vivo [1,2-13C]-glucose infusions in patients
with TNBC has never been done. In TNBC, oncogenic activation of key signaling pathways leads
to altered metabolic programming resulting in an increased dependence on exogenous nutrients
such as glucose and glutamine. These data further suggest a hypothesis that TNBCs may employ
a cellular mechanism called macropinocytosis to ingest and degrade interstitial albumin to
accumulate glutamine. This process may then be exploited for therapeutic gain through
enhanced uptake by cells that utilize macropinocytosis to meet their metabolic requirements.

In this study, administration of [1,2-13C]-glucose to patients with TNBC will be done prior
to patients undergoing a biopsy of their breast cancer as well as blood sample collection
which will allow for in depth evaluation of glycolysis as well as lipid and amino acid
metabolism by Joshua Rabinowitz, PhD, at Princeton University who is an international expert
in cancer metabolomics. RAS and PI3K pathway and other genomic alterations as well as pathway
activation status will be determined by next generation sequencing (NGS) and by reverse phase
protein array (RPPA), and will be correlated with the metabolic findings, and both will be
assessed in the context of the patients' response to standard preoperative chemotherapy.

Inclusion Criteria:

A patient will be considered for enrollment in this study if all the following criteria are
met:

1. Female patients ≥18 years of age.

2. Have TNBC defined as invasive ductal cancer: ER- tumors with <10% of tumor nuclei
immunoreactive; PR- tumors with <10% of tumor nuclei immunoreactive; HER2-negative
defined as follows:

1. FISH-negative (FISH ratio <2.0), or

2. IHC 0-1+, or

3. IHC 2+ AND FISH-negative (FISH ratio<2.0)

3. Adequate hematologic function, defined by:

1. Absolute neutrophil count (ANC) >1000/mm3

2. Platelet count ≥100,000/mm3

3. Hemoglobin >9 g/dL (in the absence of red blood cell transfusion)

4. Adequate liver function, defined by:

1. AST and ALT ≤ 5 x the upper limit of normal (ULN)

2. Total bilirubin ≤1.5 x ULN

5. Adequate renal function, defined by:

a. Serum creatinine ≤ 2 x ULN or calculated creatinine clearance of ≥60 ml/min

6. Have blood glucose <250 mg/dL

7. Willing to undergo 1 mandatory core biopsy (6 passes) for research purposes.

8. All patients must be able to understand the investigational nature of the study and
give written informed consent prior to study entry.

Exclusion Criteria:

A patient will be ineligible for inclusion in this study any of the following criteria are
met:

1. Patients receiving any anti-cancer therapy (chemotherapy, immunotherapy, and/or
biologic therapy).

2. Is currently enrolled, or will enroll in, a different clinical study in which
investigational therapeutic procedures are performed or investigational therapies are
administered while participating in this study.

3. Has a history of insulin-dependent diabetes.

4. Concomitant active malignancy

5. Is pregnant or breastfeeding.