Targeting Triple Negative BREAst Cancer Metabolism With a Combination of Chemoimmunotherapy and a FASTing-like Approach in the Preoperative Setting: the BREAKFAST 2 Trial

Inclusion Criteria:

1. Female sex
2. Age ≥ 18 and ≤ 75 years.
3. Evidence of a personally signed and dated informed consent document (ICD), signed anddated from the patient of legal representative with or without an impartial witness,indicating that the patient has been informed of all pertinent aspects of the studybefore enrollment
4. Willingness and ability to comply with the prescribed FLA regimen, the scheduledvisits, treatment plans, laboratory tests and other procedures.
5. Histologically confirmed diagnosis of invasive TNBC candidate to neoadjuvantchemo-immunotherapy and subsequent curative surgery. On the basis of InternationalGuidelines, TNBC is defined by absent or minimal (<1%) expression of oestrogen andprogesterone receptors at IHC, and absence of HER2 protein over-expression and HER2gene amplification, as defined as an IHC score of 0, 1+, or an IHC score of 2+ with insitu hybridization (ISH) analysis excluding HER2 gene amplification. The expression ofhormone receptors (ER and PgR) and HER2 will be evaluated through immunohistochemistry (IHC), according to International Guidelines47,48
6. Availability of a formalin-fixed, paraffin-embedded (FFPE) block containing tumortissue, or at least 7 unstained tumor slides.
7. Patients with tumor stage T1c AND nodal stage N1-2, or tumor stage T2-4 AND nodalstage N0-2 according to TNM.
8. Presence of an Eastern Cooperative Oncology Group (ECOG) performance status 0 or 1.
9. Presence of adequate bone marrow and organ function as defined by the followinglaboratory values:
10. ANC ≥ 1.5 x 103/l
11. platelets ≥ 100 x 103/l
12. hemoglobin ≥ 9.0 g/dl
13. calcium (corrected for serum albumin) within normal limits or ≤ grade 1 accordingto NCI-CTCAE version 5.0 if not clinically significant
14. potassium within the normal limits, or corrected with supplements
15. creatinine < 1.5 ULN
16. blood uric acid < 10 mg/dl
17. ALT and AST ≤ 2 x ULN
18. total bilirubin < 1.5 ULN except for patients with Gilbert syndrome who may onlybe included if the total bilirubin is < 3.0 x ULN or direct bilirubin < 1.5 x ULN
19. Fasting glucose ≤ 250 mg/dl.
20. Female patients of childbearing potential must agree to sexual abstinence or to usetwo highly effective methods of contraception throughout the study and for at leastsix months after the end of the FLA. Abstinence is only acceptable if it is in linewith the preferred and usual lifestyle of the patient. Examples of contraceptivemethods with a failure rate of < 1% per year include tubal ligation, malesterilization, hormonal implants, established, proper use of combined oral or injectedhormonal contraceptives, and certain intrauterine devices. Alternatively, two methods (e.g., two barrier methods such as a condom and a cervical cap) may be combined toachieve a failure rate of < 1% per year. Barrier methods must always be supplementedwith the use of a spermicide. A patient is of childbearing potential if, in theopinion of the Investigator, she is biologically capable of having children and issexually active.
21. Female patients are not of childbearing potential if they meet at least one of thefollowing criteria:
22. Have undergone a documented hysterectomy and/or bilateral oophorectomy
23. Have medically confirmed ovarian failure
24. Achieved post-menopausal status, defined as: ≥ 12 months of non-therapy-inducedamenorrhea or surgically sterile (absence of ovaries); in women <45 years of ageFSH level in the postmenopausal range may be used to confirm a post-menopausalstate in women not using hormonal contraception or hormonal replacement therapy.

Exclusion Criteria:

1. Prior systemic treatment for breast cancer or other malignancies within 5 years oftreatment enrollment, except for adequately treated basal cell or squamous skin canceror in situ cervical cancer. Other malignancies diagnosed more than 5 years before thediagnosis of breast cancer must have been radically treated without evidence ofrelapse at the moment of patient enrollment in the trial.
2. Prior treatment with anthracyclines
3. Prior therapy with an anti-PD-1, anti-PD-L1, or anti-PD-L2 agent or with an agentdirected to another co-inhibitory T-cell receptor (e.g., CTLA-4, OX-40, CD137)
4. Body mass index (BMI) < 19 kg/m2.
5. History of alcohol abuse.
6. Non-intentional weight loss ≥ 5% in the previous 3 months, unless the patient has aBMI > 22 kg/m2 and weight loss has been lower than 10% at the time of enrollment inthe study; or non-intentional weight loss of ≥ 10% in the previous 3 months, unlessthe patient has a BMI > 25 kg/m2 and weight loss has been lower than 15% at the timeof the enrollment in the study. In both cases, weight must have been stable for atleast one month before study enrollment.
7. Active pregnancy or breast feeding.
8. Known active B or C hepatitis or human immunodeficiency virus (HIV) infection, oroccasional finding of active hepatitis B/C infection during screening tests beforechemotherapy initiation, as defined as positive polymerase chain reaction (PCR)testing for HBV-DNA and HCV-RNA and qualitative PCR for HIV-RNA, or requiring activetreatment at study enrollment.
9. Serious infections in the previous 4 weeks before the FLA initiation, including, butnot limited to, potential hospitalizations for complications of infections,bacteriemia or serious pneumonitis.
10. Active autoimmune diseases requiring systemic treatments (e.g., systemic steroids orimmune suppressants). Replacement therapy (e.g., thyroxine, insulin, or physiologiccorticosteroid replacement therapy for adrenal or pituitary insufficiency) is notconsidered a form of systemic treatment.
11. Active chronic therapy with systemic steroids at a dose ≥ 10 mg per day of prednisoneor equivalent at study enrollment.
12. Diagnosis of type 1 or 2 diabetes mellitus requiring pharmacologic therapy (including,but not limited to, insulin or insulin secretagogues), with the exception ofmetformin. A diagnosis of type 2 diabetes mellitus not requiring pharmacologicaltreatments, or only requiring treatment with metformin, based on the judgment of adiabetologist, is compatible with patient enrollment in the trial.
13. Anamnesis of clinically significant heart disease including:
14. angina pectoris, coronary bypass, symptomatic pericarditis, myocardial infarctionin the previous 12 months from the beginning of experimental therapy;
15. congestive heart failure (NYHA III-IV).
16. Anamnesis of clinically meaningful cardiac arrhythmias, such as ventriculartachycardia, chronic atrial fibrillation, complete bundle branch block, high gradeatrio-ventricular block like bi-fascicular block, type II Mobitz and third gradeatrio-ventricular block, nodal arrhythmias, supra-ventricular arrhythmia.
17. Left ventricular ejection fraction lower than 50% at the cardiac scan withradionuclides or at echocardiography.
18. Previous episodes of symptomatic hypotension leading to loss of consciousness.
19. History of eating disorders (anorexia, bulimia).
20. Baseline plasma fasting glucose ≤ 60 mg/dL.
21. Medical or psychiatric comorbidities rendering the patient not candidate to theclinical trial, according to the investigator's judgement.
22. Other cardiac, liver, lung or renal comorbidities, not specified in the previousinclusion or exclusion criteria, but potentially exposing the patient to a high riskof lactic acidosis.
23. Known history of active TB (Bacillus Tuberculosis).