A Confirmatory, Prospective, Open-label, Multi-centre Phase 3 Study to Evaluate Diagnostic Performance of Zirconium-labelled Girentuximab to Non-invasively Detect ccRCC by PET/CT Imaging in Patients With Indeterminate Renal Masses
Phase: PHASE3
Conditions: Clear Cell Renal Cell Carcinoma
Sponsor: Telix Pharmaceuticals (Innovations) Pty Limited

Clinical Study Protocol 
89Zr-TLX250-003 
Version: 8.0 
Date: 01-Apr-2022 
 
 
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A confirmatory, prospective, open-label, multi-centre phase 3 study 
to evaluate diagnostic performance of 89Zirconium-labelled 
girentuximab(89Zr-TLX250) to non-invasively detect clear cell renal 
cell carcinoma (ccRCC) by positron emission tomography/CT 
(PET/CT) imaging in patients with indeterminate renal masses 
(ZIRCON study) 
 
Short Title 
89Zr-TLX250 for PET/CT imaging of ccRCC – ZIRCON-Study 
Test Product: 
89Zr-girentuximab 
Study Purpose: 
Evaluation of sensitivity and specificity of PET/CT imaging with 89Zr-
TLX250 in patients with indeterminate renal masses suspicious of 
ccRCC 
Clinical study phase: 3 
Date: 
01-APR-2022 
Registration: 
EudraCT/IND no. 
2018-002773-21 
Version no.: 
8.0, Amendment 07 
Sponsor’s study no.: 
89Zr-TLX250-003 
 
 
Sponsor: 
TELIX International Pty Ltd 
Main Office, Suite 401, 55 Flemington Road 
North Melbourne VIC 3051, Australia 
Document History: 
 
Date 
Version 
Amendment  
31-Aug-2018 
2.0 (Initial Protocol) 
NA 
07-Nov-2018 
3.0 
Amendment 01 
13-Dec-2018 
4.0 
Amendment 02 
22-Mar-2019 
5.0 
Amendment 03 
10-Sep-2019 
5.1 (Belgium only) 
Amendment 04 
30-Sep-2019 
6.0 (USA and Canada only) 
Amendment 05 
15-Jun-2021 
7.0 
Amendment 06 
01-Apr-2022 
8.0 
Amendment 07 
The study will be conducted in compliance with the protocol, ICH-GCP and any applicable 
regulatory requirements 
Confidential 
The information provided in this document is strictly confidential and is intended solely for the 
guidance of the clinical investigation. Reproduction or disclosure of this document - whether in 
part or in full - to parties not associated with the clinical investigation or its use for any other 
purpose without the prior written consent of the sponsor is not permitted. 
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Clinical Study Protocol 
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Version: 8.0 
Date: 01-Apr-2022 
 
 
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Principal Investigator Agreement Page 
Study title: 
A confirmatory, prospective, open-label, multi-centre phase 3 study to 
evaluate diagnostic performance of 89Zirconium-labelled girentuximab 
(89Zr-TLX250) to non-invasively detect clear cell renal cell carcinoma 
(ccRCC) by positron emission tomography/CT (PET/CT) imaging in 
patients with indeterminate renal masses (ZIRCON study) 
Version: 
8.0, Amendment 07 
Date: 
01-Apr-2022 
Principal Investigator Signature: 
I confirm that I have read and that I understand this protocol and other appropriate related 
documentation for 89Zr-girentuximab provided by the Sponsor and the coordinating CRO.  
I agree to perform this study in accordance with this protocol, the ethical principles that have their 
origin in the Declaration of Helsinki, the International Conference on Harmonisation (ICH) guideline 
for Good Clinical Practice (GCP), and the applicable regulatory requirement(s).  
I will also appropriately direct and assist the personnel at the trial site who will be involved in the 
conduct of the study. 
 
 
 
 
 
 
 
 
(Name and Function) 
(Signature)  
 
Date 
 
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Serious Adverse Event Reporting 
 
Notification in case of Serious Adverse Events 
 
 
Pharmacovigilance 
Medwork Pharma 
Research & Consulting 
 
Phone:  
+30 / 21099 60971 
Fax:  
+30 / 21099 49485 
Mobile/emergency number: +30 / 6970804545 
Email: pharmacovigilance@medwork.gr  
 
 
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Clinical Study Protocol 
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Study Synopsis 
Study title  
A confirmatory, prospective, open-label, multi-centre phase 3 study 
to 
evaluate 
diagnostic 
performance 
of 
89Zirconium-labelled 
girentuximab (89Zr-TLX250) to non-invasively detect clear cell renal 
cell carcinoma (ccRCC) by positron emission tomography/CT 
(PET/CT) imaging in patients with indeterminate renal masses 
(ZIRCON study) 
Short title 
89Zr-TLX250 for PET/CT imaging of ccRCC  
Clinical study phase 
3 
Study objective(s) 
Primary objective 
1. To evaluate sensitivity and specificity of qualitative 
assessment of PET/CT imaging with 89Zr-TLX250 to non-
invasively detect ccRCC in patients with indeterminate renal 
masses, using histology as standard of truth. 
 
Secondary objectives 
Key secondary objectives of this study will be: 
1. To determine sensitivity of 89Zr-TLX250 PET/CT imaging to 
detect ccRCC in the subgroup of patients with indeterminate 
renal masses of ≤ 4 cm in largest diameter (cT1a) 
2. To determine specificity of 89Zr-TLX250 PET/CT imaging to 
detect ccRCC in the subgroup of patients with indeterminate 
renal masses of ≤ 4 cm in largest diameter (cT1a) 
Other secondary objectives of this study will be: 
3. To determine positive predictive value (PPV), negative 
predictive value (NPV), and accuracy of 
89Zr-TLX250 
PET/CT imaging to detect ccRCC in patients with 
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indeterminate solid renal masses, and in patients with 
indeterminate renal masses of ≤ 4 cm (cT1a) 
4. To identify a standardized uptake value (SUV) cut-off for 
89Zr-TLX250, suitable to discriminate ccRCC from non-
ccRCC 
5. To 
determine 
inter-reader 
variability 
of 
diagnostic 
assessments of 
89Zr-TLX250 PET/CT images, when 
performed by multiple readers 
6. To 
determine 
intra-reader 
variability 
of 
diagnostic 
assessment of 89Zr-TLX250 PET/CT images 
7. To establish safety and tolerability of 89Zr-TLX250 in patients 
with indeterminate renal masses. 
8. To evaluate sensitivity and specificity of 
89Zr-TLX250 
PET/CT imaging to detect ccRCC in patients with IRMs 
≤ 3 cm, IRMs ≤ 2 cm, and Bosniak 3 and 4 lesions   
 
Exploratory objectives 
1. To quantitatively estimate achievable tumour uptake, 
retention and radiation absorbed doses (Gy) for therapeutic 
177Lu-girentuximab, based on single time point 
89Zr-
girentuximab PET/CT images, a general model of average 
girentuximab tumour kinetics, derived from serial 
89Zr-
girentuximab imaging, and an assumed specific activity of 
177Lu-girentuximab. 
2. To evaluate the correlation between 89Zr-TLX250 SUVs and 
degree of histological CAIX expression. 
3. To evaluate distant masses outside the kidney identified on 
89Zr-TLX250 whole body PET/CT in patients who present 
with unexpected evidence of disseminated disease 
Project code 
89Zr-TLX250-003 
Investigational medicinal 
product (IMP) 
89Zr-TLX250, a chimeric monoclonal antibody (INN name: 
girentuximab (GTX), synonyms: cG250, TLX250) with specificity for 
the CAIX (carbonic anhydrase 9) antigen, radiolabelled with the 
positron emitting radio-metal zirconium-89 via a NSuc-DFO-TFP-
ester (DFO-TFP), linked to lysine residues of GTX, to yield 89Zr-DFO-
TFP-GTX. 
Name of active ingredients 
89Zr-TLX250 (synonyms: 89Zr-girentuximab, 89Zr-DFO-TFP-GTX) 
Doses 
A single administration of 37 MBq (±10%) 89Zr-TLX250, containing a 
mass dose of 10 mg of girentuximab. 
Route of administration 
Slow intravenous administration (IV) 
Duration of treatment 
Single diagnostic administration, followed by a diagnostic scan on 
Day 5 ± 2 days 
Reference product (RP) 
Not applicable 
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Indication 
89Zr-TLX250 is being developed as a PET/CT imaging agent for the 
characterisation, as ccRCC or non-ccRCC, of indeterminate renal 
masses (IRM).  
Diagnosis and main criteria 
for inclusion 
All patients must meet all of the following criteria: 
1. Written and voluntarily given informed consent 
2. Male or female ≥ 18 years of age 
3. Imaging evidence of a single indeterminate renal mass of ≤ 7 cm 
in largest diameter (tumour stage cT1) on standard of care 
imaging, based on national standards, not older than 90 days on 
Day 0, but performed before any screening procedure. 
4. Scheduled for lesion resection as part of regular diagnostic work-
up within 90 days from planned 89Zr-TLX250 administration.  
5. Negative serum pregnancy tests in female patients of 
childbearing potential at screening. Confirmation of negative 
pregnancy test result from urine within 24 hours prior to receiving 
investigational product. 
6. For patients included in France only, verification and 
confirmation of their affiliation with a social security 
7. Sufficient life expectancy to justify nephrectomy. 
8. Consent to practise highly effective contraception until a 
minimum of 42 days after 89Zr-TLX250 administration. 
Exclusion Criteria 
A patient will be excluded from participation in the trial if one or more 
of the following criteria are met: 
1. A biopsy procedure only (rather than partial or total nephrectomy) 
planned for histological species delineation of IRM  
2. Renal mass known to be a metastasis of another primary tumour. 
3. Active non-renal malignancy requiring therapy during the time 
frame of the study participation. 
4. Chemotherapy, radiotherapy, or immunotherapy within 4 weeks 
prior to the planned administration of 89Zr -TLX250 or continuing 
adverse effects (> grade 1) from such therapy (Common 
Terminology Criteria for Adverse Events [CTCAE] version 5.0). 
5. Planned antineoplastic therapies (for the period between 
administration of 89Zr-TLX250 and imaging). 
6. Exposure to murine or chimeric antibodies within the last 5 years. 
7. Previous administration of any radionuclide within 10 half-lives of 
the same 
8. Serious non-malignant disease (e.g. psychiatric, infectious, 
autoimmune or metabolic), that may interfere with the objectives 
of the study or with the safety or compliance of the subject, as 
judged by the investigator 
9. Mental impairment that may compromise the ability to give 
informed consent and comply with the requirements of the study. 
10. Exposure to any experimental diagnostic or therapeutic drug 
within 30 days from the date of planned administration of 
89Zr-TLX250 
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11. Women who are pregnant or breastfeeding. 
12. Known hypersensitivity to girentuximab or DFO (desferoxamine) 
13. Renal insufficiency with GFR ≤ 45 mL/min/ 1.73 m² 
14. Vulnerable patients (e.g. being in detention) 
Study design 
This will be a confirmatory, prospective, open-label, multi-centre 
phase 3 study to evaluate sensitivity and specificity of 89Zr-TLX250 
PET/CT imaging to non-invasively detect clear cell renal cell cancer 
(ccRCC) in adult patients with indeterminate renal masses (IRM), 
scheduled for partial or total nephrectomy.  
Histological confirmation will serve as standard of truth, to assess 
sensitivity, specificity, positive predictive value (PPV), negative 
predictive value (NPV), as well as accuracy of 89Zr-TLX250 PET/CT 
imaging.  
According to current clinical practice in most specialist centres, 
patients with an IRM of ≤ 7 cm in largest diameter (stage cT1, 
encompassing the subgroups cT1a ≤ 4 cm, and cT1b > 4 cm to 
≤ 7cm), restricted to the kidneys are routinely subjected to partial or 
total nephrectomy, as this intervention has curative potential in most 
cases.  
For that reason this study will be conducted in patients with IRM of 
stage cT1, and histological material will be obtained as part of routine 
nephrectomy, circumventing the need for study-specific invasive 
procedures. Given a reported high rate of non-diagnostic kidney 
biopsies, patients scheduled to undergo kidney biopsy only, rather 
than nephrectomy are not eligible for this study.  
The proportion of patients with a stage cT1 IRM, who actually do not 
have ccRCC (non-ccRCC patients, i.e. those in whom following 
surgical removal, ccRCC can be histologically ruled out) has been 
reported to range between 20–40%. This proportion appears to be 
higher in smaller (cT1a), compared with larger (cT1b) lesions. 
For a total study population of cT1 patients composed of 70% of the 
cT1a subgroup (IRM ≤ 4 cm), and assuming 34% non-ccRCC in the 
cT1a subgroup, a total sample size of 252 patients provides 90% 
power to confirm both a sensitivity and specificity of 83%, as 
previously reported for cT1a lesions for prior GTX-based imaging 
agents (124I-girentuximab, 111In-girentuximab). The total sample size 
of 252 gives 90% power to distinguish a 68% specificity threshold, 
assuming a non-ccRCC rate in the cT1b subset of at least 17%. 
In order to ensure that a sufficient number of patients with cT1a 
tumour stage and sufficient patients with non-ccRCC histopathology 
will be included into the total study population, patient accrual and 
histological results will be centrally evaluated and monitored by an 
Independent Data Monitoring Committee (IDMC); recruitment into 
the study will continue until the minimum required number of patients 
has been recruited. The IDMC members will not have access to 89Zr-
TLX250 PET/CT images, nor will they have access to the PET/CT 
results from the independent image reviewers. 
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Patients who are enrolled, but are then either not administered with 
study drug, or who do not undergo PET/CT imaging after 
administration of study drug, in whom PET/CT images can not be 
analysed due to technical failure, or in whom surgical material can 
not be assessed for presence or absence of ccRCC, are defined as 
drop-outs. Drop-out patients will be replaced for the primary analysis 
and study sample size. Missing data are not expected for efficacy 
outcomes involving the standard of truth (i.e., sensitivity, specificity, 
PPV, NPV, accuracy, inter-reader and intra-reader variability).  
Patients will be recruited in 35–40 renal cancer care specialist 
centres, who have access to state-of-the-art PET/CT imaging. 
Following informed consent, a screening visit will be performed 
during which baseline examinations will be made. The study 
schedule will be planned considering a delivery timeline for 89Zr-
TLX250 of 7 – 10 days from the central study radiopharmacy, the 
day of administration, a PET/CT scan of the kidneys at 5 ± 2 days 
post administration, and the nephrectomy to be performed any time 
after the PET/CT imaging visit, but no later than 90 days post 
administration of 89Zr-TLX250. 
On Day 0, all successfully screened patients will undergo a slow 
intravenous administration over a minimum of 3 minutes with 89Zr-
girentuximab, at the nuclear medicine service of the respective study 
site. Before and after administration, safety evaluations will be made. 
Female patients of childbearing potential will need to have their 
negative pregnancy test result from screening confirmed by a 
negative urine pregnancy test performed within 24 hours prior to 
dosing. 
Patients, in whom unexpected evidence for disseminated disease is 
observed, PET/CT imaging may be extended to whole body imaging 
(skull base to mid-thigh) at the discretion of the investigator. Patients 
will be informed as part of the consent procedure that any PET 
imaging result will not be disclosed to them until the scheduled 
nephrectomy has actually been performed or until surgery has been 
cancelled in case metastatic disease going beyond the kidney is 
present.  
A histological tumour sample from nephrectomy (15 paraffin 
embedded slides) will be prepared by the local institutional pathology 
service, and sent to the central laboratory which will determine the 
histological diagnosis of the renal mass – the standard of truth - 
(ccRCC or non-ccRCC), and determine the degree of CAIX 
expression. For patients in whom unexpected evidence of 
disseminated disease is observed, any available tissue samples 
from biopsies of extrarenal lesions will also be analysed centrally. 
On Day 42 ± 7 days p.a., a visit will be performed for all patients, 
during which the potential formation of anti-drug antibodies (HACA) 
and safety parameters will be investigated. 
At the final study visit, testing for HACA will be repeated, where 
feasible, and all necessary safety assessment will be performed. For 
patients who were nephrectomised within 28 days p.a., the final 
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study visit will be conducted on Day 42 (± 7 days). For patients with 
nephrectomy between 28 and 90 days p.a., the final study visit will 
be performed 35 days (± 7 days) after surgery. 
Image data analyses will be performed by a central image core lab. 
Qualitative visual analysis (presence or absence of localised 
89Zr-TLX250 uptake inside or in vicinity of renal lesion, as seen on 
contrast-enhanced pre-BL MRI or equivalent standard of care 
imaging with contrast agent), will be used to assess test performance 
of 89Zr-TLX250 PET/CT imaging to detect ccRCC, using histological 
results from the central histological reference laboratory as standard 
of truth. 
Lesions of interest will be spatially localised by the site, and 
independently by the image readers. The readers of the central lab 
will not have access to the spatial localisation determined by the site. 
Reading of the images will be conducted centrally and independently 
by three trained readers, blinded to patient medical history and any 
previous histology results. 
89Zr-TLX250 SUVs will be determined for each tumour lesion. 
Receiver operating characteristics (ROC) will be analysed to identify 
a SUV cut-off value, most appropriate to discriminate between 
ccRCC or non-ccRCC (ccRCCnegative) as evidenced by central 
histology results. 
89Zr-TLX250 activity and antibody mass concentrations in tumour at 
the time of imaging (MBq/cm³, mg/cm³) will be determined, 
considering the absolute activity bound to the tumour, lesion volume 
as determined by CT/MRI, and the decay-corrected specific activity. 
Image-derived non-primary variables will be exploratively compared 
to histological and clinical parameters, where merited. 
Study Participation 
Duration 
• 
Screening period: 30 days (Day -30 to Day -1) 
• 
Experimental part of the study: 
- 
Treatment: IMP administered on Day 0 
- 
Imaging visit: Day 5 ± 2 days  
- 
Surgery: any time after imaging visit, but no later than Day 90 
p.a. 
• 
Day 42 ± 7 days p.a., HACA testing 
• 
Final study evaluation 
- 
HACA testing and safety assessments: either Day 42 p.a., or 
35 ± 7 days after nephrectomy, depending on day of surgery 
Methodology 
Pre-screen morphological image for identification of an 
indeterminate solid renal mass 
Availability of a recent contrast-enhanced abdominal MRI or 
equivalent imaging modality with contrast agent as part of 
standard of care, not older than 90 days on Day 0, but before 
any screening procedure, providing evidence of a newly 
diagnosed, single renal mass, confined to the kidney, and 
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measuring ≤ 7 cm in greatest diameter (stage cT1) (inclusion 
criterion). 
Pre-BL contrast-enhanced images will be collected for precise 
volumetric tumour delineation, since in the context of the study, 
no contrast-enhanced CT or MRI will be performed. 
89Zr-TLX250 PET/CT imaging 
1. PET imaging 
Abdominal PET/CT scans including the kidneys will be acquired 
over 20 minutes in a single bed position if possible at a single time 
point on Day 5 ± 2 post administration (p.a.) of 89Zr-TLX250 using 
static image acquisition and low dose CT.  
Patients found to have evidence of N1 or M1 disease may 
undergo additional whole body PET/CT imaging (skull base to 
mid-thigh) using 6-8 bed positions with 10 minutes acquisition 
time per bed position at the discretion of the treating clinician to 
support comprehensive staging. The additional scan if requested 
by the treating physician needs to be completed on Day 5 ± 2 post 
administration of the investigational product.  
2. Qualitative 89Zr-TLX250 tumour targeting 
89Zr-TLX250 tumour uptake will qualitatively be assessed (yes / 
no), considering whether or not 89Zr-TLX250 binding inside or in 
the vicinity of the target lesion, as delineated on structural imaging 
(contrast-enhanced pre-BL imaging), can be detected.  
3. Quantitative 89Zr-TLX250 tumour targeting 
Absolute activity concentrations of tracer in tumour (MBq/cm³) will 
be calculated using attenuation-corrected count rates, and tumour 
volumes, as determined by contrast-enhanced pre-BL imaging. 
Considering specific activity (MBq/mg), protein mass dose 
concentrations of tracer in tumour at the time point of imaging 
(mg/cm³) will be calculated. 
4. Estimation of 177Lu-girentuximab tumour targeting 
Protein mass dose concentrations of tracer in tumour (mg/cm³) at 
the single time point of imaging, and a general model of average 
girentuximab kinetics in tumour over time (derived from sequential 
89Zr-TLX250 biodistribution data), will be used, to estimate 
possible girentuximab protein kinetics in tumour lesions over a 
period of one week, assuming the kinetics of diagnostic 89Zr-
TLX250 and therapeutic 177Lu-girentuximab are essentially similar. 
Such protein kinetic data can be used, to generate simulated time-
activitiy curves for 177Lu-girentuximab in tumour for different 
specific activity levels, to yield estimates of achievable therapeutic 
absorbed doses to tumour (Gy). 
Determination of histological standard of truth 
Surgical resection material, along with appropriate documentation 
of its in situ origin (to allow identification with lesion localisation on 
PET images) will be sent to local pathology for routine histological 
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work-up (H&E staining, histological diagnosis: ccRCC vs. non-
ccRCC). 
In addition, non-stained slides of the indeterminate mass 
removed during surgery will be sent to a central histology lab, for 
independent determination of histological diagnosis and 
detection of CAIX. 
In addition, where available, histological diagnosis of ccRCC and 
the detection of CAIX will be conducted on available tissue 
samples from biopsies of extrarenal lesions from patients in 
whom unexpected evidence of disseminated disease has been 
observed. 
Diagnostic performance  
Test performance parameters (sensitivity, specificity, positive and 
negative predictive values, accuracy), will be determined 
considering visually determined qualitative 89Zr-TLX250 tumour 
uptake (yes/no), and histology (ccRCC+/ ccRCC-) as standard of 
truth. 
Safety 
The following safety evaluations will be made: 
1. Standard laboratory (haematology, biochemistry) 
2. Adverse event recording (NCI-CTC v 5.0) 
3. Concomitant medication recording 
4. 12-lead ECG 
5. Vital signs 
6. HACA (human anti-chimeric antibodies) 
Type of control 
Not applicable 
 
Planned study dates 
Start of study 
recruitment 
Q1/2019  
End of 
recruitment 
Q3/2022 
 
 
End of study 
Q4/2022 
Planned number of study 
centres/countries 
35-40 centres in the EU (Belgium, France, Spain, the Netherlands), 
UK, Turkey, Australia, Canada and USA. 
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Number of patients 
Total: approximately 252 patients scheduled for partial or total 
nephrectomy  
Sample Size: 
The total number of patients expected to be enrolled is n=252: it is 
expected that these will include 194 patients with cT1a tumours and 
58 patients with cT1b tumours  
With 194 patients with cT1a tumours it is expected that these will 
include at least the required number of 128 patients that are ccRCC 
positive and 66 patients that are ccRCC negative. Based on the 
actual number of patients observed during trial enrolment with cT1a 
tumours that are ccRCC positive and ccRCC negative, the total 
sample size might need to be increased to ensure the minimum of at 
least 128 and 66, respectively. Therefore, the distribution of enrolled 
patients will be centrally monitored (reviewing of staging and 
histology (without imaging results). 
Co-primary variables 
Sensitivity and Specificity of 89Zr-TLX250 PET/CT imaging to 
detect ccRCC 
These will be determined, considering the histological diagnosis 
(ccRCC+ or ccRCC-) as determined by the central study pathology 
as standard of truth, and the qualitative 89Zr-TLX250 tumour 
targeting (tracer uptake in target lesion: yes/no), as determined by 
visual reading, to yield a 2 x 2 table as follows: 
 
ccRCC+ 
ccRCC- 
PET+ 
TP 
FP 
PET- 
FN 
TN 
Abbreviations: FN=false negative; FP=false positive; 
TN=true negative; TP=true positive 
a) Sensitivity will be the proportion of study patients with a true 
positive (TP) PET scan, out of those with positive histology for 
ccRCC 
 
Sensitivity (%) = TP / (TP + FN) 
b) Specificity will be the proportion of study subjects with a true 
negative (TN) PET scan, out of those with negative histology for 
ccRCC 
 
Specificity (%) = TN / (TN + FP) 
Secondary variables 
Further test performance parameters  
a) Positive predictive value (PPV)  
 
 
PPV (%) = TP / (TP + FP) 
b) Negative predictive value (PPV)  
 
 
NPV (%) = TN / (TN + FN) 
c) Accuracy  
 
 
Accuracy (%) = TP + TN / (TP + FP + TN + FP) 
Standardised uptake value (SUV) 
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SUV = Cimage / (injected dose / body weight) 
Inter-reader variability 
Fleiss´ kappa statistics will be used to determine the agreement 
between the qualitative visual assessment of 89Zr-TLX250 tumour 
targeting (tracer uptake in target lesion: yes/no), as assessed by 
three independent blinded readers. An intra-class kappa of 0.70 or 
higher will be considered as an acceptable value. Note that both 
sensitivity and specificity will be determined for each of three 
independent readers. The study will be successful if the lower 
bounds of the 95% confidence intervals (CIs) for sensitivity (>70%) 
and specificity (>68%) in at least the same 2 out of 3 independent 
readers. 
Intra-reader variability 
Cohen´s kappa statistics will be used to determine the 
reproducibility of the qualitative visual assessment by individual 
readers when analysing the same data repeatedly.  
Safety 
a) General safety parameters: 
Frequency of occurrence and severity of abnormal findings in 
safety investigations (physical examination, vital signs, 12-lead 
ECG, clinical laboratory, AEs, concomitant medication) 
b)  HACA 
Exploratory Variables 
a) In situ biological half-life of girentuximab; achievable 
therapeutic absorbed dose to tumour (Gy) for several specific 
activities and hypothetical activity doses of 177Lu. 
b) Sub group analysis based on tumour characteristics. 
c) 
Correlation between 89Zr-TLX250 SUVs and degree of 
histological CAIX expression. 
d) Qualitative 89Zr-TLX250 tumour targeting (tracer uptake in 
extrarenal lesion: yes/no), as determined by visual reading. 
Plan for statistical analysis 
To take multiple testing for the two co-primary endpoints into 
account, testing will occur in a strictly sequential order. Firstly, the 
observed sensitivity will be compared against a predefined 
minimum expected threshold for sensitivity, using a binominal 
confidence interval. If the null hypothesis for sensitivity testing can 
be rejected, the test for specificity is performed using the same 
methodology, applying a predefined threshold for specificity. This 
strategy ensures a global level of significance of p < 0.05. 
Reader variability, as the most important secondary objectives will 
be determined using Kappa statistics. 
All other secondary variables will be analysed descriptively using 
exploratory statistics. 
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Table 1 
Schedule of Study Assessments 
 
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Table of Contents 
Sponsor Approval Signature Page ...................................................................................................... 2 
Principal Investigator Agreement Page ............................................................................................... 3 
Serious Adverse Event Reporting ....................................................................................................... 4 
Study Synopsis .................................................................................................................................... 5 
List of Abbreviations ........................................................................................................................... 22 
Glossary ............................................................................................................................................. 24 
Study Administrative Structure .......................................................................................................... 25 
1 
Introduction .................................................................................................................................. 27 
1.1 
Background ......................................................................................................................... 27 
1.2 
Rationale of the Study ......................................................................................................... 29 
1.3 
Benefit-Risk Assessment .................................................................................................... 30 
2 
Study Objectives.......................................................................................................................... 33 
2.1 
Primary Objective ................................................................................................................ 33 
2.2 
Secondary Objectives ......................................................................................................... 33 
2.3 
Exploratory Objectives ........................................................................................................ 33 
3 
Overview of Methodology and Design ........................................................................................ 35 
3.1 
Study Design ....................................................................................................................... 35 
3.2 
Study Endpoints .................................................................................................................. 37 
3.3 
Justification of the Study Design ......................................................................................... 38 
3.4 
Protocol Adherence ............................................................................................................. 39 
4 
Study Population ......................................................................................................................... 40 
4.1 
Patient Population ............................................................................................................... 40 
4.2 
Eligibility ............................................................................................................................... 40 
4.2.1 
Inclusion Criteria .......................................................................................................... 40 
4.2.2 
Exclusion Criteria ......................................................................................................... 40 
4.2.3 
Recruitment .................................................................................................................. 41 
4.3 
Withdrawal of Patients from Study Participation or Medication .......................................... 42 
4.3.1 
Withdrawal.................................................................................................................... 42 
4.3.2 
Withdrawal Procedures ................................................................................................ 42 
4.3.3 
Replacement ................................................................................................................ 43 
4.4 
Patient Identification ............................................................................................................ 44 
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5 
Study Treatment .......................................................................................................................... 45 
5.1 
Study Drug 89Zr-TLX250...................................................................................................... 45 
5.1.1 
Chemical Properties ..................................................................................................... 45 
5.1.2 
Pharmaceutical Properties ........................................................................................... 45 
5.1.3 
Storage and Handling .................................................................................................. 45 
5.1.4 
Dosage and Administration .......................................................................................... 45 
5.1.5 
Packaging and Labelling .............................................................................................. 46 
5.1.5.1 
Medication Numbering .......................................................................................... 47 
5.1.6 
Drug Logistics and Accountability ................................................................................ 47 
5.1.6.1 
Supply, Storage, Dispensation and Return .......................................................... 47 
5.1.6.2 
Drug Accountability ............................................................................................... 48 
5.2 
Treatment Assignment ........................................................................................................ 48 
5.3 
Blinding ................................................................................................................................ 49 
5.4 
Treatment Compliance ........................................................................................................ 49 
5.5 
Radiation Precautions ......................................................................................................... 49 
6 
Therapies other than Study Treatment ....................................................................................... 50 
6.1 
Prior and Concomitant Therapy .......................................................................................... 50 
6.1.1 
Prohibited Medication .................................................................................................. 50 
6.1.2 
Permitted Concomitant Medication .............................................................................. 51 
6.2 
Post-Study Therapy ............................................................................................................. 51 
7 
Schedule of Evaluations and Visit Description ........................................................................... 52 
7.1 
Schedule of Evaluations ...................................................................................................... 52 
7.2 
Screening ............................................................................................................................ 52 
7.3 
Treatment (Day 0) ............................................................................................................... 53 
7.3.1 
Pre-dose ....................................................................................................................... 53 
7.3.2 
Administration of Study Drug (Time-point 0) ............................................................... 53 
7.3.3 
Time-points 0.5 and 1 Hours p.a. ................................................................................ 53 
7.3.4 
Time-point 2 Hours p.a. ............................................................................................... 53 
7.4 
Imaging (Day 5 ± 2 Days, but not sooner than 72 hours p.a.) ........................................... 54 
7.5 
Surgery (Until Day 90 p.a.) .................................................................................................. 54 
7.6 
Post-Imaging Visit (Day 42 ± 7 days p.a.) .......................................................................... 54 
7.7 
Final Study Visit ................................................................................................................... 55 
7.7.1 
Final Study Visit, if Surgery  28 Days p.a. (Day 42 ± 7 Days p.a.): .......................... 55 
7.7.2 
Final Study Visit, if Surgery >28 Days p.a. (35 ± 7 Days after Surgery) ..................... 55 
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8 
Procedures and Variables ........................................................................................................... 56 
8.1 
Baseline Characteristics ...................................................................................................... 56 
8.1.1 
Demographic Characteristics ....................................................................................... 56 
8.1.2 
Medical and Surgical History, Baseline Findings ........................................................ 56 
8.1.3 
Prior and Concomitant Medication .............................................................................. 56 
8.1.4 
Pre-baseline Morphological Imaging ........................................................................... 57 
8.1.5 
Pregnancy Tests and Assessment of Postmenopausal Status .................................. 58 
8.2 
Imaging during the Study .................................................................................................... 58 
8.2.1 
89Zr-TLX250 PET / CT Imaging ................................................................................... 59 
8.2.1.1 
PET/CT Imaging ................................................................................................... 59 
8.2.2 
Imaging Analysis .......................................................................................................... 59 
8.2.2.1 
Qualitative 89Zr-TLX250 Tumour Targeting .......................................................... 59 
8.2.2.2 
Quantitative 89Zr-girentuximab Tumour Targeting ............................................... 60 
8.2.2.3 
Estimation of 177Lu-girentuximab Tumour Targeting ............................................ 60 
8.2.2.4 
Local Review of PET/CT Images ......................................................................... 60 
8.2.2.5 
Independent Central Review of PET/CT Images ................................................. 60 
8.3 
Determination of Histological Standard of Truth ................................................................. 61 
8.3.1 
Local Pathology Assessment ....................................................................................... 61 
8.3.2 
Independent Central Pathologist ................................................................................. 61 
8.4 
Diagnostic Performance ...................................................................................................... 62 
8.5 
Safety Evaluation ................................................................................................................ 62 
8.6 
Sample Shipment ................................................................................................................ 62 
8.7 
Sample Retention / Destruction .......................................................................................... 62 
8.8 
Safety ................................................................................................................................... 63 
8.8.1 
Baseline Findings ......................................................................................................... 63 
8.8.1.1 
Definition of Baseline Finding ............................................................................... 63 
8.8.1.2 
Serious Baseline Findings .................................................................................... 64 
8.8.2 
Adverse Events ............................................................................................................ 64 
8.8.2.1 
Definition of Adverse Event .................................................................................. 64 
8.8.2.2 
Categories of Adverse Event Assessment ........................................................... 65 
8.8.2.3 
Assessment and Documentation of Adverse Events ........................................... 66 
8.8.2.4 
Expected Adverse Events .................................................................................... 67 
8.8.2.5 
Serious Adverse Events ....................................................................................... 68 
8.8.2.6 
Other Relevant Safety Information ....................................................................... 69 
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8.8.3 
Clinical Laboratory Tests ............................................................................................. 70 
8.8.4 
Vital Signs .................................................................................................................... 71 
8.8.5 
12-Lead ECG ............................................................................................................... 72 
8.8.6 
Physical Examination ................................................................................................... 72 
8.8.7 
HACA Determination in Serum .................................................................................... 72 
8.9 
Total Volume of Blood ......................................................................................................... 73 
8.10 
Total Radiation Exposure .................................................................................................... 73 
9 
Statistical Methods and Determination of Sample Size .............................................................. 74 
9.1 
List of Variables and Population Characteristics ................................................................ 74 
9.1.1 
Co-Primary Variables ................................................................................................... 74 
9.1.2 
Secondary Variables and Exploratory Analyses ......................................................... 75 
9.1.2.1 
Predictive Values and Accuracy ........................................................................... 75 
9.1.2.2 
Standardized Uptake Value (SUV) ....................................................................... 76 
9.1.2.3 
Inter-reader Variability .......................................................................................... 76 
9.1.2.4 
Intra-reader Variability .......................................................................................... 76 
9.1.2.5 
Sub group Analysis ............................................................................................... 77 
9.1.2.6 
Safety .................................................................................................................... 77 
9.1.2.7 
Exploratory Variables ........................................................................................... 77 
9.1.3 
Population Characteristics ........................................................................................... 77 
9.2 
Statistical and Analytical Plans ........................................................................................... 78 
9.2.1 
General Considerations ............................................................................................... 78 
9.2.2 
Analysis Sets ................................................................................................................ 78 
9.2.3 
Statistical Analyses ...................................................................................................... 79 
9.2.3.1 
Analysis of Primary and Key Secondary Objectives ............................................ 79 
9.3 
Determination of Sample Size ............................................................................................ 80 
9.3.1 
Sample Size Estimation ............................................................................................... 80 
9.3.2 
Independent Data Monitoring Committee .................................................................... 81 
10 
Data Handling and Quality Assurance.................................................................................... 82 
10.1 
Data Recording.................................................................................................................... 82 
10.1.1 
Source Data and Records ........................................................................................... 82 
10.1.2 
Electronic Case Report Form (eCRF) ......................................................................... 82 
10.1.3 
Missing Data ................................................................................................................ 83 
10.1.4 
Storage of Study Records ............................................................................................ 83 
10.2 
Monitoring ............................................................................................................................ 84 
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10.3 
Data Processing .................................................................................................................. 84 
10.4 
Data Confidentiality ............................................................................................................. 85 
10.4.1 
Documentation of Patient´s Participation .................................................................... 85 
10.4.2 
Data Protection ............................................................................................................ 85 
10.5 
Auditing ................................................................................................................................ 85 
10.6 
Archiving .............................................................................................................................. 86 
11 
Premature Termination of the Study ....................................................................................... 86 
12 
Investigator’s Obligations and Regulatory Aspects ................................................................ 86 
12.1 
Investigator’s Commitment .................................................................................................. 86 
12.2 
Documentation .................................................................................................................... 87 
12.2.1 
Approvals and Agreements ......................................................................................... 87 
12.2.2 
Hospital Case Notes .................................................................................................... 88 
12.3 
Insurance ............................................................................................................................. 88 
13 
Ethical and Legal Aspects ...................................................................................................... 88 
13.1 
Ethical and Legal Conduct of the Study .............................................................................. 88 
13.2 
Patient Information and Consent ........................................................................................ 89 
13.3 
Financial Disclosure ............................................................................................................ 90 
13.4 
Publication Policy ................................................................................................................ 90 
13.5 
Compensation for Health Damage of Patients / Insurance ................................................ 90 
14 
Appendices.............................................................................................................................. 91 
15 
References .............................................................................................................................. 92 
 
List of Figures 
Figure 1 Infusion set with filter ......................................................................................................... 46 
Figure 2 Overview of kidney segments for spatial localisation ....................................................... 58 
 
List of Tables 
Table 1 
Schedule of Study Assessments....................................................................................... 15 
Table 2 
Study Disposition of Enrolled Patients with Incomplete Data for Primary Analysis ......... 43 
Table 3 
Prohibited Concomitant Medication .................................................................................. 51 
Table 4 
Summary of Blood Volumes Collected for Each Patient .................................................. 73 
Table 5 
Probability Calculated on All Cases with Positive Histopathology ................................... 75 
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Table 6:  Planned sample size estimates* ....................................................................................... 81 
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List of Abbreviations 
AE 
Adverse event 
ADR 
Adverse drug reaction 
BP 
Blood pressure 
BT 
Body temperature 
CAIX 
Carbonic anhydrase IX 
ccRCC 
Clear cell renal cell carcinoma 
CRA 
Clinical research associate 
CRO 
Contract research organisation 
CT 
Computed tomography 
CTCAE 
Common criteria for adverse events 
DFO 
Desferoxamine 
eCRF 
Electronic case report form 
ECG 
Electrocardiogram 
EDC 
Electronic data capture 
EOS 
End of study 
FAS 
Full analysis set 
FDA 
Food and Drug Administration 
FN 
False negative 
FP 
False positive 
F/U 
Follow-up 
GCP 
Good Clinical Practice 
GFR 
Glomerular filtration rate 
GMP 
Good Manufacturing Practice 
GTX 
Girentuximab 
HACA 
Human anti-chimeric antibody 
HR 
Heart rate 
ICH 
International Conference on Harmonisation 
IDMC 
Independent data monitoring committee 
IEC 
Independent ethics committee 
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IMP 
Investigational medicinal product 
INR 
International normalised ratio 
IRB 
Institutional review board 
IRM 
Indeterminate renal mass 
ISF 
Investigator´s site file 
IV 
Intravenous 
mAb 
Monoclonal antibody 
MBq 
Megabecquerel 
MIRD 
Medical Internal Radiation Dose 
mSv 
Millisievert 
mGy 
Milligray 
MRI 
Magnetic resonance imaging 
NPV 
Negative predictive value 
p.a. 
Post administration 
PET 
Positron-emission tomography 
PI 
Principal Investigator 
PPV 
Positive predictive value 
Pre-BL 
Pre-baseline 
RCC 
Renal cell carcinoma 
ROC 
Receiver operating characteristics 
RP 
Reference product 
SAE 
Serious adverse event 
SAF 
Safety analysis set 
SAP 
Statistical analysis plan 
SPECT 
Single photon emission computed tomography 
SRM 
Small renal masses 
SUV 
Standardized uptake value 
TMF 
Trial master file 
TN 
True negative 
TP 
True positive 
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WB 
Whole body 
 
Glossary 
Equivalent imaging modality as 
part of the standard of care 
In the context of this study, “equivalent imaging” means 
tomographic anatomical imaging, preferably with contrast 
media, of the abdominal region and/or any other clinically 
indicated anatomical region 
 
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Study Administrative Structure 
Responsibility 
Name 
Affiliation / Address 
Sponsor 
Telix International Pty Ltd  
Main Office, Suite 401, 55 Flemington Road 
North Melbourne VIC 3051 
Australia 
Coordinating CRO 
(for imaging and data 
management as well 
as monitoring of 
European sites) 
ABX-CRO 
ABX-CRO advanced pharmaceutical 
services Forschungsgesellschaft m.b.H. 
Schössergasse 19 
D-01067 Dresden – Germany 
Tel: +49-351-214 44-0 
Fax: +49-351-214 44-15 
http://www.abx-cro.com 
Study Physicist  
Dr. Marcus Bronzel 
ABX-CRO, Dresden 
Tel.:+49-351-214 44-289 
Fax:+49-351- 214 44-15 
Email bronzel@abx-cro.com 
Pharmacovigilance 
Pharmacovigilance 
Medwork Pharma Research & 
Consulting 
Medwork Pharma Research & Consulting, 
Greece 
Tel.:+30 - 21099 60971 
Fax:+30 - 21099 49485 
Mobile: +30 / 6970804545 
Email: pharmacovigilance@medwork.gr 
Central Lab for 
Histology 
MLM Medical Labs GmbH 
MLM Medical Labs GmbH 
Dohrweg 63 
41066 Mönchengladbach, Germany 
Tel.: +49-2161-4642-0 
Email: info@mlm-labs.com 
Central Lab for 
Haematology and 
clinical chemistry & 
Sample 
Management for 
HACA Samples 
Sonic Clinical Trial Pty Ltd 
Sonic Clinical Trial Pty Ltd 
14 Giffnock Avenue 
Macquarie Park NSW 2113, Australia 
Tel.: +61-2-9855-6000 
Email: Mjoshi@sonicclinicaltrials.com 
Biostatistician 
Albert Chinhenzva 
 
 
 
 
 
Dr. Norman Bitterlich 
ABX-CRO, South Africa 
101, Big Bay Office Park, Beach Estate 
Boulevard, Big Bay, Cape Town, 7441 
South Africa 
Tel: +27 (0) 021 555 2078 
Email: albert.chinhenzva@abx-cro.com 
 
ABX-CRO, Dresden 
Tel.:+49-351-214 44-282 
Fax:+49-351-214 44-15 
Email: bitterlich@abx-cro.com 
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Responsibility 
Name 
Affiliation / Address 
HACA Testing 
Agilex Biolabs Pty Ltd (formerly 
CPR Pharma) 
Agilex Biolabs Pty Ltd (formerly CPR 
Pharma) 
28 Dalgleish Street 
Thebarton SA 
Australia 5031 
Tel.: +61 8 8159 6233 
Fax: +61 8 81 59 6348 
Email: enquiries@cprpharma.com 
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1 
Introduction 
Small renal masses (SRM) of unknown origin are frequently detected due to more frequent radiologic 
evaluations of the abdomen. Conventional imaging methods cannot reliably distinguish benign solid 
lesions from renal cell carcinoma (RCC) (Kutikov et al., 2006, Snyder et al., 2006, Schachter et al., 
2007). This frequently leads to the difficult decision for urologists whether to perform a (partial) 
nephrectomy on a potentially benign mass or to refrain from surgery and enter patients with a 
potentially aggressive malignancy into a follow-up protocol until disease progression occurs. 
Specimens obtained by ultrasound- or computed tomography (CT)–guided biopsies have a relatively 
high sensitivity and specificity, but the procedures are invasive and require close follow-up of the 
patient (Lebret et al., 2007, Volpe et al., 2008). In addition, pooled sensitivity of fluorine-18-
fluorodeoxyglucose positron-emission tomography (18F-FDG-PET) imaging for detecting primary 
RCC was found to be only 62% (Wang et al., 2012). Post-operative benign disease was found in 
15% to 30% of clinical T1a lesions in patients with a presurgical diagnosis of suspected renal cancer 
(Kutikov et al., 2006, Snyder et al., 2006, Schachter et al., 2007). In consequence, more advanced 
imaging methods are needed to prevent invasive biopsies or unnecessary surgeries, and to improve 
the detection of lesions suspected for metastatic and local recurrence RCC. 
1.1 
Background 
Zirconium-89 (89Zr) is coupled safely to the monoclonal antibody (mAb) using a succinylated 
derivative of desferrioxamine B (DFO-TFP) as bifunctional chelate. After intracellular catabolism of 
the radio-conjugate, 89Zr stays in the target cells. 
89Zr-TLX250 is under clinical development as a tracer for renal tumour masses and metastases using 
PET imaging.  
Preclinical studies suggest that labelling girentuximab with the residualizing positron emitter 89Zr 
leads to higher tumour uptake and more sensitive detection of ccRCC lesions than the non-
residualizing 124I (Cheal et al., 2014) and that it is able to detect very small tumours and metastases 
down to 100 mg (Brouwers et al., 2004), or 7 mm3 (Stillebroer et al., 2013). 
The clinical potential of 89ZrPET and PET/CT for tumour detection was initially demonstrated in head-
and-neck cancer patients (Börjesson et al., 2009), and has since emerged as a promising imaging 
method for tumour targeting mAbs (Dijkers et al., 2010; Rizvi et al., 2012; Gaykema et al., 2013; van 
Asselt et al., 2014; Oosting et al., 2015). 
Also for the diagnostic work-up of patients with either newly diagnosed renal lesions of unknown 
biological dignity, or for patients with an established diagnosis of ccRCC and a suspected 
progression or recurrence, the non-invasive detection of CAIX-expressing viable tumour tissue by 
molecular imaging with 89Zr-TLX250 PET, may contribute to an improved clinical decision making in 
RCC patients. The existing experience from the proof-of-principle study (No. 08121986, ZIRDEE) 
suggests, that 89Zr-TLX250 has the potential to (a) avoid unnecessary surgical interventions in 
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benign disease, (b) support minimal invasive treatment options such a partial nephrectomy, (c) 
improve staging of metastatic disease by whole body imaging, and (d) provide a functional imaging 
tool, allowing to non-invasively monitor the biological behaviour of indeterminate lesions following a 
conservative active surveillance strategy (Hekman et al., 2018). 
Currently, SPECT/CT imaging using 111In-labeled girentuximab is frequently used for the diagnosis 
of RCC. Girentuximab is a monoclonal antibody that recognises carbonic anhydrase IX (CAIX), a 
cell surface antigen abundantly expressed in renal cancer (Steffens et al., 1997). More than 95% of 
clear cell renal cancers express CAIX and the antigen is not found in normal renal tissue or in benign 
cysts. In an extensive analysis, the binding of girentuximab to normal human tissues was found to 
be restricted to the gastric and intestinal epithelium, the large biliary ducts in the liver, and some 
pancreatic acini (Oosterwijk et al., 1986). An IgG1 chimeric version of monoclonal antibody 
girentuximab (cG250) was constructed by Centocor (Malvern, PA). When girentuximab is labelled 
with a radionuclide it can be used as an imaging probe for SPECT or PET. After intravenous 
administration of this probe, both primary tumour, lymph nodes, and distant metastases can be 
assessed by non-invasive whole-body PET or SPECT imaging. Because of its specific and high level 
of expression, CAIX is an excellent target for imaging clear-cell renal cell cancer (ccRCC) lesions. 
The advantages of girentuximab imaging are that it is non-invasive and does not require the use of 
intravenous iodine contrast agents, which makes it suitable for patients with an impaired renal 
function. 
Numerous studies were performed using radiolabelled girentuximab in ccRCC patients in the past 
20 years, and more than 2,500 girentuximab administrations have been performed worldwide in 
several clinical trials since its discovery (Muselaers et al., 2013, 2014, Steffens et al., 1997, 1998, 
1999; Brouwers et al., 2002, 2003, 2004, 2005; Oosterwijk et al., 2003; Stillebroer et al., 2013; Divgi 
et al., 1998, 2004). No severe side effects or allergic reactions to the antibody infusions have been 
reported to date. In these studies, the pharmacokinetics, toxicity, immunogenicity, and imaging 
characteristics of radiolabelled girentuximab in ccRCC patients were determined, and the feasibility 
to detect ccRCC lesions using radiolabelled girentuximab was demonstrated. Clear cell RCC is the 
most common subtype of renal cancer (80%), and has a higher metastatic potential than e.g., 
papillary or chromophobe RCCs. It is therefore especially important to detect ccRCC with high 
accuracy.  
There is extensive experience with the ability of girentuximab radiolabelled with 131I, 111In, 177Lu, 90Y 
and 124I to target ccRCC lesions in animals as well as in patients (Muselaers et al., 2013, 2014, 
Steffens et al., 1997, 1998, 1999; Brouwers et al., 2002, 2003, 2004, 2005; Oosterwijk et al., 2003; 
Stillebroer et al., 2013; Divgi et al., 1998, 2004). In 2007, Divgi et al. reported the possibility of 
specifically detecting ccRCC preoperatively with PET using 124I-labeled girentuximab in 16 patients 
with renal masses. 15 of 16 clear-cell carcinomas were identified accurately by PET, and all nine 
non-clear-cell renal masses were negative for the tracer. The false negative PET in one patient with 
ccRCC was probably because of extensive necrosis. The sensitivity of 124I-cG250 PET for ccRCC in 
this trial was 94%; the negative predictive value was 90%, and specificity and positive predictive 
accuracy were both 100% (Divgi et al., 2007). In 2012 Divgi et al. confirmed the high accuracy of 
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124I-girentuximab PET/CT in the preoperative, non-invasive identification of ccRCC in 195 patients. 
They showed that the sensitivity (86%; 95%-confidence interval [CI], 75–97) and specificity (86%; 
95%-CI, 69–100) of 124I-girentuximab were markedly higher than those of conventional CT (Divgi et 
al., 2012). At Radboud UMC, girentuximab labelled with the gamma-emitting radionuclide indium-
111 (111In-grientuximab) is used to detect ccRCC lesions. In 2013 a retrospective analysis was 
performed with 22 patients with a SRM to assess the diagnostic value of 111In-girentuximab 
SPECT/CT (Muselaers et al., 2013). Uptake of 111In-girentuximab in the lesion was seen in 15/15 
patients with ccRCC and in 1 patient with a papillary type II RCC. No uptake was reported in 6 
patients, and they either did not have a ccRCC or showed no progression on long-term follow-up. 
Furthermore 111In-girentuximab imaging proved to be valuable in 7 patients suspected of relapse or 
metastatic ccRCC. In four of these patients, the lesions showed preferential uptake of 111In-
girentuximab and local or systemic treatment was initiated. In three other cases, no 
111In-girentuximab targeting was observed. During follow-up of these three patients, one showed 
progression, for which systemic treatment was started. In the two other patients, no progression 
occurred, suggesting a benign nature of the lesions. 
Distinct advantages of PET and PET/CT as compared to SPECT are the superior resolution, the 
short acquisition time for whole-body 3D images, and the potential for quantitative analysis of tumour 
targeting. Clinical PET trials with 89Zr‐labeled mAbs have been performed or are ongoing with at 
least 15 mAbs, including most of the FDA approved mAbs. 89Zr‐PET has become an integrated part 
of the mAb development programs of several of the world-leading pharmaceutical and biotech 
companies. Girentuximab can be stably labelled with the PET radionuclide 89Zr (89Zr-girentuximab) 
and in preclinical studies the in vivo distribution of 89Zr-girentuximab was shown to be identical to 
that of 111In-girentuximab (Brouwers et al. 2004). In addition, due to prolonged trapping of the 
radiolabel in the tumour and simultaneous washout from normal tissues, PET imaging with 89Zr-
girentuximab was shown to be superior to 124I-girentuximab (Cheal et al., 2014). Combining the 
superior characteristics of PET with the use of the residualizing 89Zr radionuclide are major steps 
forward in the development of this imaging biomarker.  
1.2 
Rationale of the Study 
The early identification of ccRCC is crucial for planning possible surgery and treatment. 
Radiolabelled girentuximab has been shown in several studies, that it has useful targeting properties 
to detect ccRCC in PET/CT imaging. The tumour cell specificity of 89Zr-girentuximab using PET is 
able to differentiate between ccRCC and tumour or metastases from other origin, as well as 
differentiating from non-malignant renal masses, and thus avoid repeated biopsy or unnecessary 
surgery. It is anticipated to develop 89Zr-girentuximab (89Zr-TLX250) as an improved imaging agent 
for ccRCC.  
In a single-centre, single-arm and open label proof-of-concept study No. 08121986 (Phase 2b – 
ZIRDEE study), conducted and recently completed by Radboud, 30 patients suspected of primary, 
recurrent or metastatic ccRCC and in whom conventional diagnostics were inconclusive, were 
included. A PET/CT was acquired 4 to 5 days after single intravenous administration of 5 mg 
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89Zr-TLX250 (37 MBq). Preliminary results of this study suggest that 89Zr-TLX250 PET imaging can 
have a positive impact on clinical decision-making management of ccRCC. The extent of the tumour 
disease can be evaluated, the number of metastatic sites can be identified, and the imaging 
distinguishes solitary and oligometastatic ccRCC from more extensive metastatic ccRCC. The 
results of the study also demonstrated the capability of 89Zr-TLX250 to differentiate between ccRCC 
and non-malignant tumours of the kidneys based on histology results. 
Results of a bridging study (ZIRDOSE), investigating the safety and tolerability and the impact of two 
different mass doses (5 mg and 10 mg) of the antibody on biodistribution and tracer uptake has been 
completed. The study showed a safety profile similar to that of other radiolabelled monoclonal 
antibodies, and favourable imaging properties of the 10 mg mass dose compared to the 5 mg mass 
dose.  
According to current clinical practice in most specialist centres, patients with an IRM of ≤ 7 cm in 
largest diameter (stage cT1, encompassing the subgroups cT1a ≤ 4 cm, and cT1b > 4 cm to 
≤ 7 cm), restricted to the kidneys are routinely subjected to partial or total nephrectomy, as this 
diagnostic intervention has curative potential in most cases. 
The aim of this phase 3 study (ZIRCON) is to investigate the potential of 89Zr-TLX250 to determine 
whether an IRM of ≤ 7 cm (stage cT1) has the aggressive ccRCC phenotype verified by 
histopathology as standard of truth.  
1.3 
Benefit-Risk Assessment 
Girentuximab is a monoclonal antibody against carbonic anhydrase IX (CAIX), a cell surface antigen 
that is expressed abundantly in renal cancer (Steffens et al., 1997). More than 95% of clear cell renal 
cancers express CAIX. In an extensive analysis, the binding of girentuximab to normal human 
tissues was found to be restricted to the gastric and intestinal epithelium, the large biliary ducts in 
the liver, and some pancreatic acini.  
There is more than 20 years of experience in humans with SPECT or PET imaging using 
girentuximab labelled with various radioligands including 124I and 111In. These studies investigated 
the pharmacokinetics, toxicity, immunogenicity, and imaging characteristics of radiolabelled 
girentuximab in ccRCC patients, and demonstrated the feasibility to detect ccRCC lesions using 
radiolabelled girentuximab. Although never observed in previous trials, allergic-type reactions are 
possible during and immediately following the administration of girentuximab. There are extensive 
safety data in numerous studies, more than 2500 administrations of girentuximab have been 
performed in several clinical studies, unlabelled girentuximab has been administered to 545 patients 
across 5 studies and radiolabelled girentuximab has been administered to >500 patients. In clinical 
studies administration of Zirconium-89 (89Zr) labelled monoclonal antibodies were proven to be safe 
(Börjesson et al., 2009, Oosting et al., 2015). 
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In preclinical studies imaging using 89Zr-girentuximab was proven to be safe and feasible. No local 
or systemic side effects were observed. Girentuximab can be stably labelled with the PET 
radionuclide 89Zr the in-vivo biodistribution of 89Zr-TLX250 was shown to be identical to that of 111In-
girentuximab (Brouwers et al., 2004). 89Zr-TLX250 was shown to have higher diagnostic resolution 
124I-girentuximab in animal studies due to prolonged trapping of the radiolabel in the tumour and 
simultaneous washout from normal tissues (Cheal et al., 2014). 
The pharmacokinetics and pharmacodynamics of 131I-girentuximab were studied by Steffens et al. 
(1997). For large kidney tumours overall tumour uptake ranges from 2.4% to 9.0%. The mean blood 
clearance curves of girentuximab fitted a two-compartment model: a distribution phase and an 
elimination phase. The half-life of the distribution phase was 3.8 hours (SD 2.0 hours). The half-life 
of the elimination phase was dependent on the protein dose level. At the 2 mg protein dose level, 
t1/2, was significantly lower (t1/2 = 39.6 ± 9.6 hours), compared with the other, higher protein dose 
levels (t1/2 = 68.5 ± 13.5 hours). Loh et al. showed in 1998 that there is a wide variability in 
pharmacokinetic parameters among patients. This reflects the differences in individual patient 
clearance and exchange kinetics of girentuximab (Loh et al., 1998).  
In a clinical phase 1 study investigating safety, tolerability, imaging characteristics, biodistribution 
and dosimetry, 89Zr-TLX250 was found to be safe, and to provide improved imaging characteristics, 
compared to 124I-girentuximab, in line with preclinical findings (Cheal et al., 2014).  
In the present phase 3 ZIRCON trial, 89Zr-TLX250 will be administered as a single dose with 37 MBq 
of 89Zr as an imaging agent. The total girentuximab dose will be adjusted to 10 mg in 0.9% saline. 
This is a radioactivity dose which is established in mAb imaging with 89Zr.  
Radiation dosimetry was evaluated in a bridging dosimetry study ZIRDOSE investigating the safety 
and tolerability of 89Zr-girentuximab. The whole body effective dose for administration of 89Zr-
girentuximab in this phase 1 study was 0.487 ± 0.014 mSv/MBq using the FDA-approved dose 
calculation tool OLINDA 1.1 and the ICRP 60 standard (Stabin et al., 2005). The absorbed/effective 
dose was calculated accordingly and resulted in a total whole body effective dose of 18.0 ± 0.5 mSv 
for 37 MBq. When a newer software IDAC-Dose 2.1 and the ICRP 103 standard (Andersson et al., 
2017) is used, the resulting effective dose will be 0.551 ± 0.030 mSv/MBq or 20.5 ± 1.1 mSv for 
37 MBq. 
Preliminary safety data in the bridging study (ZIRDOSE) with 89Zr-girentuximab administered to 5 
patients per 5 mg and 10 mg girentuximab mass dose, each, did not prompt any safety concern over 
the treatment. In the course of the study, no treatment-related SAEs or SUSARs were reported from 
any of the 10 patients. The severe SAE of postoperational bleeding was considered by the 
investigator as not related to the study treatment. A total of 7 AEs were experienced by 4 patients. 
An unlikely or no relationship to treatment was assessed by the investigator for 6 AEs. Mild nausea 
in one patient was considered by the investigator as possibly related to the study treatment.  
All patients within the present phase 3 ZIRCON trial will undergo an abdominal PET/CT scan. The 
CT scan will be a low-dose CT for the purpose of attenuation correction of the PET data only. In 
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order to keep the effective dose of this abdominal low-dose CT within a specified limit of 1 mSv, or 
less, the acquisition parameters for the low-dose CT will be restricted. These parameters for imaging 
will be defined in a separate subject imaging manual. 
The combined whole body effective dose of 89Zr-girentuximab administration and abdominal low-
dose CT is expected to be below 20 mSv based on the accepted standard OLINDA 1.1 and ICRP 
60, or below 23 mSv based on IDAC-Dose 2.1 and ICRP 103, for all patients. The lifetime attributable 
risk for incidence of radiation-induced cancer for an effective dose of 23 mSv is 0.4% (ICRP 103, 
2007), which is comparable to the risk from a diagnostic CT of chest, abdomen and pelvis (Smith-
Bindman et al., 2009). 
In the context of this phase 3 trial, no additional diagnostic CT will be performed. Patients with 
suspected metastatic disease may undergo an optional additional whole body PET/CT scan, which 
would result in an additional radiation dose from the low-dose CT of approx. 3 mSv applying the 
same restrictions on the CT acquisition protocol as mentioned above. 
Given the well-known safety and tolerability of radiolabelled girentuximab, confirmed for 89Zr- 
TLX250 in the context of a phase I safety study, and further considering the low antibody doses used 
in this study, no harmful effects exceeding the risk of established diagnostic imaging procedures are 
to be expected. The results of this study may contribute to the development of 89Zr-TLX250 as an 
improved imaging agent for ccRCC, allowing to avoid or delay the need for partial or total 
nephrectomy - a procedure associated with up to 20% overall complication, and 0.5% – 1.0% 
lethality rate (Lowrance et al., 2010) – in patients with renal lesions of indeterminate dignity. 
Although, highly unlikely, 89Zr-TLX250 may cause allergic-type reactions. The study centres are well 
equipped to treat allergic/anaphylactic reactions.  
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2 
Study Objectives 
2.1 
Primary Objective 
The primary objective of this study will be: 
To evaluate sensitivity and specificity of qualitative assessment of PET/CT imaging with 89Zr-TLX250 
to non-invasively detect ccRCC in patients with indeterminate renal masses, using histology as 
standard of truth. 
2.2 
Secondary Objectives 
Key Secondary objectives of this study will be: 
1. To determine sensitivity of 89Zr-TLX250 PET/CT imaging to detect ccRCC in the subgroup of 
patients with indeterminate renal masses of ≤ 4 cm in largest diameter (cT1a) 
2. To determine specificity of 89Zr-TLX250 PET/CT imaging to detect ccRCC in the subgroup of 
patients with indeterminate renal masses of ≤ 4 cm in largest diameter (cT1a) 
 
Other Secondary objectives of this study will be: 
3. To determine positive predictive value (PPV), negative predictive value (NPV), and accuracy 
of 89Zr-TLX250 PET/CT imaging to detect ccRCC in patients with indeterminate solid renal 
masses, and in patients with indeterminate renal masses of ≤ 4 cm (cT1a) 
4. To identify a standardized uptake value (SUV) cut-off for 89Zr-TLX250, suitable to discriminate 
ccRCC from non-ccRCC 
5. To determine inter-reader variability of diagnostic assessments of 89Zr-TLX250 PET/CT 
images, when performed by multiple readers 
6. To determine intra-reader variability of diagnostic assessment of 89Zr-TLX250 PET/CT images 
7. To establish safety and tolerability of 89Zr-TLX250 in patients with indeterminate renal masses. 
8. To evaluate sensitivity and specificity of 89Zr-TLX250 PET/CT imaging to detect ccRCC in 
patients with IRMs ≤ 3 cm, IRMs ≤ 2 cm, and Bosniak 3 and 4 lesions.  
2.3 
Exploratory Objectives 
Exploratory objectives will be:  
1. To quantitatively estimate achievable tumour uptake, retention and radiation absorbed doses 
(Gy) from therapeutic 177Lu-girentuximab, based on single time point 89Zr-TLX250 PET/CT 
images, a general model of average girentuximab tumour kinetics, derived from serial 89Zr-
girentuximab imaging, and an assumed specific activity of 177Lu-girentuximab. 
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2. To evaluate the correlation between 89Zr-TLX250 SUVs and degree of histological CAIX 
expression 
3. To evaluate the distant masses outside the kidney identified on 89Zr-TLX250 whole body 
PET/CT in patients who present with unexpected evidence of disseminated disease 
 
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3 
Overview of Methodology and Design 
3.1 
Study Design 
This will be a confirmatory, prospective, open-label, multi-centre phase 3 study (ZIRCON) in adult 
patients with pre-study imaging evidence of indeterminate renal masses (IRM) of ≤ 7 cm in largest 
diameter, and scheduled for partial or total nephrectomy as part of their standard of care. The study 
is designed to evaluate sensitivity and specificity of 89Zr-TLX250 PET/CT imaging to non-invasively 
detect clear cell renal cell cancer (ccRCC).  
Histological confirmation will serve as standard of truth, to assess sensitivity, specificity, positive 
predictive value (PPV), negative predictive value (NPV), as well as accuracy of 89Zr-TLX250 PET/CT 
imaging.  
Consequently, this study will be conducted in patients with IRM of stage cT1, in which histological 
material is obtained as part of routine nephrectomy, circumventing the need for study-specific 
invasive procedures. Given a reported high rate of non-diagnostic kidney biopsies, patients 
scheduled to undergo kidney biopsy only, rather than nephrectomy are not eligible for this study.  
Approximately 252 adult patients will be recruited in 35 – 40 renal cancer care specialist centres in 
Europe (Belgium, France, Spain, the Netherlands), UK, Turkey, Australia, Canada and USA, who 
have access to state-of-the-art PET/CT imaging. The number of enrolled patients may be increased 
to ensure adequate precision in measuring both sensitivity and specificity of 89Zr-TLX250 PET/CT 
imaging. 
Study Conduct 
Following informed consent, a screening visit will be performed during which baseline examinations 
will be made. The study schedule will be planned, considering a delivery timeline for 89Zr-TLX250 of 
7 - 10 days from the central study radiopharmacy, an imaging interval of 5 ± 2 days post 
administration (p.a.), and nephrectomy to be performed any time after the PET/CT imaging visit, but 
no later than 90 days post administration of 89Zr-TLX250 and after image requisition. 
On Day 0, all successfully screened patients will undergo a slow intravenous administration of the 
study drug over a minimum of 3 minutes with 89Zr-TLX250, at the nuclear medicine service of the 
respective study site. Before and after the administration, safety evaluations will be made. 
In patients, in whom unexpected evidence for disseminated disease is observed, PET/CT imaging 
may be extended to complete whole body imaging (skull base to mid-thigh) using 6-8 bed positions 
with 10 minute acquisition time per bed position at the discretion of the investigator. The additional 
scan if requested by the treating physician needs to be completed on Day 5 ± 2 post administration 
of the investigational product.  
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Patients will be informed as part of the consent procedure, that any PET imaging result will not be 
disclosed to them, until the scheduled nephrectomy has actually been performed or until surgery has 
been cancelled in case metastatic disease going beyond the kidney is present.  
A histological tumour sample from nephrectomy (15 paraffin embedded slides) will be prepared by 
the local institutional pathology service, and sent to the central histological reference laboratory, 
which will determine the histological diagnosis of the renal mass (ccRCC or non-ccRCC), and 
determine the degree of CAIX expression. For patients in whom unexpected evidence of 
disseminated disease is observed, any available tissue samples from biopsies of extrarenal lesions 
will also be analysed centrally for the histological diagnosis of ccRCC and CAIX expression. 
Patients who do not have an evaluable PET/CT imaging post study drug administration and do not 
have a confirmed histopathology diagnosis are defined as drop-outs. To ensure credibility in the 
assessment of sensitivity and specificity, drop-out patients will be replaced to achieve the desired 
sample size and power for the primary analysis.  
On Day 42 ± 7 days, a post-imaging visit will be performed in all patients, during which the potential 
formation of anti-drug antibodies (HACA) and some safety parameters will be investigated.  
A final study visit will be performed either on Day 42 ± 7 days p.a. for patients with nephrectomy 
within 28 days after administration of 89Zr-TLX250, and 35 ± 7 days after surgery for patients with 
nephrectomy between 28 and 90 days p.a. 
Image data analyses will be performed by a central image core lab. Qualitative visual analysis 
(presence or absence of localised 89Zr-TLX250 uptake inside or in vicinity of the target lesion, as 
seen on contrast-enhanced CT or MRI), will be used to assess test performance of 89Zr-TLX250 
PET/CT imaging to non-invasively detect ccRCC, using histological results from the central 
histological reference laboratory as standard of truth. 
Reading for the co-primary endpoints (sensitivity and specificity) will be conducted independently by 
three trained readers, blind to history, and histology results. Inter-reader concordance will be 
assessed using kappa statistics. Similarly, kappa statistics will be used to assess intra-reader 
variability, using a subset of 10% of randomly selected cases read twice by individual readers.  
89Zr-TLX250 SUVs will be determined for each tumour lesion. Receiver operating characteristics 
(ROC) will be analysed, to identify a SUV cut-off value, most appropriate to discriminate between 
ccRCC or non-ccRCC as evidenced by central histology results. 
89Zr-TLX250 activity and antibody mass concentrations in tumour at the time of imaging (MBq/cm³, 
mg/cm³) will be determined, considering the absolute activity bound to the tumour, lesion volume as 
determined by CT/MRI, and the decay-corrected specific activity. 
Image-derived non-primary variables will be exploratively compared to histological and clinical 
parameters, where merited. 
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No interim analysis is planned. 
The duration for the study itself including recruitment phase is estimated to be 12 months. 
The study duration for a single patient will be approximately between 4 - 6 months. 
3.2 
Study Endpoints 
The co-primary endpoints of this study are the sensitivity and specificity of 89Zr-TLX250 PET/CT 
imaging to detect ccRCC in patients with IRM of tumour stage cT1, i.e. ≤ 7 cm in largest diameter 
and scheduled nephrectomy. PET/CT scans will be determined as true positive (TP) and true 
negative (TN) by visual reading (among 3 independent readers) and comparison to histopathological 
diagnosis for ccRCC. Image data analyses will be performed by a central image core lab. Qualitative 
visual analysis (presence or absence of localised 89Zr-TLX250 uptake inside or in vicinity of lesions, 
as seen on contrast-enhanced pre-baseline (pre-BL) imaging), will be used to assess test 
performance of 89Zr-TLX250 PET/CT imaging to non-invasively detect ccRCC, using histological 
results from the central histological reference laboratory as standard of truth.  
Secondary endpoints include the determination of the study drug’s potential to detect ccRCC in IRMs 
≤ 4 cm in largest diameter (tumour stage cT1a), as well as determination of predictive values 
(standard uptake values (SUVs)) of PET signals in the kidney. Moreover, the reproducibility of the 
qualitative visual assessment of tumour targeting will be determined and safety and tolerability will 
be assessed. 
Reading for the co-primary endpoints (sensitivity and specificity) will be conducted independently by 
three trained readers, blind to history, and histology results. Inter-reader concordance will be 
assessed using kappa statistics. Similarly, kappa statistics will be used to assess intra-reader 
variability, using a subset of 10% of randomly selected cases read twice by individual readers. 
89Zr-TLX250 SUVs will be determined for each tumour lesion. Receiver operating characteristics 
(ROC) will be analysed to identify a SUV cut-off value most appropriate to discriminate between 
ccRCC or non-ccRCC as evidenced by central histology results. 
89Zr-TLX250 activity and antibody mass concentrations in tumour at the time of imaging (MBq/cm³, 
mg/cm³) will be determined, considering the absolute activity bound to the tumour, lesion volume as 
determined by CT/MRI, and the decay-corrected specific activity, using a general model of average 
girentuximab kinetics in tumour over time (derived from sequential 89Zr-TLX250 biodistribution data 
from earlier studies). 
A sub-group analysis will evaluate sensitivity and specificity of 89Zr-TLX250 PET/CT imaging to 
detect ccRCC in patients with IRMs ≤ 3 cm, IRMs ≤ 2 cm, and Bosniak 3 and 4 lesions. 
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3.3 
Justification of the Study Design 
This open-label phase 3 study is designed to confirm the sensitivity and specificity of PET/CT 
imaging with 89Zr-TLX250 to non-invasively detect ccRCC in patients with a pre-study diagnosed 
IRM of ≤ 7 cm (stage cT1) who are scheduled for partial or total nephrectomy. 
For the evaluation of specificity of a diagnostic imaging agent, study patients with histologically 
confirmed absence of the target disease (non-ccRCC) are required.  
An estimated total of 252 patients with an IRM of ≤ 7 cm and scheduled partial or radical 
nephrectomy will be included in the study. However, this number may be increased depending on 
the proportion of eligible patients with stage cT1a tumours, and the proportion considered non-
ccRCC patients after surgery and histological verification, in order to maintain the planned statistical 
robustness of the study. 
In this phase 3 study, a protein mass dose of the mAb girentuximab of 10 mg is chosen. From a 
small clinical dose-escalation study (Steffens et al., 1997) with five protein dose levels (2, 5, 10, 25 
and 50 mg) of girentuximab it can be assumed that higher doses of girentuximab (10 mg and above) 
result in a lower hepatic uptake and a lower bowel activity, providing a lower physiological 
background signal. Additionally, a mass dose of 10 mg of girentuximab is in current clinical use in 
the USA. 
In a clinical bridging study (ZIRDOSE) investigating safety, tolerability, imaging characteristics, 
biodistribution and dosimetry, 89Zr-TLX250 was found to be safe, and to provide improved imaging 
characteristics, compared to 124I-girentuximab, in line with preclinical findings (Cheal et al., 2014).  
In the present phase 3 trial, 89Zr-TLX250 will be administered as a single dose with 37 MBq of 89Zr 
as an imaging agent. The total girentuximab dose will be adjusted to 10 mg in 0.9% saline. This is a 
radioactivity dose which is established in mAb imaging with 89Zr. Radiation dosimetry was evaluated 
in the now completed bridging dosimetry trial (ZIRDOSE) investigating the safety and tolerability of 
89Zr-girentuximab. 
The whole body effective dose for administration of 89Zr-girentuximab in this phase 1 study was 
0.487 ± 0.014 mSv/MBq using the most widely established dose calculation tool OLINDA 1.1 and 
the ICRP 60 standard (Stabin et al., 2005). The absorbed/effective dose was calculated accordingly 
and resulted in a total whole body effective dose of 18.0 ± 0.5 mSv for 37 MBq.  
When a newer software IDAC-Dose 2.1 and the ICRP 103 standard (Andersson et al., 2017) is used, 
the resulting effective dose will be 0.551 ± 0.030 mSv/MBq or 20.5 ± 1.1 mSv for 37 MBq. 
All patients within the present phase 3 trial will undergo an abdominal PET/CT scan. The CT scan 
will be a low-dose CT for the purpose of attenuation correction of the PET data only. In order to keep 
the effective dose of this abdominal low-dose CT within a specified limit of 1 mSv, or less, the 
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acquisition parameters for the low-dose CT will be restricted. These parameters for imaging will be 
defined in a separate subject imaging manual. 
The combined whole body effective dose of 89Zr-girentuximab administration and abdominal low-
dose CT is expected to be below 20 mSv based on the accepted standard OLINDA 1.1 and ICRP 
60, or below 23 mSv based on IDAC-Dose 2.1 and ICRP 103, for all patients. The lifetime attributable 
risk for incidence of radiation-induced cancer for an effective dose of 23 mSv is 0.4% (ICRP 103, 
2007), which is comparable to the risk from a diagnostic CT of chest, abdomen and pelvis (Smith-
Bindman, 2009). 
In the context of this phase 3 trial, no additional diagnostic CT will be performed. Patients with 
suspected metastatic disease may undergo an optional additional whole body PET/CT scan, which 
would result in an additional radiation dose from the low-dose CT of approximately 3 mSv applying 
the same restrictions on the CT acquisition protocol as mentioned above. 
Given the well-known safety and tolerability of radiolabelled girentuximab, confirmed for 89Zr- 
TLX250 in the context of a phase I safety study, and further considering the low antibody doses used 
in this study, no harmful effects exceeding the risk of established diagnostic imaging procedures are 
to be expected. The results of this study may contribute to the development of 89Zr-TLX250 as an 
improved imaging agent for ccRCC, allowing to avoid or delay the need for partial or total 
nephrectomy - a procedure associated with up to 20% overall complication, and 0.5 – 1.0% letality 
rate (Lowrance et al., 2010) – in patients with renal lesions of indeterminate dignity. Although, highly 
unlikely, 89Zr-TLX250 may cause allergic-type reactions. The study centres are well equipped to treat 
allergic/anaphylactic reactions. 
This study does not offer any treatment for patients with ccRCC; therefore, patients will be offered 
state of the art therapeutic options after imaging with the study drug 89Zr-TLX250. Cancer treatment 
will not be delayed by study participation. 
3.4 
Protocol Adherence 
Strict adherence to all specifications laid down in this protocol is required for all aspects of the study 
conduct; the investigator may not modify or alter the procedures described in this protocol. If protocol 
modifications are necessary, all alterations that are not solely of an administrative nature will require 
a formal protocol amendment (see Section 13.1 for the involvement of Independent Ethics 
Committee(s) IEC(s) / Institutional Review Board(s) IRB(s)). 
If an investigator has deviated from the protocol in order to eliminate an immediate hazard to patients, 
or for other inevitable medical reasons, the investigator has to document all such deviations, 
including the reasons thereof, and submit the document to the sponsor and the head of the medical 
institution as applicable. 
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4 
Study Population 
4.1 
Patient Population 
It is planned to have 252 adult patients with an indeterminate renal mass (IRM) on standard of care 
imaging, obtained at pre-study, and who are clinically suspicious for renal cell carcinoma and 
scheduled for partial or total nephrectomy as part of their regular diagnostic work-up/clinical care. 
4.2 
Eligibility  
4.2.1 
Inclusion Criteria 
All patients must meet all of the following criteria: 
1. Written and voluntarily given informed consent 
2. Male or female ≥ 18 years of age 
3. Imaging evidence of a single indeterminate renal mass of ≤ 7 cm in largest diameter (tumour 
stage cT1), on standard of care imaging based on national standards, not older than 90 days 
on Day 0, but performed before any screening procedure. 
4. Scheduled for lesion resection as part of regular diagnostic work-up within 90 days from planned 
IV 89Zr-TLX250 administration. 
5. Negative serum pregnancy tests in female patients of childbearing potential at screening. 
Confirmation of negative pregnancy test result from urine within 24 hours prior to receiving 
investigational product. 
6. For patients included in France only, verification and confirmation of their affiliation with a social 
security. 
7. Sufficient life expectancy to justify nephrectomy. 
8. Consent to practise highly effective contraception until a minimum of 42 days after IV 89Zr-
TLX250 administration. 
4.2.2 
Exclusion Criteria 
A patient will be excluded from participation in the trial if one or more of the following criteria are met: 
1. A biopsy procedure only (rather than partial or total nephrectomy) planned for histological 
species delineation of IRM. 
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2. Renal mass known to be a metastasis of another primary tumour. 
3. Active non-renal malignancy requiring therapy during the time frame of the study participation. 
4. Chemotherapy, radiotherapy, or immunotherapy within 4 weeks prior to the planned 
administration of 89Zr -TLX250 or continuing adverse effects (> grade 1) from such therapy 
(Common Terminology Criteria for Adverse Events [CTCAE] version 5.0). 
5. Planned antineoplastic therapies (for the period between IV administration of 89Zr-TLX250 and 
imaging). 
6. Exposure to murine or chimeric antibodies within the last 5 years. 
7. Previous administration of any radionuclide within 10 half-lives of the same. 
8. Serious non-malignant disease (e.g. psychiatric, infectious, autoimmune or metabolic), that may 
interfere with the objectives of the study or with the safety or compliance of the subject, as 
judged by the investigator 
9. Mental impairment that may compromise the ability to give informed consent and comply with 
the requirements of the study 
10. Exposure to any experimental diagnostic or therapeutic drug within 30 days from the date of 
planned administration of 89Zr-TLX250 
11. Women who are pregnant or breastfeeding. 
12. Known hypersensitivity to girentuximab or DFO (desferoxamine) 
13. Renal insufficiency with GFR ≤ 45 mL/min/ 1.73 m² 
14. Vulnerable patients (e.g. being in detention) 
4.2.3 
Recruitment 
Potential patients of this study will be recruited by the urological service of the study centre and 
undergo a formal screening visit. Patients will be approached to find out whether they would be 
interested in participating in the study. Interested patients will be provided with an information sheet 
and will undergo an informed consent procedure prior to any study procedures (see Section 13.2). 
Should the patient consent to the study, a schedule will be planned. Administration of 89Zr-TLX250 
on Day 0 will be performed.  
Recruitment may be stopped at the sponsor’s discretion. An estimated total of 252 patients with an 
IRM of ≤ 7 cm and scheduled partial or radical nephrectomy will be included in the study. However, 
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in order to maintain adequate study power, this number may be increased depending on the 
proportion of non-ccRCC patients after surgery and histological verification. 
4.3 
Withdrawal of Patients from Study Participation or Medication 
4.3.1 
Withdrawal 
Patients may decide to withdraw from the study at any time for any reason without prejudice to their 
further medical care. The investigator may withdraw a patient for any of the following reasons: 
• 
Adverse event (AE): if patient is unwilling to continue because of an AE or if continued 
participation of the patient would be an unnecessary risk to the patient’s health, in the opinion 
of the investigator. 
• 
Non-compliance 
• 
Protocol violation 
• 
Pregnancy 
• 
Lost to follow-up 
4.3.2 
Withdrawal Procedures 
Although patients are not obliged to give their reason(s) for withdrawing prematurely from a trial, the 
investigator should make every effort to ascertain the reason(s) for withdrawal while fully respecting 
the patient’s rights. The investigator will make every effort to contact the patient and complete the 
termination page on the case report form (CRF) and, if possible, the assessments outlined for early 
withdrawal.  
A termination eCRF page is to be completed for every patient, whether or not the patient completed 
the study. The reason for any early discontinuation should be indicated on this form. The primary 
reason for a patient withdrawing prematurely should be selected from the following standard 
categories of early termination: 
• 
Safety Reason/AE: Clinical or laboratory events occurred that in the medical judgment of the 
investigator, for the best interest of the patient, are reasons for discontinuation. This includes 
serious and non-serious AEs regardless of relation to study medication. 
• 
Protocol Violation: The patient’s findings or conduct failed to meet at least one protocol entry 
criterion, met at least one exclusion criterion, or failed to adhere to the protocol requirements 
(e.g., drug non-compliance, failure to return for defined number of visits) as judged by the 
investigator or sponsor. The violation necessitated premature termination from the study. 
• 
Withdrawal of Consent: The patient desired to withdraw from further participation in the study 
in the absence of an investigator-determined medical need to withdraw. If the patient gave a 
reason for withdrawing, it should be recorded in the eCRF. 
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• 
Lost to Follow-Up: The patient stopped coming for visits, patient did not undergo surgery within 
the specified protocol timelines, and/or study personnel were unable to contact the patient. 
• 
Incorrect Enrolment: The patient did not meet the required inclusion/exclusion criteria for the 
study. 
The date of study drug administration must be documented. 
Appropriate follow-up of withdrawn patients will be performed, as required. 
Attempts to contact a patient who withdraws from a study must be documented. 
4.3.3 
Replacement 
A number of patients enrolled in the study may have incomplete data. Their study dispensation is as 
follows in Table 2 (see also Section 9.2.2). 
Table 2 
Study Disposition of Enrolled Patients with Incomplete Data for Primary Analysis 
Reason study data are incomplete  
FullAnalysis 
Set?  
Safety 
Analysis 
Set? 
Notes 
Withdrawal prior to administration of IV 89Zr-
TLX250 
No 
No 
Replace (All subsequent 
categories assume 
administration of IV 89Zr-
TLX250 occurred) 
Withdrawal before PET/CT imaging  
No 
Yes 
 
PET/CT images cannot be analysed due to 
technical failure 
No 
Yes 
eCRF to document 
technical failures 
Incorrect enrolment (did not meet the 
required inclusion/exclusion criteria) 
No 
Yes 
 
Patient withdrawal for reasons not related to 
disease (pregnancy, noncompliance, etc.) 
No 
Yes 
See section 4.3.2  
Evidence of N1 or M1 disease on 89Zr-
TLX250 PET/CT imaging, leading to 
additional staging and/or change in 
treatment strategy. 
Yes 
Yes 
Histopathologic 
determination of any lesion 
(primary renal or 
metastatic) will be taken as 
standard of truth 
No evidence of N1 or M1 disease, and 
nephrectomy material not available for 
evaluation of presence or absence of 
ccRCC - for example if surgery is performed 
and no tissue is removed for assessment. 
No 
Yes 
eCRF to document reasons 
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Sample size determination is based on the Full Analysis Set. 
All patients in the Safety Analysis Set will complete final study visit procedures following withdrawal 
or study completion. 
Patients who have received study drug and are withdrawn due to an AE related to the study drug 
will be included in the safety analysis. 
Patients who received study PET imaging, but do not have adequate surgical material to analyse 
may be followed-up by further imaging at the discretion of the investigator, in the best interest of the 
patient. 
4.4 
Patient Identification 
All patients who attend a screening visit will be identified by a unique identification number (“Patient 
Number”) that consists of 5 digits in two parts: 
• 
The site number is a 2-digit number that is provided by the sponsor or the ABX-CRO project 
manager prior to the start of recruitment. 
• 
The screening number is a 3-digit number that is consecutively assigned by the site to each 
patient after informed consent. 
Example: The first patient screened by site “01” will receive patient number 01-001. 
Example: The third patient at site “12” will receive patient number 12-003. 
The screening number will be assigned at the screening visit by the responsible nuclear medicine 
service of the study centre, if the initial review of the patient’s history/patient interview indicates 
possible eligibility, and if the informed consent form has been signed by the patient.  
Investigational sites are required to keep a patient identification list in the trial master file (TMF) (see 
also Section 10.4.1), identifying their patients by name, date of birth, patient number and status 
(screen failure/completed study/withdrawn). This list will be reviewed by assigned monitors, but has 
to stay on site and will not be collected, in order to protect confidentiality. 
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5 
Study Treatment 
5.1 
Study Drug 89Zr-TLX250 
5.1.1 
Chemical Properties 
89Zr-TLX250, is a chimeric monoclonal antibody (INN name: girentuximab) with specificity for the 
CAIX (carbonic anhydrase 9) antigen, radiolabelled with the positron emitting radio-metal zirconium-
89. Girentuximab has a CAS number of 916138-87-9. 
The chemical formula, without the 89Zr and the desferrioxamine, is C6460H1006N1718O2018S48 with a 
molecular mass of 146.5 kg/mol. 
5.1.2 
Pharmaceutical Properties 
89Zr-TLX250 is formulated as a solution for intravenous administration in glass vials (Europe, 
Australia, Turkey and Canada) or in a syringe (USA) at the nominal dosage strength 37 MBq (±10%) 
for single intravenous use. The 89Zr-TLX250 drug product is manufactured as “ready-to-use”. The 
composition of 89Zr-TLX250 solution for IV administration includes the active pharmaceutical 
ingredient in a buffered solution without other excipients, as described in the investigator’s brochure. 
A complete record of batch numbers and expiry dates of all study medication will be maintained in 
the trial master file (TMF). 
5.1.3 
Storage and Handling 
The product is to be shipped and stored at room temperature (15°C to 30°C) inside the lead-shielded 
container provided and protected from light.  
The product must be handled within a hospital environment only, by an accredited radiopharmacist 
and/or nuclear medicine physician according to international and local radiation protection 
guidelines. 
5.1.4 
Dosage and Administration 
The mass dose of 89Zr-TLX250 to be used in this phase 3 study will be 10 mg, labelled with 37 MBq 
(±10%) 89Zr per dose. 
Each patient will receive a single slow intravenous (IV) administration over a minimum of 3 minutes 
on Day 0 (after pre-dose assessments), at the nuclear medicine service of the respective study site. 
No dietary restrictions prior to dosing are necessary. 
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Please refer to the IMP Handling Manual for a detailed description. In brief, prior to administration, 
an indwelling intravenous catheter has to be placed into the antecubital vein or an equivalent venous 
access. Please refer to Figure 1. 
 
Figure 1 
Infusion set with filter 
Intravenous infusion set-up showing 0.22 micrometer filter in-line between syringe and infusion port (for 
reference only). 
The radiopharmaceutical will be slowly administered through the indwelling catheter and followed 
with a ≥15 mL saline flush. The syringe will be assayed prior and after administration to assess the 
injected radioactive dose (MBq). 
The dose that will be administered to the individual patient will be assessed using a dosing calibrator 
as outlined in the IMP Handling Manual. 
5.1.5 
Packaging and Labelling 
89Zr-TLX250 solution for IV administration will be supplied in glass vials (Europe, Australia, Turkey 
and Canada) or in a syringe (USA) in appropriate packaging (lead-shielded containers bearing a 
radioactive warning symbol in accordance with radioactive pharmaceutical requirements). The labels 
of the packaging supplied by the sponsor will include the following information as a minimum: 
• 
Name and address of sponsor 
• 
Study number 
• 
Name of study drug and formulation 
• 
Dose strength 
• 
Batch number 
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• 
Expiry date 
• 
Storage instructions 
• 
Radioactive warning symbol 
• 
“For Clinical Trial Use only”. 
All manufacturing, formulation and labelling will be done in accordance with applicable current GMP 
and local guidelines and laws. 
5.1.5.1 
Medication Numbering 
A system of medication numbering in accordance with all requirements of Good Manufacturing 
Practice (GMP) and any applicable regulatory requirement will be used for all study drugs. This will 
ensure that, for each patient, any dosing of study drug can be identified and traced back to the 
original bulk ware of the active ingredients. 
Lists linking all numbering levels will be maintained by the institutions in charge of study drug 
packaging. 
5.1.6 
Drug Logistics and Accountability 
5.1.6.1 
Supply, Storage, Dispensation and Return 
89Zr-TLX250 solution for IV administration will be manufactured, handled and stored in accordance 
with GMP. 89Zr-TLX250 contains radioactive material and should only be handled by personnel 
trained in the use of radioactive isotopes with proper shielding and monitoring. Receipt and use of 
89Zr-TLX250 is limited to institutions holding an appropriate handling permit by their competent 
national or regional authority. 
All required documentation, e.g. written approval from the independent ethics committee 
(IEC)/institutional review board (IRB) and regulatory authority, as appropriate, needs to be provided 
before ordering for a site can take place. The dose order will be a direct order from the study site to 
the Sponsor who shall arrange appropriate supply of IMP. The coordinating CRO will also be in copy 
of the order (please refer to the IMP Handling Manual for details). Upon establishment of patient 
eligibility (see Section 4.2), the clinical site manager will order individualised doses of 89Zr-TLX250 
solution for IV administration, via the Sponsor for direct delivery to the study site. A dose can be 
cancelled at any time however if the cancellation is less than 2 days prior to administration date then 
the site will need to follow IMP handling manual for appropriate disposal of product.  89Zr-TLX250 for 
IV administration will be provided by Telix International Pty Ltd and used unchanged from the original 
state. The treating investigator at the site will delegate ordering of 89Zr-TLX250 solution for IV 
administration to the clinical site manager, overseeing eligibility and planned treatment dates, for 
direct delivery to the site to the attention of the radiopharmacist. 
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The IMP will be shipped at room temperature (15°C to 30°C) inside an appropriately shielded 
container. 
Upon receipt at site, 89Zr-TLX250 solution for IV administration will be kept in a secure, temperature-
controlled, restricted-access location and in accordance with applicable regulatory requirements at 
the radiopharmacy of the site. The IMP should be stored at ambient temperature (15°C to 30°C) 
without freezing, and should be used by the expiration date and time printed on the label. 
89Zr-TLX250 doses will be accompanied by an individual certificate of analysis for each batch. Upon 
verification of the correct radioactive dose, as specified by the study protocol, the radiopharmacist 
will hand over the investigational product in a syringe, kept in a lead-shielded container, to the 
nuclear medicine investigator, or a designated and suitably qualified deputy for administration. This 
syringe will be labelled by the radiopharmacist according to institutional standards. 
Storage, handling and destruction must be performed according to local guidelines regarding 
radioactive waste management. Details are outlined in the IMP Handling Manual. 
5.1.6.2 
Drug Accountability 
The investigator (or radiopharmacist, whatever applicable in certain countries) will confirm receipt of 
the study drug by telefax or the method given in the IMP Handling Manual and will use the study 
drug only within the scope of this clinical study and in accordance with this study protocol. He / she 
will keep a record of the dispensed study drug. 
Receipt, distribution and return of the study drug must be properly documented on the forms provided 
by the sponsor giving the following information: study protocol number, sender, receiver, date, mode 
of transport, quantity, batch number, expiration date and retest date, if applicable. 
The coordinating clinical research organization (CRO) will monitor the drug accountability records at 
regular points during the study and will perform drug reconciliation at the end of the study. 
5.2 
Treatment Assignment 
Once full establishment of eligibility by the site, the screening physician will confirm eligibility. 
Imaging day must be scheduled before the administration of the study drug after which, the individual 
patient number will be allocated. 
Upon patient number assignment, the authorized site representative for the study can order the study 
drug through the “89Zr-TLX250 clinical trial IMP Order Form” in the IMP Handling Manual. 
More details on the procedure are given in the IMP Handling Manual. 
 
 
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5.3 
Blinding 
This is an open-label study. 
5.4 
Treatment Compliance 
89Zr-TLX250 will be administered by study personnel at the site. Details of each administration will 
be recorded in the eCRF. 
Treatment of Overdose 
89Zr-TLX250 has a very favourable safety profile. 
The risk of overdosing is minimal in this trial, as individual doses will be prepared centrally by a 
radiopharmaceutical contract manufacturer. Nevertheless, if accidental overdosing of radio-labelled 
product should occur, it will result in increased radioactive tissue exposure, with kidney and bone 
marrow as the critical organs. 
In the event of an overdose of 89Zr-TLX250, no specific treatments are available, and the patient 
should be treated at the discretion of the investigator. 
5.5 
Radiation Precautions 
Medical administration of radioactive diagnostic tracers such as 89Zr-TLX250 is guided by national 
radiation safety regulations, differing extensively between countries.  
Excretion limits acceptable for discharge will be defined by the investigators in compliance with the 
local regulations. Commonly, patients will be discharged from the hospital 2 hours p.a., unless the 
investigator decides otherwise.  
Patients will be encouraged to increase fluid intake and to void frequently through the first day after 
administration. 
The following safety precautions apply for patients: 
• 
Patients should be advised to observe rigorous hygiene in order to avoid risk of contamination 
of others using the same toilet facility. 
• 
A double toilet flush is recommended. 
• 
Patients should wash their hands thoroughly every time after using the toilet. 
• 
During the first week after treatment, patients should follow detailed instructions, as given in 
the trial participant card, regarding their distance from and contact to other persons. 
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The following precautions apply for health care workers and for laboratory assessments: 
Healthcare personnel are advised to limit the time of close contact with patients injected with (89Zr)-
labelled radiopharmaceuticals. Use appropriate shielding on the day of administration. Laboratory 
assessments will be performed by the central laboratory. Because of the potential for radioactivity in 
some blood and urine samples, the site personnel must adhere to their SOPs and/or any guidance 
and regulations for handling radioactive substances. It is mandatory to use protective high quality 
(latex/nitrile) gloves in any direct contact with the radiopharmaceutical (vial/syringe) and with the 
patient. 
Please also refer to the IMP Handling Manual. 
6 
Therapies other than Study Treatment 
6.1 
Prior and Concomitant Therapy 
Prior medications (within 30 days from planned dosing visit at Day 0) and all medications (including 
herbal medications) taken from Day 0 until EOS must be recorded in the patient’s eCRF. 
Treatment (concomitant medication or physical therapy) for AEs must be recorded in the AE section 
of the patient’s eCRF. 
The reason for treatment, generic name, administration form, strength, dose, frequency of dosing, 
route of administration, start date and, if applicable, stop date should also be recorded in the eCRF. 
All therapies and medications will be encoded according to the World Health Organization Drug 
Dictionary classification. 
6.1.1 
Prohibited Medication 
The following medications and therapies are prohibited, and patients will be withdrawn from the study 
if one of the following is administered during study participation. However, patients can be included 
when the respective washout period before enrolment into the study is considered (Table 3). 
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Table 3 
Prohibited Concomitant Medication 
Drug / Therapy 
Washout Period (before first administration 
of study drug) 
Any radiopharmaceutical 
10 half-lives of the radionuclide 
Any other experimental diagnostic or 
therapeutic IMP 
4 weeks 
Any chemo-, radio- or immunotherapy 
4 weeks 
Exposure to murine or chimeric antibodies 
5 years 
Planned antineoplastic therapies are not allowed for the study period between administration of study 
drug and imaging. 
6.1.2 
Permitted Concomitant Medication 
Vitamins, herbal preparations and other nutritional supplements are permitted during this study but 
must be recorded.  
At each visit, the investigator will ask the patient whether any medication was taken since the 
previous visit.  
Other therapy considered necessary for the patient’s health and well-being may be given at the 
discretion of the investigator. 
Patients are allowed to be vaccinated against COVID-19; the recommendation is for the patient to 
be asymptomatic and have recovered from any side effects prior to infusion. The vaccine must be 
listed as a concomitant medication.   
Patients with co-morbidities such as hypertension and other chronic medical conditions requiring 
ongoing medications need to stay on their medications, unless they are part of the list of forbidden 
medication as listed above. 
6.2 
Post-Study Therapy 
Following completion of this study, the patients will be treated according to clinical practice at the 
discretion of the investigator. This includes treatment of the tumour disease as well as any conditions 
that may arise during the trial. Description of these conditions and treatments will be provided in the 
study report as appropriate.  
Patients who received study PET imaging, but do not have adequate surgical material to analyse 
may be followed-up by further imaging at the discretion of the investigator, in the best interest of the 
patient. 
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7 
Schedule of Evaluations and Visit Description 
7.1 
Schedule of Evaluations 
A detailed schedule of events is presented in Table 1 
For time points when more than one procedure is scheduled, the assessments will be performed in 
an order as clinically appropriate (e.g. pre-dose schedule assessments in following order: vital signs, 
blood sampling for haematology and clinical chemistry, urine sampling, 12-lead ECG). 
Concomitant medication and adverse events (AEs) will be recorded continuously from Day 0 until 
EOS. 
7.2 
Screening 
Screening is to take place between 30 days and 1 day before (-30 days to -1 day) administration of 
89Zr-TLX250 on Day 0. Evidence of an IRM must be given from pre-study standard of care imaging 
(based on national standards), conducted within 90 days of Day 0 (Day -90 to Day -1), but before 
any screening procedure is performed.  
After signing the informed consent form, patients will undergo the following screening investigations 
and procedures: 
• 
Review of inclusion/exclusion criteria 
• 
Medical history 
• 
Physical exam 
• 
Vital signs 
• 
Haematology 
• 
Serum chemistry 
• 
Urinalysis (Dipstick) 
• 
Pregnancy test from serum (for premenopausal female patients) 
• 
12-lead ECG 
• 
Concomitant medications 
• 
Baseline findings 
• 
HACA testing 
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7.3 
Treatment (Day 0) 
The following examinations and procedures will be performed on Day 0:  
7.3.1 
Pre-dose 
• 
Update of medical history 
• 
Vital signs 
• 
Haematology 
• 
Serum chemistry 
• 
Urinalysis (Dipstick) 
• 
Pregnancy test from urine (for premenopausal female patients) within 24 hours before 
administration 
• 
12-lead ECG 
• 
Concomitant medication 
• 
Baseline findings 
7.3.2 
Administration of Study Drug (Time-point 0) 
Administration of 89Zr-TLX250 will be slowly conducted over a minimum of 3 minutes via the IV route 
(see Section 5.1.4). 
7.3.3 
Time-points 0.5 and 1 Hours p.a. 
• 
Vital signs 
• 
Concomitant medications 
• 
Adverse event monitoring 
7.3.4 
Time-point 2 Hours p.a. 
• 
Vital signs 
• 
12-lead ECG which can be conducted at 2h ± 5 mins after administration of the IMP. 
• 
Concomitant medication 
• 
Adverse event monitoring 
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7.4 
Imaging (Day 5 ± 2 Days, but not sooner than 72 hours p.a.) 
As part of PET/CT hybrid acquisition, abdominal PET static and low dose CT including the kidneys 
will be performed. In case of unexpected evidence of disseminated disease (N1, M1) on imaging, 
patients may have an additional whole body PET/CT scan from skull base to mid-thigh at the 
discretion of the treating clinician for complete staging.  
• 
89Zr-TLX250 PET/CT imaging  
o Abdominal static PET/CT using low dose CT without contrast agent in a single bed 
position using an acquisition time of 20 minutes to maximise image quality.  
o Optional additional whole body PET/CT imaging (skull base to mid-thigh) using 6-8 bed 
positions with 10 minute acquisition time per bed position in case of unexpected evidence 
of disseminated disease (N1, M1). The additional scan if requested by the treating 
physician needs to be completed on Day 5 ± 2 post administration of the investigational 
product. 
• 
Haematology 
• 
Serum chemistry 
• 
Urinalysis (Dipstick) 
• 
Concomitant medications 
• 
Adverse event monitoring 
7.5 
Surgery (Until Day 90 p.a.) 
• 
Pre-scheduled partial or total nephrectomy as standard of care, open or laparoscopic, as 
locally established (to be performed any time after imaging, but no longer than 90 days p.a. 
and image acquisition). In patients who have foci of extra-renal radioactivity accumulation, a 
biopsy of the most accessible lesion may be carried out instead of the planned nephrectomy. 
• 
Central histology of the renal mass or extra-renal lesion to characterise ccRCC/non-ccRCC 
and degree of CAIX expression 
• 
Concomitant medications 
• 
Adverse event monitoring 
7.6 
Post-Imaging Visit (Day 42 ± 7 days p.a.) 
All patients will have a visit on Day 42 ± 7 days p.a., irrespective of their nephrectomy and if feasible, 
which will include the following examinations/procedures: 
• 
Vital signs 
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• 
Concomitant medications  
• 
Adverse event monitoring 
• 
HACA testing 
• 
Pregnancy test from urine (for premenopausal female patients)  
7.7 
Final Study Visit 
The final study visit will be conducted depending on the nephrectomy date.  
It is expected that most patients will have their partial or total nephrectomy scheduled between 28 
and 90 days p.a. (see Section 7.7.2). 
A minor proportion of patients is expected to have a scheduled nephrectomy early after 
administration of 89Zr-TLX250, i.e. within 28 days p.a. (see Section 7.7.1). 
7.7.1 
Final Study Visit, if Surgery  28 Days p.a. (Day 42 ± 7 Days p.a.): 
For patients who had their nephrectomy scheduled within 28 days p.a., the visit on Day 42 ± 7 
days p.a. will serve as the final study visit and the following assessments will be done in addition 
to the ones described in Section 7.6 on the same day: 
• 
Physical examination 
• 
Haematology 
• 
Serum chemistry 
• 
Urinalysis (Dipstick) 
7.7.2 
Final Study Visit, if Surgery >28 Days p.a. (35 ± 7 Days after Surgery) 
For patients whose nephrectomy was scheduled between 28 and no longer than 90 days p.a., the 
final study visit will be at 35 ± 7 days after surgery, and the following assessments will be performed. 
• 
Physical examination 
• 
Vital signs 
• 
Haematology 
• 
Serum chemistry 
• 
Urinalysis (Dipstick) 
• 
Concomitant medications  
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• 
Adverse event monitoring 
• 
HACA testing 
8 
Procedures and Variables 
Patients will provide written informed consent before any study-related procedures can be performed 
(see Section 13.2). 
Patient-related events and activities including specific instructions, procedures, concomitant 
medications, dispensing of study drug, and descriptions of AEs are to be recorded in the appropriate 
source documents and eCRFs. 
The schedule of assessments is provided in Table 1. Unless otherwise specified, all examinations 
and procedures will be performed by the investigator or other regular study personnel. 
An additional visit can be scheduled at any time if the investigator considers it necessary. 
8.1 
Baseline Characteristics 
It is anticipated to recruit 252 evaluable male or female patients  18 years with evidence of an IRM 
scheduled for partial or total nephrectomy (see Section 4.2). 
8.1.1 
Demographic Characteristics 
The following demographic characteristics will be recorded:  
• 
date of birth or age, depending on local EC requirements 
• 
weight, height, ethnic origin 
8.1.2 
Medical and Surgical History, Baseline Findings 
Medical/surgical history and medical conditions present before the administration of 89Zr-TLX250 will 
be recorded at the screening visit and pre-dose on Day 0. 
Detailed instructions on the differentiation between (i) medical / surgical history and (ii) baseline 
findings can be found in Section 8.8.1.1. 
The patients should have a sufficient life-expectancy to justify nephrectomy (see Section 4.2). 
8.1.3 
Prior and Concomitant Medication 
Prior and concomitant medication will be recorded on the eCRF from screening and throughout the 
study, beginning on Day 0, until the EOS visit (see Section 6).  
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The following concomitant medication should not be recorded on the eCRF:  
• 
Anaesthetics, analgesics, sedatives and laxatives given in routinely used regimen and 
dosage in connection with nephrectomy 
8.1.4 
Pre-baseline Morphological Imaging 
Patients with suspected ccRCC, typically receive abdominal MRI or CT with and without contrast 
agent as part of their initial diagnostic work-up. Contrast enhanced MRI or CT is also the standard 
for re-staging in patients after initial therapy. The imaging methodology will be conducted according 
to the institutional routine practise. 
Pre-baseline images will be collected for evidence of a single indeterminate renal mass (IRM) and 
for precise volumetric tumour delineation. 
A current contrast-enhanced abdominal MRI or equivalent standard of care imaging (based on 
national standards) with contrast agent, not older than 90 days on Day 0, but conducted before any 
screening procedure, should be available, providing evidence of a newly diagnosed, single renal 
mass, confined to the kidney, and measuring ≤ 7 cm in greatest diameter (stage cT1) (inclusion 
criterion). Ultrasound images will not be acceptable. 
In the scope of this clinical study, no contrast-enhanced CT or MRI will be performed. 
Lesions of interest will be spatially localised by the site and independently by the central image 
readers. The central image readers will not have access to the spatial localisation determined by the 
site. For lesions located within the kidney, spatial localisation should be conducted as follows 
- 
Definition of the diseased kidney (left or right) 
- 
Definition of the segment within the kidney containing the lesion. The segments are based 
on Figure 2 
- 
In the event of a total nephrectomy the pathologist should specify the segment location that 
was used to provide the tissue samples used for central analysis 
 
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Figure 2 
Overview of kidney segments for spatial localisation 
From: Gray's Anatomy, 40th Edition, chapter 74, Figure 12 
For patients with extra-renal disease the location of the lesion used to obtain the sample should be 
described by the pathologist. The independent image reviewers will define the image location of 
interest for extra-renal lesions in a blinded fashion. 
8.1.5 
Pregnancy Tests and Assessment of Postmenopausal Status 
Part of the blood samples taken for the clinical laboratory tests at screening will be used to perform 
a serum -HCG pregnancy test in women of childbearing potential. On Day 0, a urine pregnancy test 
will be performed within 24 hours before administration of study drug to confirm the negative 
pregnancy result from screening. Furthermore a urine pregnancy test will be performed on Day 42 
± 7 days p.a. 
In postmenopausal women < 55 years a permanent postmenopausal status must be proven through 
history of hysterectomy or hormone analysis in serum, with estradiol < 20 pg/mL and follicle 
stimulating hormone FSH < 40 IU/L, or last spontaneous bleeding at least 2 years before start of the 
study.  
8.2 
Imaging during the Study 
The parameters used to acquire each image in this study are outlined in the Subject Imaging Manual. 
The image review charter provides detailed descriptions of all imaging procedures, including 
baseline imaging, as well as the process used for spatial colocalisation of lesions on PET images.  
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8.2.1 
89Zr-TLX250 PET / CT Imaging  
8.2.1.1 
PET/CT Imaging 
Abdominal PET/CT scans including the kidneys will be acquired over 20 minutes in a single bed 
position at a single time point on Day 5 ± 2 post administration (p.a.) of 89Zr-TLX250 using static 
image acquisition and low dose CT without contrast agent.  
Patients found to have evidence of N1 or M1 disease may undergo additional whole body imaging 
(skull base to mid-thigh) using 6-8 bed positions with 10 minute acquisition time per bed position at 
the discretion of the treating clinician to support comprehensive staging. The additional scan if 
requested by the treating physician needs to be completed on Day 5 ± 2 post administration of the 
investigational product. 
8.2.2 
Imaging Analysis 
Reading for the co-primary endpoints (sensitivity and specificity) will be conducted independently by 
3 trained readers, blind to history, and histology results.  
Details of the assessments are described in the Image Review Charter that will be provided to the 
central reviewer. 
8.2.2.1 
Qualitative 89Zr-TLX250 Tumour Targeting 
89Zr-TLX250 tumour uptake will qualitatively be assessed (yes /no), considering whether or not 89Zr-
TLX250 binding inside or in the vicinity of the target lesion, as delineated on structural imaging 
(contrast-enhanced pre-BL imaging), can be detected. 
Local and central reviewers will designate the lesions as having a status of positive (ccRCC) or 
negative (other than ccRCC). The interpretation of the 89Zr-TLX250 PET/CT images as positive or 
negative for ccRCC will be made on the basis of visual examination only.  
The lesion will be classified as PET-positive if:  
• 
Radioactivity in the lesion is clearly visible, AND  
• 
Radioactivity in the lesion is greater than that in normal tissue (for example, in ipsilateral or 
contralateral kidney)  
If these two criteria are not met, the lesion will be classified as negative. A 89Zr-TLX250 PET/CT scan 
is considered positive, if there is at least one positive tumour lesion. 
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8.2.2.2 
Quantitative 89Zr-girentuximab Tumour Targeting 
Absolute activity concentrations of tracer in tumour (MBq/cm³) will be calculated using attenuation-
corrected count rates, and tumour volumes, as determined by contrast-enhanced pre-BL MRI or 
equivalent imaging modality with contrast agent as part of the standard of care. Considering specific 
activity (MBq/mg), protein mass dose concentrations of tracer in tumour at the time point of imaging 
(mg/cm³) will be calculated. 
8.2.2.3 
Estimation of 177Lu-girentuximab Tumour Targeting 
Protein mass dose concentrations of tracer in tumour (mg/cm³) at the single time point of imaging, 
and a general model of average girentuximab kinetics in tumour over time (derived from sequential 
89Zr-TLX250 biodistribution data), will be used, to estimate possible girentuximab protein kinetics in 
tumour lesions over a period of one week, assuming the kinetics of diagnostic 89Zr-girentuximab and 
therapeutic 177Lu-girentuximab are essentially similar. Such protein kinetic data can be used, to 
generate simulated time-activity curves for 177Lu-girentuximab in tumour for different specific activity 
levels, to yield estimates of achievable therapeutic absorbed doses to tumour (Gy). 
8.2.2.4 
Local Review of PET/CT Images 
Local image review will involve qualitative assessment only and will follow the same guidelines as 
being used for the qualitative independent, blinded review. However, local reviewers will not be 
blinded with respect to patient data. 
8.2.2.5 
Independent Central Review of PET/CT Images 
A blinded central review of the 89Zr-TLX250 PET/CT images will be undertaken by an Independent 
Review Committee (IRC) consisting of 3 experienced reviewers not involved in the conduct of the 
trial. Reviewers will be independent of the study and without affiliation to the trial Sponsor. They will 
be blinded with regard to institution, histopathological diagnosis and clinical data. The central 
PET/CT reviewers will be asked to evaluate both kidneys and the link to the actually operated kidney 
will be done on the basis of the local pathology report retrospectively. This evaluation will be based 
on PET/CT images (low dose CT proportion without contrast) only. 
Image sets covering extra-renal body regions will have all assessments conducted in the same way 
by blinded readers. The readers will localise the region within the body of the lesion of interest and 
then identify it as PET positive or PET negative, based on comparative regional uptake of activity. 
The readers will be blinded to the histology information on the tissue in question. In the event of 
multiple non-target lesions, the largest 2 lesions as determined by longest diameter, in each organ, 
will be evaluated for PET response. 
Image data analyses will be performed by a central image core lab. Qualitative visual analysis 
(presence or absence of localised 89Zr-TLX250 uptake inside or in vicinity of the target lesion, as 
seen on contrast-enhanced pre-BL imaging), will be used to assess test performance of 89Zr-TLX250 
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PET/CT imaging to non-invasively detect ccRCC, using histological results from the central 
histological reference laboratory as standard of truth.  
8.3 
Determination of Histological Standard of Truth 
Partial and total nephrectomy are routinely used in the management of cT1 renal tumours.  
All patients enrolled in the study will already be scheduled for partial nephrectomy or total 
nephrectomy as part of standard work-up and management of an indeterminate renal mass. 
A small number of patients may be found to have an extra-renal focus of increased radioactivity 
accumulation that is suspicious for metastatic disease. In these patients, the investigator may elect 
to undertake further diagnostic work-up including additional imaging, which may result in a change 
in surgical strategy. Results of the PET scans should not dictate clinical management. 
If results of further standard workup confirm metastatic disease, then biopsy might be performed. 
Biopsy results will be considered in the exploratory analysis (See Section 9.1.2.7). 
The resected lesion will be localised by the site surgeon or pathologist using the localisation scheme 
in 8.1.4 above. The independent image readers will not have access to this evaluation. 
8.3.1 
Local Pathology Assessment 
Surgical resection material, along with appropriate documentation of its in situ origin, allowing 
identification with lesion localisation on PET images will be sent to the local pathology department 
for routine histological work-up (H&E staining, histological diagnosis: ccRCC vs. non-ccRCC). 
If surgical material is taken from extra-renal locations then samples of this tissue should be prepared 
in the same way as renal samples and submitted for analysis in the same way. 
The results from the local pathology assessment on diagnosis will not be part of the study. 
8.3.2 
Independent Central Pathologist 
Representative, non-stained but paraffin-embedded slides of lesion tissue (N=15) will be sent to a 
central pathology service as contracted by the Sponsor. The procedures for preparation, labelling 
and shipment of these representative slides from the local pathologists to the central pathologist will 
be described in a separate Pathology Manual to be provided to the local pathologists.  
The primary purpose of the independent histopathology review is the determination of the histological 
diagnosis of the renal mass (ccRCC or non-ccRCC) as the standard of truth for comparison with 
89Zr-TLX250 imaging.  
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For patients in whom unexpected evidence of disseminated disease has been observed, any 
available tissue samples from biopsies of extrarenal lesions will also be analysed centrally. 
Details of the central evaluation procedure are described in a separate document prepared by the 
central pathology service. 
8.4 
Diagnostic Performance 
Test performance parameters (sensitivity, specificity, positive and negative predictive values, 
accuracy), will be determined considering visually determined qualitative 89Zr-TLX250 tumour uptake 
(yes/no), and histopathology (ccRCC+/ ccRCC-) as standard of truth. 
8.5 
Safety Evaluation 
As extensive safety information on 89Zr-TLX250 and on girentuximab radiolabelled with other 
radionuclides is already available, only the following basic standard safety evaluations will be made: 
1. Standard laboratory (hematology, clinical chemistry and urinalysis) 
2. Physical examination 
3. 12-lead ECG 
4. Vital signs 
5. Adverse event recording (NCI-CTCAE v 5.0) 
6. Concomitant medication recording 
7. HACA testing 
8.6 
Sample Shipment 
Study product will be shipped as requested to the site in patient specific vials (Europe, Australia, 
Turkey and Canada) or syringe (USA) in appropriately shielded containers. Sites should complete 
the “89Zr-TLX250 Order Form” and submit this to the study sponsor or designated contact. 
Acknowledgement of order will be sent to the site. Product accountability will be monitored during 
the study with the appropriate study specific form.  
8.7 
Sample Retention / Destruction 
Blood and urine samples will be immediately processed for safety reasons. No samples will be 
retained. Blood samples drawn for analysis will be discarded / destroyed after analysis has been 
completed. 
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8.8 
Safety 
8.8.1 
Baseline Findings 
8.8.1.1 
Definition of Baseline Finding 
A baseline finding is defined as any untoward medical condition in a study patient who has signed 
the informed consent form but not yet received the first dose of the study drug. This includes 
conditions stabilised by treatment. By definition, a baseline finding cannot be causally related to 
study drug; however, it may be causally related to the study (e.g. caused by study-conduct-related 
investigations). 
Differentiation between medical / surgical history and baseline findings: 
Conditions which started before signature of informed consent and for which no symptoms or 
treatment are present until the first administration of study drug (e.g., seasonal allergy without acute 
complaints) are recorded as medical / surgical history. 
Conditions which started before signature of informed consent and for which symptoms or treatment 
are present between signature of informed consent and first administration of study drug (e.g. allergic 
pollinosis) are recorded as baseline findings. 
Differentiation between baseline findings and adverse events: 
Conditions (e.g., abnormal physical examination findings, symptoms, diseases, laboratory) present 
before the first administration of study drug will be documented as baseline findings. 
Conditions which started or deteriorated after the first administration of study drug will be 
documented as adverse events. 
Categories, assessments and documentation of baseline findings 
The date and time of the first acute occurrence of the event is documented as the onset. 
If the baseline finding is "continuing" into the treatment phase, no AE is to be recorded if, after start 
of study treatment, the event has the same or milder pattern and intensity. If the finding worsens in 
terms of either the pattern or intensity after study drug administration, the event must be documented 
as an AE. 
If the event is concluded, this should be recorded in the eCRF ("resolved"). If the event vanishes but 
re-occurs during treatment, an AE with a start date of its re-occurrence should be entered. 
All baseline findings will be assessed and documented by the investigator according to the following 
categories: 
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• 
Seriousness: for each baseline finding, the seriousness must be determined according to the 
criteria given in Section 8.8.2.2. If serious, the baseline finding has to be handled in the same 
way as an SAE. 
• 
Intensity 
• 
Specific drug treatment 
• 
Specific non-drug treatment 
• 
Causal relationship to study conduct 
• 
Outcome 
The intensity of an event, the causal relationship to study conduct, and the outcome of the baseline 
finding should be classified according to the same categories used for AEs, as specified in 
Section 8.8.2.2. 
8.8.1.2 
Serious Baseline Findings 
Definition 
Baseline findings will be regarded as serious if they meet the criteria used for defining serious 
adverse events (SAEs) and will be reported on the SAE form (see Section 8.8.2.5). 
8.8.2 
Adverse Events 
8.8.2.1 
Definition of Adverse Event 
The definitions below follow International Conference on Harmonization (ICH) – Good Clinical 
Practice (GCP) (see also ICH Guideline for Clinical Safety Data Management: Definitions and 
Standards for Expedited Reporting): 
Adverse event (AE) 
Any untoward medical occurrence in a patient or clinical investigation subject administered a 
pharmaceutical product and which does not necessarily have a causal relationship with this 
treatment. An AE can therefore be any unfavourable and unintended sign (including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of a medicinal 
(investigational) product, whether or not considered related to the medicinal (investigational) product. 
By definition, for this study, all AEs are regarded as 'treatment emergent', i.e., not seen before 
treatment or, if already present before treatment, worsened after start of treatment. 
Pre-planned or elective surgeries or therapies should be recorded in the patient’s source documents 
but are not to be considered AEs unless there was any change to the patient’s medical condition 
during the AE collection period.  
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All AEs will be assessed and documented by the investigator according to the categories detailed in 
Section 8.8.2.2. 
8.8.2.2 
Categories of Adverse Event Assessment 
Seriousness 
The seriousness must be determined for each AE, according to the criteria given in Section 8.8.2.5. 
Intensity 
The intensity of an AE is classified according to NCI-CTCAE version 5.0, taking into account the 
possible range of the intensity of the event: 
• 
NCI-CTCAE Grade 1 (mild) 
• 
NCI-CTCAE Grade 2 (moderate) 
• 
NCI-CTCAE Grade 3 (severe) 
• 
NCI-CTCAE Grade 4 (life-threatening) 
• 
NCI-CTCAE Grade 5 (fatal) 
Study drug action 
AEs requiring any action, i.e. medication or therapy for treatment, should be treated according to 
recognised standards of medical care to protect the health and well-being of the patient. 
Any potential study drug action to resolve the AEs is to be documented as follows 
• 
Drug withdrawn 
• 
Dose reduced 
• 
Dose not changed 
• 
Other action (stopped: definitely, temporarily with exact dates) 
Any potential study drug action to resolve the AEs is to be documented in free text in the eCRF, e.g. 
'dose interrupted', 'dose interrupted and re-started'. 
Causal relationship to study drug 
The possible causal relationship between the AE and the administration of the study drug is classified 
according to the following question: 
“Is there a reasonable likelihood that the event was caused by the study drug?” 
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Possible answers are: 
• 
Related (plausible time relationship to the administration of IMP/RP. No plausible explanation 
by underlying/concurrent disease or other drugs/events),  
• 
Possible (plausible time relationship to the administration of IMP/RP, but the AE can be also 
plausibly explained by the underlying/concurrent disease or other medicinal products / 
events),  
• 
Unlikely (unlikely temporal relationship to the administration of IMP/RP. Other medicinal 
products, events, and the underlying/concurrent disease provide a plausible explanation)  
• 
Not related (clear evidence that the AE is not connected to the IMP/RP administration) 
• 
Not assessable (no evaluation possible based on present data, additional clarification and 
follow-up necessary) 
Causal relationship to study conduct 
The possible causal relationship between the AE and any study-conduct-related procedures and 
activities required by the protocol is classified according to the following question: 
The assessment of a possible causal relationship between the AE and the study conduct other than 
the relationship to study drug is based on the following question: 
“Is there a reasonable likelihood that the event was caused by the study conduct?” 
Possible answers are “related”, “not related”, “not assessable”. 
Outcome 
The outcome of the AE is to be documented as follows: 
• 
Recovered 
• 
Recovered with sequelae 
• 
Ongoing 
• 
Fatal 
• 
Unknown. 
8.8.2.3 
Assessment and Documentation of Adverse Events 
At every assessment time point during the study until EOS, the patient will be asked a non-leading 
question such as “Have you had any health problems since you were last asked / since your last 
visit?”. All AEs reported in response to questioning, as well as AEs reported spontaneously and 
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occurring at any other time, will be recorded on the ‘adverse event’ page(s) in the eCRF, regardless 
of causality. 
If an AE fulfils any of the SAE criteria, both the AE pages of the eCRF and the Serious Adverse 
Event Form must be completed. SAEs are recorded for the entire duration of the study. 
For both serious and non-serious AEs, documentation must be supported by an entry in the patient’s 
hospital notes. Required information includes: the type of AE, seriousness of the event, start date, 
date of resolution, actions required, outcome and an assessment of its relationship to study drug and 
an estimate of its severity (using National Cancer Institute-Common Toxicity Criteria [NCI-CTCAE] 
criteria, version 5.0, see Appendix I). NCI-CTCAE severity will be marked in the SAE Report Form 
using the numeric grades: grade 1 (mild), grade 2 (moderate), grade 3 (severe), grade 4 (life-
threatening) and grade 5 (fatal). 
All abnormal laboratory, vital signs and 12-lead ECG results and findings from the physical 
examination considered to be clinically relevant by the investigator should also be recorded as AEs. 
If an abnormal laboratory result meets any of the SAE criteria, this must also be reported on a Serious 
Adverse Event Form. 
All AEs that meet one criterion for “serious” require the completion of an SAE Report Form, in 
addition to being recorded on the AE pages of the patients’ eCRF. This applies to all SAEs, whether 
or not they were considered to be related to study treatment. 
8.8.2.4 
Expected Adverse Events 
Expected Conduct-related AEs 
The use of an indwelling cannula for the purpose of blood sampling and administration of study drug 
may be accompanied by mild bruising and also, in rare cases, by transient inflammation of the vessel 
wall. After initial irritation, the presence of an indwelling cannula is usually painless and hardly 
noticeable. The same applies to single vein punctures for blood sampling. 
Patients may also experience discomfort from lying in the camera, e.g. back pain. 
Expected Adverse Drug Reactions 
The definition below follows ICH-GCP (see also ICH Guideline for Clinical Safety Data Management: 
Definitions and Standards for Expedited Reporting): 
Adverse drug reaction (ADR) 
In the pre-approval clinical experience with a new medicinal product or its new usages, particularly 
as the therapeutic dose(s) may not be established, all noxious and unintended responses to a 
medicinal product related to any dose should be considered as ADR. The phrase 'responses to a 
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medicinal product' means that a causal relationship between a medicinal product and an AE is at 
least a reasonable possibility, i.e., the relationship cannot be ruled out.  
An overview on the ADRs that were observed in clinical studies with 89Zr-TLX250 or girentuximab 
radiolabelled with comparable radionuclides can be retrieved from the Investigator’s Brochure. 
Unexpected Adverse Drug Reactions 
An unexpected adverse drug reaction is defined as any adverse drug experience, the nature, 
specificity or severity of which is not consistent with the applicable product information (e.g. 
investigator’s brochure for an unapproved investigational product or Summary of Product 
Characteristics for an approved product). “Unexpected” as used in this definition refers to an adverse 
drug experience that has not been previously observed and included in the product information, 
rather than from the perspective of such experience not being anticipated from the pharmacological 
properties of the investigational product. Any unexpected ADR, as of formal criteria of an SAE may 
not be met, (see above), has to be reported by the investigator immediately after informing the 
sponsor, using an SAE form. 
8.8.2.5 
Serious Adverse Events 
Definition of Serious Adverse Events 
The following SAE definition is based on ICH guidelines and the final rule issued by the Food and 
Drug Administration (FDA) and effective 06 Apr 1998. It is to be applied to both, AEs (defined in 
Section 8.8.2.1) and baseline findings (defined in Section 8.8.1). 
An SAE is classified as any untoward medical occurrence that at any dose 
• 
Results in death, or 
• 
Is life threatening, or 
• 
Requires inpatient hospitalization or prolongation of existing hospitalization, or 
• 
Results in persistent or significant disability / incapacity, or 
• 
Is a congenital anomaly / birth defect. 
The term ‘life threatening’ in the definition refers to an event in which the patient was at risk of death 
at the time of the event, it does not refer to an event which hypothetically might have caused death 
if it were more severe. 
Medical and scientific judgment should be exercised in deciding whether it is appropriate to also 
report an AE as serious in other situations, such as important medical events that may not be 
immediately life threatening or result in death or hospitalization but may jeopardize the patient or 
may require intervention to prevent one of the other outcomes listed in the definition above. These 
should also usually be considered serious. Examples of such events are intensive treatment in an 
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emergency room or at home for allergic bronchospasm; blood dyscrasias or convulsions that do not 
result in inpatient hospitalization; or development of drug dependency or drug abuse. 
Actions and Reporting Obligations in Case of Serious Adverse Events 
All AEs that meet the criteria for serious require the completion of a SAE Report Form, in addition to 
being recorded on the AE pages of the patients’ eCRF. This applies to all SAEs, whether or not they 
were considered to be related to study treatment.  
SAEs must be reported within 24 hours, once the Investigator or other study site personnel are 
aware of the event. The reporting is delegated by the Sponsor to the coordinating CRO (see page 
5). An initial written report should be prepared using the SAE Report Form and faxed to the Sponsor. 
This report should provide a detailed description of the SAE. Any other relevant documents such as 
anonymised copies of hospital records may also be attached, if available. If it is not possible to notify 
the Sponsor by fax within 24 hours, an initial notification by telephone should be made, to include 
the following information: 
• 
Identification of the Investigator and centre. 
• 
Patient number and initials 
• 
Confirmation of study medication given, with date and dose. 
• 
Concomitant medication and indication for using such medication. 
• 
Information on the event, including date and time of onset of symptoms, severity, resolution 
(if applicable), date of death or other outcome (as applicable). 
• 
Relationship with study medication in the Investigator’s opinion. 
All reports of death, both toxic death and death as a result of progression of disease, should be 
reported to the Sponsor immediately using the SAE Report Log. A detailed description of the cause 
of death should be provided. Autopsy reports, if available, should also be sent to the Sponsor as 
soon as they become available. Any additional information which becomes known to the Investigator 
should be provided in a follow-up report. 
8.8.2.6 
Other Relevant Safety Information 
The following other safety relevant information must be documented in the patient medical record as 
well as in the AE pages of the eCRF, even if side effects (ADRs) resulting from the event were not 
observed. 
Additionally, for all events (post-study related safety information, pregnancies, overdose, drug 
interaction, medication error) that fulfil the criteria for seriousness, an SAE Form must be completed 
by authorized staff and signed by the investigator. 
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a) Post-study related safety information 
Any SAE (including deaths) which occurs until the final study visit should be reported by the 
investigator to the sponsor in case the investigator becomes aware of it. 
b) Pregnancies 
Every effort will be made to avoid pregnancy during the use of the IMP. Pregnancies occurring during 
the study (foetal exposure to the IMP) need to be reported. 
In case of pregnancy during the study, the investigator should complete the Pregnancy Notification 
Form and send or fax it to the project manager or designee. 
Follow-up information on the outcome of mother and foetus will be requested by a sponsor 
representative. 
Overdose, interaction, and medication error 
The following safety relevant information should be reported as AE or, if the reaction fulfils one of 
the criteria for seriousness, as SAE. 
c) Drug overdose 
An overdose is a deliberate or inadvertent administration of a treatment at a dose higher than 
specified in the protocol and higher than the known therapeutic dose that is of clinical relevance. The 
reaction must be clearly identified as an overdose and reported accordingly using the Adverse Event 
reporting form. 
d) Drug interaction 
A drug interaction is a situation in which a substance or medicinal product affects the activity of an 
IMP, i.e. increases or decreases its effects, or produces as effect that none of the products would 
exhibit on its own. The reaction must be clearly identified as a drug interaction. 
e) Medication error 
A medication error involves the inadvertent administration or unintended use of a medicinal product 
which may be caused by the naming, presentation of pharmaceutical form/packaging, or instructions 
for use/labelling. The reaction must be clearly identified as a medication error. 
8.8.3 
Clinical Laboratory Tests 
Blood and urine samples will be taken for measurement of haematology and biochemistry 
parameters and dip stick urinalysis at the following time points: 
• 
Screening Visit 
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• 
Day 0 pre-dose  
• 
Day 5 ± 2 days 
• 
Final study visit: Day 42 ± 7 days p.a. (for patients with nephrectomy  28 days p.a.) 
• 
Final study visit: 35 ± 7 days after surgery (for patients with nephrectomy > 28 days p.a.) 
Laboratory assessments will be performed by a central laboratory. Because of the potential for 
radioactivity in some blood samples, the laboratory must adhere to their SOPs and/or any guidance 
and regulations for handling radioactive substances. 
Samples will be tested for the following parameters:  
Haematology: haemoglobin, haematocrit, mean corpuscular volume (MCV), mean corpuscular 
haemoglobin (MCH), white blood cell count (total and differential: leukocytes, 
neutrophils, eosinophils, basophils, lymphocytes, monocytes), red blood cells, 
platelets 
Biochemistry: 
sodium, potassium, chloride, calcium, glucose, creatinine, urea, albumin, total 
bilirubin, aspartate transaminase (AST), alanine transaminase (ALT), alkaline 
phosphatase, gamma-glutamyl transferase (GGT), lipase, amylase, total protein 
Clotting status: prothrombin time (quick), reagent-independent prothrombin ratio (international 
normalised ratio; INR), activated partial thromboplastin time (aPTT). 
Immunogenicity: HACA. 
Urinalysis: 
density, pH, protein, glucose, blood, urobilinogen, erythrocytes, leukocytes, ketones, 
bilirubin, nitrite. 
A serum -HCG pregnancy test will be performed only in premenopausal women at screening. 
Confirmation of the negative result will be done with a urine pregnancy test within 24 hours before 
administration of the study drug on Day 0 and at the Day 42 (± 7 days) time point (see Section 8.1.5). 
The investigator will sign each laboratory assessment to confirm review of the results. Clinically 
relevant values have to be highlighted as “c.s.” (“clinically significant”). The results will be sent back 
to the investigational sites and be included in the patient’s eCRF. 
8.8.4 
Vital Signs 
Body temperature and supine blood pressure and heart rate will be measured on the non-dominant 
arm after 5 minutes of supine rest at the following time points: 
• 
Screening Visit 
• 
Day 0, pre-dose, 0.5, 1 and 2 hours p.a.  
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• 
Post-Imaging Study visit Day 42 ± 7 days (for all patients) 
• 
35 ± 7 days after surgery (for patients with nephrectomy 28 to 90 days p.a.) 
Results will be recorded in the eCRF and in the medical records. 
8.8.5 
12-Lead ECG 
12-Lead ECGs will be recorded after 5 minutes supine rest at the following time points:  
• 
Screening Visit 
• 
Day 0, pre-dose and 2 hours p.a.  
ECG-results will be classified by the local investigator into normal or abnormal, respectively, at 
baseline. Follow-up ECGs will be assessed with regard to clinically relevant changes, relative to 
baseline by the investigator. Relevant changes will be categorically (e.g., arrhythmia, ischemic signs, 
other) documented in the patient's file, and pseudonymised copies of the pertaining ECG will be 
collected as part of the eCRF. 
8.8.6 
Physical Examination 
Physical examinations will be performed at the following time-points: 
• 
Screening Visit 
• 
Day 42 ± 7 days (for patients with nephrectomy within 28 days p.a.) 
• 
35  7 days after surgery (for patients with nephrectomy from 28 to 90 days p.a.) 
The physical examination will consist of general appearance, orientation to time, space and person, 
cardio-pulmonary auscultation, manual abdominal examination, and further investigation of any 
abnormal system, as appropriate. 
8.8.7 
HACA Determination in Serum 
In order to detect possible formation of antibodies against girentuximab, serum samples will be 
collected at Screening, on Day 42 ± 7 days p.a. and at the final study visit.  
The final study visit will be conducted in relation to the scheduled nephrectomy.  
i) 
If the scheduled nephrectomy occurs > 28 day p.a. (i.e., between 28 and 90 days p.a.), 
the final study visit and the blood draw for HACA serum sample will be on Day 35 ± 7 
days after surgery. 
ii) 
If the scheduled nephrectomy occurs  28 days p.a. (i.e. within 28 days p.a.), the final 
study visit and the blood draw for HACA serum sample will be on Day 42 ± 7 days after 
administration. 
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Blood sampling will be ≤ 3 mL per sample.  
An approximately 2 mL blood sample will be collected in an unheparinized (clotted) tube, stored 
overnight at 2-8°C and centrifuged at 1000-2000 rpm for 10 minutes. Three 200 µL serum aliquots 
will be transferred into three separately labelled 2 mL cryo-vial and stored at –20°C. Please refer to 
the central laboratory manual for details on shipping. 
The presence of HACA in sera of patients will be tested quantitatively and qualitatively using 
validated ELISAs in the Bioanalytics Department of Agilex Biolabs Pty Ltd, South Australia, Australia. 
8.9 
Total Volume of Blood 
A summary of the blood to be collected from each patient in this study is presented in Table 4. The 
maximum total volume of blood to be collected from patients over the study period will be 115 mL. 
For patients who will have their final study visit at Day 42 ± 7 days, 18 mL of blood less will be drawn 
amounting to a total of 97 mL. 
Table 4 
Summary of Blood Volumes Collected for Each Patient 
Sample 
Volume per sample  
Number of samples 
Total volume 
Clinical laboratory tests:  
 
Screening (incl. -HCG) 
 
Day 0, pre-dose 
 
Day 5  2 days 
 
Day 42 ± 7 days 
 
Up to 10 days before surgery, 
including the day of surgery 
 
Final visit (on Day 35 ± 7 days after 
 
surgery, if not Day 42 ± 7 days) 
 
23 mL 
20 mL 
18 mL 
18 mL 
 
18 mL 
18 mL 
 
1 
1 
1 
1 
 
1 
1 
 
23 mL 
20 mL 
18 mL 
18 mL 
 
18 mL 
18 mL 
Overall TOTAL 
- 
- 
115 mL 
8.10 
Total Radiation Exposure 
The 89Zr-TLX250 related radiation exposure will be 37 MBq (+/-10%) per single administration. 
The combined whole body effective dose of 89Zr-girentuximab administration and abdominal low-
dose CT is expected to be below 20 mSv based on the accepted standard OLINDA 1.1 and ICRP 
60, or below 23 mSv based on IDAC-Dose 2.1 and ICRP 103, for all patients (Section 1.3). 
Patients with suspected metastatic disease may undergo an additional whole body PET/low dose 
CT at the discretion of the Principal Investigator. The additional radiation of this optional imaging is 
approx. 3 mSv. 
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9 
Statistical Methods and Determination of Sample Size 
The study design, statistical hypotheses, sample size calculations, and statistical methods selected 
for this study are based on previous scientific advice granted by the US Food and Drug 
Administration (FDA) for a planned confirmatory study with girentuximab as an imaging agent. 
9.1 
List of Variables and Population Characteristics 
9.1.1 
Co-Primary Variables 
The primary study objective is to evaluate the diagnostic efficacy in all patients by comparing the 
sensitivity and specificity of 89Zr-TLX250 PET/CT imaging to thresholds of 0.70 (sensitivity) and 0.68 
(specificity), using histology as standard of truth. 
The co-primary variables of this study will be the sensitivity and specificity of 89Zr-TLX250 PET/CT 
imaging to detect ccRCC. 
a) Sensitivity is defined as the proportion of study patients with a true positive (TP) 89Zr-TLX250 
PET/CT scan (detection of clear cell carcinoma), relative to those with positive 
histopathological diagnosis for ccRCC:  
 
 
Sensitivity (%) = TP / ( TP + FN) 
b) Specificity is defined as the proportion of study patients with a true negative (TN) 89Zr-TLX250 
PET/CT imaging result (no ccRCC), relative to those with a negative histopathological 
diagnosis of non-ccRCC (histological result:= TN + FP):  
 
 
Specificity (%) = TN / (TN + FP) 
The sensitivity and specificity of 89Zr-TLX250 PET/CT imaging will be compared separately to their 
respective prespecified thresholds. The comparison of sensitivity/specificity data will be based on data 
from the following 2x2 table (Table 5) which summarises the results of the qualitative 89Zr-TLX250 
tumour targeting (tracer uptake in target lesion: yes/no) as determined by visual reading and the 
central study pathology as standard of truth. 
 
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Table 5 
Probability Calculated on All Cases with Positive Histopathology 
 
Reference Standard 
Histopathology (standard of Truth) 
 
Total 
positive (ccRCC) 
negative 
(no ccRCC) 
Outcome 
89Zr-TLX250 
PET/CT scan 
positive 
(ccRCC) 
TP 
FP 
# of cases with positive 
PET/CT: TP+FP 
negative  
(no ccRCC) 
FN 
TN 
# of cases with negative 
PET/CT:  
FN+TN 
 
total 
# of cases with ccRCC 
TP+FN 
# of cases without 
ccRCC FP+TN 
 
N 
Abbreviations: FN = false negative; FP = false positive; TN = true negative; TP = true positive; 
The point estimate of sensitivity of PET/CT is TP/(TP+FN) and the point estimate of specificity is 
TN/(TN+FP). Wilson’s binomial (score) confidence intervals will be used to compare the 95% 
confidence interval lower boundary of each quantity to the threshold of 0.70 (sensitivity) and 0.68 
(specificity). 
Note that both sensitivity and specificity will be determined for each of three independent readers. 
The study will be successful if the lower bounds of the 95% confidence intervals (CIs) for sensitivity 
(>70%) and specificity (>68%) in at least the same 2 out of 3 independent readers.  
9.1.2 
Secondary Variables and Exploratory Analyses 
To investigate diagnostic performance in the subgroup of patients with small lesions (cT1a, 
dimension ≤ 4 cm in longest diameter), sensitivity and specificity with corresponding Wilson (score) 
95% CIs will be calculated for such patients. 
In addition to the primary efficacy parameters (sensitivity, specificity), the positive predictive value, 
the negative predictive value and the accuracy will also be calculated as secondary efficacy 
parameters using data from patients in the subgroup of tumours ≤ 4 cm in largest diameter. 
Sensitivity and specificity in the cT1a group will be the key secondary endpoints; while positive 
predictive value, the negative predictive value and the accuracy in the cT1a group will be additional 
secondary endpoints. 
9.1.2.1 
Predictive Values and Accuracy 
a) Positive predictive value (PPV) 
The positive predictive value is defined as the probability that a positive histopathology diagnosis 
was obtained given that the result of the 89Zr-TLX PET/CT scan is positive (detection of ccRCC). 
 
 
PPV (%) = TP / (TP + FP) 
b) Negative predictive value (PPV) 
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The negative predictive value is defined as the probability that a negative histopathology 
diagnosis was obtained given that the result of the 89Zr-TLX250 PET/CT scan is negative (no 
detection of ccRCC). 
 
 
NPV (%) = TN / (TN + FN) 
c) Accuracy 
The accuracy or probability of a correct test result is defined as the probability that the 89Zr-
TLX250 PET/CT scan result is correct, i.e. the probability that the PET/CT scan is positive if the 
histopathological diagnosis for ccRCC is positive or that the PET/CT scan is negative if the 
histopathological diagnosis for ccRCC is negative. 
 
 
Accuracy (%) = TP + TN / (TP + FP + TN + FP) 
9.1.2.2 
Standardized Uptake Value (SUV) 
89Zr-TLX250 SUVs will be determined for each tumour lesion. Receiver operating characteristics 
(ROC) will be analysed, to identify a SUV cut-off value, most appropriate to discriminate between 
ccRCC or non-ccRCC as evidenced by central histology results. 
SUV = Cimage / (injected dose / body weight) 
9.1.2.3 
Inter-reader Variability 
Fleiss´ kappa statistics will be used to determine the agreement between the qualitative visual 
assessment of 89Zr-TLX250 tumour targeting (tracer uptake in target lesion: yes/no), as assessed 
by three independent blinded readers (section 8.2.2.4). An intra-class kappa of 0.70 or higher will be 
considered as an acceptable value. Note that both sensitivity and specificity will be determined for 
each of three independent readers. The study will be successful if the lower bounds of the 95% 
confidence intervals (CIs) for sensitivity (>70%) and specificity (>68%) in at least the same 2 out of 
3 independent readers. 
9.1.2.4 
Intra-reader Variability 
Intra-reader variability will be assessed by having each of the 3 independent blinded readers perform 
2 image evaluations on a randomly selected set of 10% cases. A washout period will be introduced 
between the two interpretations to minimize recall bias. The percent of agreement between the two 
interpretations will be computed for each reader. Cohen´s kappa statistics will be used to determine 
the reproducibility of the qualitative visual assessment by individual readers when analysing the 
same data repeatedly. 
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9.1.2.5 
Sub group Analysis 
Evaluation of sensitivity and specificity of 89Zr-TLX250 PET/CT imaging to detect ccRCC in patients 
with IRMs ≤ 3 cm, IRMs ≤ 2 cm, and Bosniak 3 and 4 lesions, as follows: 
1) Bosniak 3 and 4 lesions (as determined by the independent central readers) 
2) Indeterminate renal masses ≤ 3 cm in largest diameter (as determined by the independent 
central readers) 
3) Indeterminate renal masses ≤ 2 cm in largest diameter (as determined by the independent 
central readers) 
9.1.2.6 
Safety 
a) General safety parameters: 
Frequency of occurrence and severity of abnormal findings in safety investigations (physical 
examination, vital signs, 12-lead ECG, clinical laboratory, urinalysis, adverse events, concomitant 
medication) 
b) HACA testing 
9.1.2.7 
Exploratory Variables 
In situ biological half life of girentuximab protein in tumour lesions will be estimated, using a general 
model of average girentuximab kinetics in tumour tissue, derived from serial 89Zr-TLX250 imaging. 
Based on (a) protein residence times in the lesions, (b) an assumed specific activity of therapeutic 
labelling with Lutetium-177 (177Lu), and (c) the measured tumour lesion volume (CT dimensions), an 
achievable therapeutic absorbed dose to tumour (Gy), will be determined for several specific 
activities and hypothetical activity doses of 177Lu. 
Exploratory analyses will be delineated in more detail in the Statistical Analysis Plan (SAP) prior to 
analysis including extra-renal lesions used as a histology standard of truth (when N1 or M1 
disseminated disease is suspected)  
Additional exploratory investigations correlating the 89Zr-TLX250 tumour lesion SUVs, semi-
quantitation of CAIX expression as determined by immunohistochemisty, and evaluation of the 
distant masses outside the kidney identified on 89Zr-TLX250 whole body PET/CT in patients with 
unexpected evidence of disseminated disease will be conducted. 
9.1.3 
Population Characteristics 
Population characteristics will include:  
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• 
Clinical suspicion of ccRCC due to imaging evidence of indeterminate renal mass of ≤ 7 cm 
(stage cT1) 
• 
Scheduled for total or partial nephrectomy as part of regular diagnostic work-up at a given 
date 
Summary tables and listings will be provided for demographics and other baseline characteristics, 
including:  
• 
Age, ethnic origin, sex, physical exam 
• 
Medical/surgical history and baseline findings  
• 
Prior and concomitant medication 
9.2 
Statistical and Analytical Plans 
A detailed description of the study analyses and statistical methods will be presented in the Statistical 
Analysis Plan (SAP). The SAP will be finalized by the study physician and approved by the sponsor 
prior to the start of the statistical analysis. 
9.2.1 
General Considerations 
The aim of this study is to evaluate sensitivity, specificity, PPV, NPV, as well as accuracy of 89Zr-
TLX250 PET/CT imaging using a 37 MBq (1 mCi) activity dose to detect ccRCC in patients with IRM 
of stage cT1, and who are scheduled for partial or total nephrectomy.  
Histological confirmation from nephrectomy (or biopsies of extrarenal lesions from patients in whom 
unexpected evidence of disseminated disease is observed) will serve as standard of truth. The 
qualitative 89Zr-TLX250 PET/CT imaging assessments of 3 independent readers will be the primary 
imaging result. 
All data will be listed and trial summary tables will be provided. Descriptive statistics will be 
presented. Secondary variables will be summarized. The statistical evaluation will be performed by 
using SAS® statistical software (version 9.4, or higher). 
9.2.2 
Analysis Sets 
The Full Analysis Set (FAS) will consist of all enrolled patients who have evaluable PET/CT imaging 
and have a confirmed histopathology diagnosis (Table 2).  
The Safety Analysis Set (SAF) will consist of all patients who received 89Zr-TLX250. 
The Screening Analysis Set (for CONSORT-style accounting of subject disposition) will consist of all 
patients assigned a Patient Number (section 4.4). 
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All primary and secondary efficacy analyses will be carried out using the FAS.  
9.2.3 
Statistical Analyses 
Statistical analyses will be performed after database lock, after all study data including the final study 
visit have been collected and cleaned. 
For all variables (primary and secondary), the statistical analyses in this study will be descriptively 
using exploratory statistics. 
Descriptive analyses will include:  
• 
Mean, standard derivation, median and range for continuous variables, 
• 
Median, range and frequency distribution for discrete (ordinal) variables, 
• 
Frequency distribution for nominal variables 
9.2.3.1 
Analysis of Primary and Key Secondary Objectives 
Within this trial, two co-primary endpoints (sensitivity and specificity) shall be analysed.  
The analysis for sensitivity uses only those patients with a positive histopathological diagnosis of 
clear cell carcinoma. These are expected to be about 70% of the included patient population. 
Sensitivity of 89Zr-TLX250 will be considered adequate if the lower boundary of a 95% Wilson 
(score) confidence interval for sensitivity is higher than 0.7 for at least the same two of three 
independent readers. 
The analysis for specificity uses only those patients with a negative histopathological diagnosis of 
clear cell carcinoma. These are expected to be about 30% of the included patient population. 
Specificity of 89Zr-TLX250 will be considered adequate if the lower boundary of a 95% Wilson 
(score) confidence interval for specificity is higher than 0.68 for at least the same two of three 
independent readers. Two-sided tests will be consistently used in the evaluation. 
To account for multiplicity and to control Type I error under the paradigm of two co-primary endpoints, 
sensitivity and specificity will each be estimated at the 5% significance level. For the study to be 
deemed successful, the lower limit of the 95% Wilson confidence interval for both sensitivity and 
specifity must exceed their respective pre-specified thresholds.  
Assuming the null hypothesis is rejected for both co-primary endpoints, formal statistical testing will 
proceed to the family of Key Secondary Endpoints (i.e., sensitivity and specificity in the cT1a group). 
Within this family, the fixed-sequence method will first assess sensitivity, followed by specificity. 
Results pertaining to specificity will only be considered formal evidence if the null hypothesis 
pertaining to sensitivity is rejected. 
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Additional details will be provided in the SAP. 
9.3 
Determination of Sample Size 
It is planned to include approximately 252 evaluable patients in the study.  
9.3.1 
Sample Size Estimation 
The study sample size for the population of patients with indeterminate renal mass (i.e., patients with 
cT1 tumors) has 2 components: Sensitivity and Specificity. Sample size is estimated for Sensitivity 
and Specificity, respectively, and the larger of the two estimates will represent the final study sample 
size. The basic assumptions underlying sample size estimation are the following: 
• 
In the population of patients with indeterminate renal mass (i.e. cT1 patient population), 
approximately 70% are cT1a and 30% are cT1b patients. 
• 
In the cT1a subpopulation, approximately a third (34%) are expected to show no signs of 
renal cell carcinoma following histopathology assessment (i.e. ccRCC negative). 
• 
It is expected from a clinical standpoint that the subpopulation of cT1b patients would show 
a much lower rate of negative histopathologies than the cT1a subpopulation. For the purpose 
of powering this trial, it is assumed that the rate of non-ccRCC histopathologies in the cT1b 
subpopulation would be at least 17%, half the rate in the cT1a subpopulation. 
Sensitivity: to ensure the study has 90% power to show that the lower limit of the 2-sided 95% 
confidence interval (Wilson) for sensitivity is above the critical limit (or non-inferiority limit) of 70%, 
the minimum sample size required for the population of cT1 patients under above assumptions is 
125, when assuming a true sensitivity of 83%.  
Specificity: to ensure the study has 90% power to show that the lower limit of the 2-sided 95% 
confidence interval (Wilson) for the specificity is above the critical limit (or non-inferiority limit) of 
68%, the minimum sample size required for the population of cT1 patients under above assumptions 
is 252, when assuming a true specificity of 83%.  
An estimated total of 252 patients with an IRM of ≤ 7 cm and scheduled partial or radical 
nephrectomy will be included in the study. However, in order to maintain adequate study power, this 
number may be increased depending on the proportion of non-ccRCC patients after surgery and 
histological verification. 
Table 6 provides an example of the expected sample size required with different observed non-
ccRCC rates.  
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Table 6:  
Planned sample size estimates* 
 
Outcome 
Null 
Alt. 
Non-ccRCC 
Rate in 
CT1a Group 
Non-ccRCC 
Rate in 
CT1b Group 
Alpha 
Power 
N Total 
Scenario (1) 
Specificity 
0.68 
0.83 
0.34 
0.17 
0.05 
0.90 
252 
Sensitivity 
0.70 
0.83 
0.34 
0.17 
0.05 
0.90 
125 
Scenario (2) 
Specificity 
0.68 
0.83 
0.25 
0.20 
0.05 
0.90 
284 
Sensitivity 
0.70 
0.83 
0.25 
0.20 
0.05 
0.90 
116 
Scenario (3) 
Specificity 
0.68 
0.83 
0.25 
0.15 
0.05 
0.90 
317 
Sensitivity 
0.70 
0.83 
0.25 
0.15 
0.05 
0.90 
114 
* Sample size estimates to achieve 90% power based on rates of non-ccRCC in both CT1a and 
CT1b groups. Scenario (1) represents the originally planned sample size; while Scenario (2) and 
Scenario (3) provide potential sample size updates based on different non-ccRCC rates. 
Note that both sensitivity and specificity will be determined for each of three independent readers. 
The study will be successful if the lower bounds of the 95% confidence intervals (CIs) for sensitivity 
(>70%) and specificity (>68%) in at least the same 2 out of 3 independent readers.  
 
9.3.2 
Independent Data Monitoring Committee 
An independent data monitoring committee (IDMC) will be established by the sponsor and will 
monitor the number of evaluable patients cT1a and cT1b tumors, and with ccRCCpositive ccRCCnegative 
tumors and give feedback to the sponsor on whether the planned sample size is appropriate or not.  
The IDMC will evaluate patient accrual and histological results at 50% (126) and 75% (189) of 
evaluable cases. Counts of evaluable cases (excluding cases where 89Zr-TLX250 PET/CT imaging 
and/or tissue collection were either not performed or are pending) in 4 categories based on initial 
tumour size (cT1a, cT1b) and IRM histology (ccRCC, non-ccRCC). The IDMC will provide feedback 
to the sponsor of whether the proposed sample size will be likely to be sufficient or not. Based upon 
this feedback the sponsor may consider an amendment to the protocol that could modify inclusion 
criteria to include only cT1a patients subsequently or to increase the sample size to ensure sufficient 
power.   
Enrollment will not be halted during the data review procedure. 
The IDMC members will not review 89Zr-TLX250 PET/CT images or imaging data, nor will they have 
access to the results generated by either the independent image readers or the local reader. 
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The committee will be composed of at least three members, specialised in biostatistics, pathology 
and/or oncology. The committee will have the above described responsibility only that will be detailed 
in an IDMC charter. 
10 
Data Handling and Quality Assurance 
10.1 
Data Recording 
10.1.1 
Source Data and Records 
Source data are defined as all information related to clinical findings, observations, or other activities 
in the study, written down in original records or certified copies of original records, allowing 
reconstruction and evaluation of the clinical study. 
The investigator will maintain adequate source records (e.g. case histories or patient files for each 
patient enrolled). Source records should be preserved for the maximum period of time required by 
local regulations. 
For each patient enrolled, the investigator will indicate in the source record(s) that the patient 
participates in this study. 
All data entered in the eCRF must be supported by source data in the patient records. 
10.1.2 
Electronic Case Report Form (eCRF) 
For this study, patient data will be entered into a sponsor defined electronic case report form (eCRF) 
within the Electronic Data Capture (EDC) system, transmitted electronically to the sponsor or 
designee and combined with data provided from other sources in a validated data system. The case 
report form will be supplied for recording all study data from each patient. It is the responsibility of 
the investigator to ensure that the eCRFs are completed in full. All data therein must be supported 
by source documentation at the study centre.  
The investigator may authorize site staff (e.g. sub-investigators, nurses) to enter study data into the 
validated EDC system. This must be documented in the Delegation of Authority Log signed by the 
investigator. 
All site personnel will be trained on the EDC system and study specific eCRFs prior to receiving 
access to the live database for data entry. 
The site will also receive approved eCRF Completion Guidelines which will assist data entry and 
data issues/questions. Once the data base is active, the site will be notified to begin data entry. 
Additional site training may be provided as refreshers throughout the study, if needed.  
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The completion of study page of the eCRF must be signed by the principal investigator at the end of 
the study confirming that he/she is satisfied with its completion and accuracy. An eCRF must be 
completed for every patient who signed an informed consent. The eCRFs must be kept up-to-date 
so that they always reflect the latest observations on the patient. 
Study monitors will perform source data verification as defined for the study. 
If any errors or discrepancies in the eCRFs are found during data entry or review, discrepancies will 
be generated within the EDC system, and ‘manual’ queries will be generated by either a monitor or 
data management. 
Discrepancies and queries can only be corrected by the investigator(s) or other authorised site 
personnel. Study monitors must never enter or correct date in the eCRF. An audit trail in the EDC 
documents all changes to the data over the entire study period. 
In all cases, patient initials or personal data will not be collected by or transmitted to the sponsor or 
the coordinating CRO. 
10.1.3 
Missing Data 
If any information is not available, and it is considered by the Investigator that it will never be available 
(e.g. the weight at a particular visit was not recorded), the Investigator will score out the question 
box in the eCRF and, if appropriate, explain, on the eCRF, why the investigation was missed out 
(e.g. the patient was not well enough to undergo the procedure). 
Since patients who do not have evaluable PET/CT or do not have a confirmed histopathology 
diagnosis are considered drop-outs and replaced (Section Error! Reference source not found.); 
missing data are not expected for efficacy outcomes which involve the standard of truth (i.e., 
sensitivity, specificity, PPV, NPV, accuracy, inter-reader and intra-reader variability).  
10.1.4 
Storage of Study Records 
It will be the responsibility of the Investigator to guarantee adequate storage for all study records, 
including the hospital notes during the study and for a minimum of 15 years following the end of the 
study, or as per current national regulations. If he/she leaves the employ of the hospital he/she will 
inform the sponsor and nominate a contact person who will have access to the study documents. 
The investigator should take measures to prevent accidental or premature destruction of these 
documents. 
Essential documents shall be archived in such a way that ensures that they are readily available 
upon authorities’ request. 
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The investigator’s site file (ISF) is not to be destroyed without the sponsor’s approval. The 
investigator’s contract will contain all regulations relevant for the study centre. 
Archiving is described in Section 10.6. 
10.2 
Monitoring 
This study will be monitored at all stages of its development by Accredited Study Monitors appointed 
by the Sponsor / CRO. Monitoring will include personal visits and telephone communication to 
ensure that the investigation is conducted according to the protocol and in order to comply with 
guidelines of GCP and applicable regulatory requirements. On-site review of eCRFs will include a 
review of data entries in the EDC for completeness and clarity, and consistency with source 
documents available for each patient. Additionally, remote checks of eCRF entries by monitors may 
take place, if required. 
Each eCRF will be reviewed on site and checks will be made against source documents to ensure 
accurate, authentic and complete data that reflects the actual experience of the patient in the study 
(see Section 10.1.2). In addition, monitoring must ensure that the safety and rights of subjects are 
being protected. The Investigator must ensure that the hospital notes will be available for direct 
verification of source data. The Sponsor will not keep any records of patients’ full identity.  
To this end, the Investigator agrees to allow regular visits (frequency depending on recruitment, but 
estimated at monthly) by the study monitors and to ensure they have a suitable area in which to work 
(e.g. a desk) and adequate access to study personnel and documents. 
Medical monitors and clinical research associates (CRAs) or assistants may request to witness 
patient evaluations occurring as part of this protocol. The investigator and appropriate personnel will 
be periodically requested to attend meetings or trainings organised by the sponsor to ensure 
acceptable protocol execution. 
10.3 
Data Processing 
The coordinating CRO (ABX-CRO) will be responsible for the processing and quality control of data. 
Data management will be carried out as described in the CRO’s standard operating procedures 
(SOPs) for clinical studies to ensure the integrity of the data, e.g. removing errors and 
inconsistencies of the data. This includes double data entry into the electronic database, generation 
and resolution of data queries. 
Data entry into database will be carried out by trained persons according to SOPs for clinical studies 
at ABX-CRO, Dresden, Germany. Data entry and correction will be tracked by a validated audit trail. 
All systems are validated and compliant to FDA’s ordinance 21 CFR part 11. 
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The FDA-validated medical dictionary MedDRA will be used for data coding (e.g., AEs, baseline 
findings, medication, medical/surgical history). The processes used for coding will be specified in the 
SAP. 
10.4 
Data Confidentiality 
10.4.1 
Documentation of Patient´s Participation 
For all patients who give informed consent, regardless of whether they receive any study medication, 
the Investigator must record patient identification data in the "Patient Identification List" (full name, 
initials, date of birth, patient identification code). The patient identification list must allow for the 
definite identification of any patient that takes part in the study. In addition, study participation must 
be documented in the patient’s regular medical records. For details about patient identification, see 
Section 4.4. 
10.4.2 
Data Protection 
To protect the patient's identity, a unique patient identification code will be assigned by the 
Investigator to each trial patient and used in lieu of the patient's name when the Investigator reports 
adverse events and/or other trial related data. Thus, this number, rather than the patient's name, will 
appear on all documents and will be cross-referenced by the patient's date of birth. Personal 
information will be treated as confidential, but may need to be reviewed by the PIs, the ethics 
committee and regulatory authorities. 
In order to be compliant with any country-specific laws, all relevant submissions to the respective 
authorities will be done and the corresponding approvals will be obtained before collection of any 
data considered to be sensitive, such as: ethnic origin, race, full date of birth etc. 
10.5 
Auditing 
A member of the sponsor’s (or the coordinating CRO´s) quality assurance unit may arrange to visit 
the investigator in order to audit the performance of the study at the study site and the study 
documents originating there. The auditor(s) will usually be accompanied by a CRA or the study team 
lead. The investigator will be informed about the outcome of the audit. 
In addition, inspections by health authority representatives - including foreign authorities - and IEC(s) 
/ IRB(s) are possible at any time. The investigator is to notify the sponsor of any such inspection 
immediately. 
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10.6 
Archiving 
The sponsor and the investigator / medical institution shall, in every case, retain the essential 
documents relating to this study for at least 15 years after its completion or as per current national 
regulations. They shall retain the documents for a longer period if required by other applicable 
regulatory requirements or by a separate agreement between the sponsor and the investigator. 
Essential documents shall be archived in such a way that ensures that they are readily available 
upon authorities’ request. 
Electronic CRFs (including queries and audit trails) will be retained by the sponsor, and copies will 
be sent to the investigator to maintain as the investigator copy. 
Patient (hospital) files will be archived according to local regulations and in accordance with the 
maximum period of time permitted by the hospital, institution or private practice. The ISF is not to be 
destroyed without the sponsor’s approval. The investigator’s contract will contain all regulations 
relevant for the study centre. 
Storage is described in Section 10.1.4. 
11 
Premature Termination of the Study 
At the discretion of the PI, the entire study may be cancelled for medical reasons. In addition, 
Sponsor retains the right to end the study for medical-scientific or GCP-relevant reasons. In case of 
premature termination, the investigators, IECs and Regulatory Authorities will be informed by the 
project manager / study manager. As required by local law, current safety-relevant information will 
be provided to the IEC and the regulatory authorities by the sponsor. The sponsor will also inform all 
investigators about relevant safety events according to the applicable regulations. 
If a trial is prematurely terminated or suspended for any reason, the investigator should promptly 
inform the trial patients and should assure appropriate therapy and follow-up. Should the study be 
terminated and/or the site closed for whatever reason, all documentation will be stored at the 
institution for the legally required period. Access will be granted to the coordinating CRO during this 
period. All radioactive study medication pertaining to the study must be discarded in compliance to 
the applicable local regulations. 
12 
Investigator’s Obligations and Regulatory Aspects 
12.1 
Investigator’s Commitment 
By signing this protocol, the investigator accepts to carry out all procedures related to this study 
according to the laws and guidelines of their respective countries and the European Union related to 
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the conduct of clinical research. All investigators must allow access to all documents pertinent to the 
study. 
The study may be subject to inspection or audit by Regulatory Authorities and will be monitored by 
authorized company personnel to ensure adherence to these guidelines.  
The protocol must be read thoroughly and the instructions herein must be followed exactly. Any 
deviations should be agreed between the sponsor and the investigator, with appropriate written 
protocol amendments made to reflect the changes agreed upon. Substantial amendments to the 
protocol will not be implemented until after approval by the appropriate IEC / IRB / regulatory 
authority according to national legislation. Where the deviation occurs for the well-being of the 
patient, the monitor must be informed and a course of action agreed. Subsequently all such 
deviations, including the reasons thereof, will be submitted to the sponsor and the IEC(s) / IRB(s) as 
well as the relevant Competent Regulatory Agencies/Authorities if applicable and according to 
national regulations. 
If an Investigator moves, withdraws from the study or retires, the responsibility for conducting the 
study and maintaining the records may be transferred to another investigator at the same centre who 
will accept responsibility for taking over the study. Notice of transfer must be made to and agreed by 
the sponsor. 
12.2 
Documentation 
12.2.1 
Approvals and Agreements 
The following documents must be made available to the Sponsor prior to enrolling patients into the 
study: 
• 
Signed final protocol Investigator’s agreement page 
• 
Completed and signed Investigator agreement, where applicable. 
• 
Curriculum Vitae and Financial disclosure of the principal investigator together with co-
investigators at his/her centre, where appropriate. Each should be up-to-date, signed and dated, 
confirming their accuracy. 
• 
Copy of the Ethics Committee/Investigational Review Board’s and Regulatory Agencies’ 
approval. 
• 
List of members of the Ethics Committee / Investigational Review Board and their affiliations. 
• 
Sample of the consent form and patient information leaflet to be used (if different from the ones 
provided by the Sponsor). 
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12.2.2 
Hospital Case Notes 
The investigator should maintain individual patient records, usually hospital notes. The records 
should include a note about the participation in the study, date and time of patient’s signature of 
informed consent, patient visit dates, records of vital signs, medical history, examinations, any 
adverse event, and other notes as appropriate. Source documents containing key data relevant to 
the patient’s condition, procedures and outcome must be kept by the Investigator and will be 
reviewed by the study monitor. All main entries on the eCRF must be backed up by source data. 
12.3 
Insurance 
Patients and investigators taking part in the study will be supplied with insurance cover according to 
the requirements of their country. 
13 
Ethical and Legal Aspects 
13.1 
Ethical and Legal Conduct of the Study 
The planning and conduct of this clinical study are subject to national laws. Only when all of the 
requirements of the appropriate regulatory authority have been fulfilled will the study begin. The 
Guidelines of the World Medical Association Declaration of Helsinki, the Guidelines of GCP as well 
as the demands of national drug and data protection laws and other applicable regulatory 
requirements will be strictly followed. 
The investigator is responsible for ensuring that no patient is subject to any study-related 
examination or activity before that patient and/or legal guardian has given informed consent. The 
patient or the parents/guardians of the patient must give written consent, after the receipt of detailed 
information. The verbal explanation will cover all the elements specified in the written information 
provided for the patient.  
The investigator will inform the patient of the aims, methods, anticipated benefits and potential 
hazards of the study including any discomfort it may entail. The investigator will inform patients that 
in providing informed consent, they are giving permission for representatives of the study centre PIs, 
ethics committees, or regulatory authorities to inspect their medical records to verify the information 
is collected. Patients will be informed that all personal information made available for inspection will 
be handled in strictest confidence and in accordance with local data protection laws. The patient 
must be given every opportunity to clarify any points he/she does not understand and if necessary, 
ask for more information. At the end of the interview the patient may be given time to reflect if this is 
required, or if the patient requests more time. Patients and/or legal guardian will be required to sign 
and date the informed consent form. After completion, the consent forms will be kept and archived 
by the investigator in the investigator’s study file (ISF).  
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It should be emphasized that the patient has the liberty to withdraw their consent to participate at 
any time, without penalty or loss of benefits to which the patient is otherwise entitled. Patients who 
refuse to give or withdraw written informed consent must not be included or continued in the study. 
13.2 
Patient Information and Consent 
All relevant information on the study will be summarized in an integrated patient information and 
consent sheet provided by the sponsor or the study centre. A sample patient information and 
informed consent form is provided as a document separate to this protocol. 
Based on this patient information sheet, the investigator will explain all relevant aspects of the study 
to each patient, before his / her entry into the study (i.e., before examinations and procedures 
associated with selection for the study are performed). 
The investigator will also mention that written approval of the IRB / IEC has been obtained. 
Each patient will have ample time and opportunity to ask questions and will be informed about the 
right to withdraw from the study at any time without any disadvantage and without having to provide 
reasons for this decision. 
Following this informative discussion, the patient will be asked if he / she is willing to sign and 
personally date a statement of informed consent, which includes consenting to the processing of his 
/ her data as explained in the patient information sheet. Only if the patient voluntarily agrees to sign 
the informed consent form and has done so, may he / she enter the study. Additionally, the 
investigator will personally sign and date the form, too. The patient will receive a duplicate of the 
signed and dated form.  
The signed informed consent statement is to remain in the ISF or, if locally required, in the patient’s 
file of the medical institution. In addition, the consent process will be documented in the source 
documents with an independent entry. 
The investigator will document in the eCRF the time and date of obtaining informed consent. In the 
event that informed consent is obtained on the date that baseline study procedures are performed, 
the study record or patient's clinical record must clearly show that informed consent was obtained 
prior to these procedures. 
The informed consent form and any other written information provided to patients will be revised 
whenever important new information becomes available that may be relevant to the patient’s 
consent, or there is an amendment to the protocol which necessitates a change to the content of the 
patient information and/or the written informed consent form. The investigator will inform the patient 
of changes in a timely manner and will ask the patient to confirm his/her participation in the study by 
signing the revised informed consent form. Any revised written informed consent form and written 
information must receive the IRB / IEC's approval in advance of use. 
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13.3 
Financial Disclosure 
Each investigator (including principal and/or any sub-investigators; as well as their spouses and 
dependent children) who is directly involved in the treatment or evaluation of research patients has 
to provide a financial disclosure according to all applicable legal requirements. All relevant 
documentation will be filed in the TMF and/or ISF, as appropriate. 
13.4 
Publication Policy 
The sponsor may be interested in the publication of the results of this study. As some of the 
information concerning the study drug and the sponsor’s development activities may be strictly 
confidential, any publication manuscript (including conference contributions, etc.) must first be 
reviewed by the sponsor and the coordinating CRO before its submission or presentation. 
Publication of subgroup data and single centre data shall not be performed until the complete study 
has been published. All relevant aspects regarding publication will be part of the contract between 
the coordinating CRO and the investigator / institution. 
The sponsor has committed to the global industry position on disclosure of information about clinical 
trials. The information regarding the study protocol is made publicly available on the internet at 
www.clinicaltrials.gov. This derives from the standards that international medical journal editors have 
established requiring protocol registration at the outset of the study as a prerequisite of consideration 
for publication. 
13.5 
Compensation for Health Damage of Patients / Insurance 
Where required by the laws and regulations of the country in which the study is performed, insurance 
of patients against health impairment occurring as a result of participation in the study will be set up 
in accordance with said laws and regulations. All relevant documentation regarding such insurance 
will be filed in the TMF and/or ISF, as appropriate. 
 
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14 
Appendices 
Appendix I – NCI CTCAE 
Version 5.0 of the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events 
(CTCAE), dated 27 November 2017, may be viewed and/or downloaded by accessing the following 
website:  
https://ctep.cancer.gov/protocoldevelopment/electronic_applications/docs/CTCAE_v5_Quick_Refer
ence_8.5x11.pdf 
A printed version will be provided to the Investigators. 
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15 
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Boerman, O.C., Oyen, W.J.G., Mulers, P.F.A. Positron Emission Tomography/Computed 
Tomography with 89Zr-girentuximab can aid in diagnostic dilemmas of clear cell renal cell carcinoma 
suspicion. Eur Urol, 2018, https://doi.org/10.1016/j.eururo.2018.04.026. 
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ICRP Publication 103. Ann. ICRP, 2007. 37 (2-4). 
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Date: 01-Apr-2022 
 
 
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