99mTc-rhAnnexin V-128 Imaging of Apoptosis and Cardiotoxicity in Relationship to Ventricular Function in Patients With Early Stage Breast Cancer Receiving Doxorubicin-Based Chemotherapy
Phase: PHASE2
Conditions: Breast Cancer, Doxorubicin Induced Cardiomyopathy
Sponsor: Advanced Accelerator Applications

AAA-Annexin-05 
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Study Protocol 
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Study Protocol 
Protocol Number 
AAA-Annexin-05 / NCT02677714
Investigational Product 
Kit for the preparation of 99mTc-rhAnnexin V-128 
Active substance 
rhAnnexin V-128 
Radiolabelled Imaging 
Product 
99mTc-rhAnnexin V-128 
Trial Phase 
Proof of Concept and Phase II 
Trial Title 
99mTc-rhAnnexin V-128 Imaging of Apoptosis and Cardiotoxicity in 
Relationship to Ventricular Function in Patients with Early Stage 
Breast Cancer Receiving Doxorubicin-Based Chemotherapy 
Short Trial Title 
99mTc-rhAnnexin V-128 Imaging and Cardiotoxicity in Patients with 
Early Breast Cancer 
Version and Date 
v.7.0 dated 11 March 2018
Investigators 
Principal Investigator: 
, MD, FRCPC, FACC 
Co-Investigators: 
, MD, FRCPC, FACC 
, PhD, MD 
, PhD 
 
, MD 
, MD 
 
, MD 
 
, PhD 
Trial Sponsor 
Advanced Accelerator Applications 
The concepts and information contained herein or generated during the study 
are considered proprietary and shall not be disclosed in whole or in part without 
the expressed written consent of Advanced Accelerator Applications 
This study is to be completed according to the guidelines of Good Clinical Practice 
(GCP) and conducted in full compliance with the World Medical Association 
Declaration of Helsinki and its most recent amendments 

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SPONSOR SIGNATORY APPROVAL PAGE 
 
 
PROTOCOL TITLE: 
99mTc-rhAnnexin V-128 Imaging of Apoptosis and Cardiotoxicity in 
Relationship to Ventricular Function in Patients with Early Stage Breast 
Cancer Receiving Doxorubicin-Based Chemotherapy 
 
PROTOCOL NUMBER:  AAA-Annexin-05 
 
Signatures on this page denote approval of the study protocol outline by the 
respective Sponsor Department 
 
 
Role 
Name and contact 
Date & Signature 
 
 
 
, MD 
Advanced Accelerator Applications SA 
Tel: 
 
 
E-mail: 
 
 
 
 
, MD, PhD 
Advanced Accelerator Applications SA 
Tel: 
 
E-mail: 
 
 
 
 
 
, PhD 
Advanced Accelerator Applications SA 
Tel:  
 
Fax: 
 
Cell: 
 
E-mail: 
 
 
 
 
 

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INVESTIGATOR ENDORSEMENT PAGE 
 
I agree to conduct the study as outlined in the protocol entitled “99mTc-rhAnnexin V-128 Imaging 
of Apoptosis and Cardiotoxicity in Relationship to Ventricular Function in Patients with Early Stage 
Breast Cancer Receiving Doxorubicin-Based Chemotherapy” in accordance with the guidelines 
and all applicable government regulations. These guidelines and regulations include, but are not 
limited to:  
 
1. Permission to allow the Sponsor and the regulatory agencies to inspect study facilities and 
pertinent records at reasonable times and in a reasonable manner that ensures participant 
confidentiality. If this study is to be inspected by a regulatory agency, the Sponsor should 
be notified as soon as possible; 
 
2. Submission of the proposed clinical investigation, including the protocol and the consent 
form to a duly constituted Research Ethic Board (REB) as well as Health Canada 
(regulatory authority) for approval and acquisition of written approval prior to study 
conduct; 
 
3. Use of written informed consent that is obtained prior to study conduct and that contains 
all the elements of consent as specified in the federal regulations and has been previously 
approved by the Sponsor, the REB and Health Canada; 
 
4. Submission of any proposed change in or deviation from the protocol to the REB to be 
approved by the Sponsor. Any proposed changes or deviations from the protocol may 
require that the informed consent also reflect such changes or deviations and that the 
revised informed consent be approved by the REB and Health Canada; 
 
5. Documentation and explanation of individual protocol deviations on the appropriate case 
report form page or in letters to the Sponsor; 
 
6. Sending written reports of serious adverse events to the Sponsor/CRO within 24 hours by 
email (
) after the Investigator’s awareness of the 
information; 
 
7. Reporting of Serious Adverse Events (SAE) according to ICH/GCP and Regulatory 
Standards. SAEs will be reported from the signing of the informed consent and followed 
until resolution or determined to be not clinically significant. 
 
8. Submission of timely progress reports to the REB and Sponsor at appropriate intervals on 
a schedule determined by the REB. 
 
Regulations require an Investigator to prepare and maintain adequate and accurate case histories 
designed to record all observations and other data (such as investigational product accountability) 
pertinent to the investigation on each individual enrolled in the study. These records must be 

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maintained by the Investigator for a minimum period of 25 years or a period of time determined 
by the Sponsor following the date a marketing application is approved for the indication for which 
it is being investigated, or, if no application is to be filed or if the application is not approved for 
such indication, a minimum of 25 years or a period of time determined by the Sponsor after the 
investigation is discontinued and the appropriate regulatory authorities are notified. 
 
In addition, I agree to provide all the information requested in the case report form in a manner to 
assure legibility and accuracy. To this end, I shall carefully follow the instructions for completing 
case report forms. 
 
I also agree that all information provided to me by the Sponsor, including protocols, case report 
forms, and verbal and written information, will be kept strictly confidential and confined to the 
clinical personnel involved in conducting the study. It is recognized that this information may be 
related in confidence to the REB/regulatory authorities. I also understand that reports of 
information about the study or its progress will not be provided to anyone who is not involved in 
the study other than to the Principal Investigator, or in confidence to the REB or to the legally 
constituted regulatory authorities. 
 
 
 
 
Principal Investigator Signature 
 
Date of Signature 
 
 
 
 
 

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Table of Contents 
SPONSOR SIGNATORY APPROVAL PAGE 
2 
INVESTIGATOR ENDORSEMENT PAGE 
3 
1. 
STUDY SYNOPSIS 
8 
2. 
LIST OF ABBREVIATIONS 
14 
3. 
BACKGROUND AND RATIONALE 
16 
4. 
STUDY OBJECTIVES 
18 
5. 
HYPOTHESES 
18 
5.1 
Primary Hypothesis 
18 
5.2 
Secondary Hypotheses 
18 
6. 
STUDY DESIGN 
18 
7. 
END OF STUDY 
19 
8. 
STUDY POPULATION 
19 
8.1 
Inclusion criteria 
19 
8.2 
Exclusion criteria 
19 
8.3 
Source of Study Population 
19 
8.4 
Participant Study Identification 
20 
8.5 
Premature Discontinuation 
20 
8.6 
Prohibitions and Restrictions 
20 
9. 
INVESTIGATIONAL PRODUCT, DOSE AND MODE OF ADMINISTRATION 
21 
9.1 
Description of Investigational Product 
21 
9.2 
Handling, Preparation and Storage 
21 
9.3 
Investigational Product Accountability 
22 
9.4 
Investigational Product Dose, Mode of Administration 
22 
10. 
STUDY PROCEDURES 
22 
10.1 Baseline Assessments 
22 
10.2 Safety Assessments 
22 
10.3 Standard Laboratory Assessments 
23 
10.4 Cardiotoxicity Biomarkers Assessments 
23 
10.5 Immunogenicity Assessments 
24 

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10.6 99mTc-rhAnnexin V-128 SPECT Imaging and Image Analysis 
24 
10.7 Cardiac Magnetic Resonance Imaging 
24 
10.8 Radiation Risk Assessment 
25 
11. 
DATA MONITORING COMMITTEE 
25 
12. 
STATISTICAL METHODS 
26 
12.1 Sample size and analysis 
26 
12.2 General statistical considerations 
26 
12.3 Demographics and Other Participant Characteristics 
26 
12.4 Efficacy 
27 
12.5 Safety 
27 
12.5.1 
Adverse Events / Serious Adverse Events 
27 
12.6 Laboratory Tests 
27 
13. 
ADVERSE EVENTS AND OTHER SAFETY ASPECTS 
28 
13.1 Definition of Adverse Events 
28 
13.2 Definition of Serious Adverse Events 
28 
13.3 Procedure in Case of Pregnancy 
28 
13.4 New Safety Information Affecting the Conduct of the Study 
30 
13.5 Data Monitoring and Safety 
30 
14. 
TERMINATION OF THE STUDY 
30 
15. 
OPERATIONAL, ETHICAL AND ADMINISTRATIVE CONSIDERATIONS 
30 
15.1 Clinical Study Monitoring and Audit 
30 
15.2 Study Documents 
31 
15.3 Ethics and Protection of Participant Confidentiality 
32 
15.3.1 
Ethical Conduct of Clinical Study 
32 
15.3.2 
Authorities 
32 
15.4 Arrangement for Use of Information and Publication of Clinical Study Data 
32 
15.5 Records Related to the Clinical Study and Confidentiality 
33 
15.6 Protocol Amendment and/or Revision and Protocol Deviations 
33 
15.7 Qualification of the Investigators and delegation of responsibility 
33 
15.8 Conflict of Interest and Financial Disclosure 
34 

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15.9 Investigator and Manufacturer Indemnity 
34 
16. 
REFERENCES 
34 
APPENDIX I – RADIOLABELING PROCEDURE OF RH-ANNEXIN V-128 AND 
QUALITY CONTROLS 
39 
APPENDIX II - EASTERN COOPERATIVE ONCOLOGY GROUP (ECOG) 
PERFORMANCE STATUS 
41 
APPENDIX III - NATIONAL CANCER INSTITUTE COMMON TERMINOLOGY 
CRITERIA FOR ADVERSE EVENTS 
42 
APPENDIX IV – SAE FORM 
ERROR! BOOKMARK NOT DEFINED.3 
APPENDIX V – PREGNANCY FORM 
ERROR! BOOKMARK NOT DEFINED.8 
 
 
 
 

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Treatment 
After reconstitution and radiolabeling, 99mTc-rhAnnexin V-128 is administered as 
a single intravenous bolus of 350 MBq +/- 10% at baseline, after the 2nd cycle, 
after the 4th cycle and 12 weeks after AC chemotherapy. 
Inclusion/ 
exclusion criteria 
Inclusion criteria 
1. Females  18 years of age with histologically confirmed early stage 
(Stage I, II or III) HER-2 negative breast cancer and planned for 
(neo)adjuvant doxorubicin-based chemotherapy (AC every 2 or 3 weeks 
x 4 cycles) 
2. Eastern Cooperative Oncology Group Status (ECOG)  2 
3. Able and willing to comply with the study procedures 
Exclusion criteria 
1. Pregnancy or lactation 
2. Moderate or severe valvular stenosis or regurgitation 
3. History of atrial fibrillation or flutter 
4. History of any disease or relevant physical or psychiatric condition which 
may interfere with the study objectives at the investigator judgment 
5. Know hypersensitivity to the investigational product (IP) or any of its 
components 
6. Prosthetic valve or pacemaker 
7. Claustrophobia or inability to lie still in a supine position 
8. Contraindication(s) to the CMRI procedure 
9. Participation in another clinical trial within 4 weeks before study inclusion, 
except for patients who have participated or who are currently 
participating in a study without any study drug administration 
10. Unwillingness to provide consent 
Study duration 
and assessments 
Maximum 26 weeks (+/- 4 weeks) including the screening and follow-up period 
for an individual participant. 
Safety 
Venous blood samples will be drawn for each participant at screening and 12 
weeks after the end of chemotherapy for laboratory analysis (as detailed in 
section 10.3). Creatinine levels will be drawn for CMRI contrast standard 
practice as required if not available clinically. 
 
To rule out the development of anti-annexin V-128 antibodies, venous blood 
samples will be collected for each participant at screening and 12 weeks after 
the end of chemotherapy. Assays for anti-rhAnnexin V-128 IgG and IgM 
antibodies will be performed in serum samples by ELISA. 
 
For the assessment of cardiotoxicity biomarkers (troponin, NT-proBNP), venous 
blood samples will also be collected at the time of the first, second, third and 
fourth 99mTc-rhAnnexin V-128 scan. 
 

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Results from clinical laboratory assessments performed during oncology 
treatment will be reviewed during the study participation to monitor any 
abnormalities. 
 
A medical review including the measurement of the height, weight, BMI and vital 
signs (systolic and diastolic blood pressure and heart rate) will be performed at 
screening and at the time of the first, second, third and fourth 99mTc-rhAnnexin 
V-128 scans. Changes in medical condition will also be recorded. Adverse 
events will be collected in the Electronic Case Report Form (e-CRF). 
Statistics 
Based on previous observations, the uptake of 99mTc-rh-Annexin-V 128 in 
normal females should be of about 1.2 +/- 0.2 % ID/gm and LVEF be 58 +/-7 
%. 
For the comparison of 99mTc-rh-Annexin-V 128 uptake using a paired analysis, 
a sample size of 26 patients will allow detection of an absolute change of about 
0.15% ID/gm with a two-sided 5% significance level and a power of 95%. For 
the comparison of left ventricular ejection fraction (LVEF) measured with CMR 
using a paired analysis, a sample size of 28 patients will allow to detect a 
difference of about 5 %LVEF units with a two-sided 5% significance level and a 
power of 95%. 
 
The final study population for recruitment size will be 30 patients, allowing for 5 
to 10% patient attrition or incomplete imaging data. 
 
Primary endpoint of PoC: 
Image quality, imaging agent uptake and clinical relevance of apoptosis imaging 
in the evaluation of doxorubicin-induced cardiotoxicity in patients with early 
stage breast cancer using 99mTc-rhAnnexin V-128 will be determined by the 
DMC (visual image review and consensus). 
 
Primary endpoint of Phase II: 
The ability of 
99mTc-rhAnnexin V-128 to detect doxorubicin-induced 
cardiotoxicity will be assessed by repeated analysis of uptake and LVEF 
compared to baseline. 
 
Secondary endpoints: 
Timing and extent of 99mTc-rhAnnexin V-128 myocardial uptake will be 
determined by an appropriate paired analysis of absolute value or Standardized 
Uptake Value (SUV) and Cardiac Uptake Ratio (CUR) at each follow-up visit 
compared to baseline. 
 
The LV function will be assessed by comparing CMRI LVEF at each follow-up 
visit compared to baseline using an appropriate paired analysis. 
 

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99mTc-rhAnnexin V-128 uptake changes will be correlated with the changes in 
LVEF and cardiotoxicity biomarkers. 
 
Safety: 
Adverse events will be listed on an individual basis, including relationship, and 
severity, and will be summarized by MedDRA System Organ Class (SOC) and 
Preferred Term (PT). Participants with more than one adverse event within a 
particular SOC and PT will be counted only once for that SOC and PT. The 
incidence of adverse events will also be summarized by severity and 
relationship to the investigational imaging product. 
 
All other safety variables will be tabulated at each measuring time. Hematology, 
clinical chemistry, urinalysis, cardiotoxicity biomarkers and immunogenicity 
data will be analyzed with respect to the normal ranges of values provided by 
the laboratory. 
 
Similarly, descriptive statistics will also be provided for vital signs, physical 
examination, etc. 
 
 
 
 

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Table 1 – Visit Schedule 
 
1 The height will only be measured at screening. 
2 See Section 10.3. Additionally, results from laboratory analysis conducted during the oncology 
treatment will be used for research analysis. 
3 Anti-rhAnnexin V-128 IgG and IgM antibodies will be quantified in serum samples by ELISA. For 
this purpose, 10 mL blood samples will be collected at screening and 12 weeks after the last 
dose of 4 cycles of doxorubicin (before 99mTc-rhAnnexin V-128 administration). Serum will be 
prepared, divided into six aliquots and frozen (-80°C). Three out of six serum samples per time-
point will be shipped to the central laboratory 
 
 
 
Study Procedures 
First UOHI 
Evaluation 
(Screening 
within 2 weeks 
prior to the start 
of AC treatment) 
Second UOHI 
Evaluation 
(After the 2nd 
cycle of 
doxorubicin and 
before the 3rd 
cycle)
Third UOHI 
Evaluation 
(After the 
4thcycle of 
doxorubicin and 
within 2 weeks) 
Fourth UOHI 
Evaluation (12 
weeks after the 
4th cycle of 
doxorubicin) 
Written informed consent 
x 
 
 
 
Inclusion/exclusion criteria 
x 
 
 
 
Medical history/review 
x 
x 
x 
x 
Concomitant medications  
x 
x 
x 
x 
Height, weight, BMI1 
x 
x 
x 
x 
Vital signs 
(BP, HR) 
x 
x 
x 
x 
Lab analysis2  
x 
 
 
x 
Immunogenicity by ELISA3 
x 
 
 
x 
Cardiotoxicity biomarkers 
(troponin and BNP) 
x 
x 
x 
x 
Pregnancy test 
x 
x 
x 
x 
Cardiac Magnetic Resonance 
Imaging
x 
x 
x 
x 
rh-Annexin V-128 
administration and planar and 
SPECT/CT imaging 
x 
x 
x 
x 
Adverse Events 
x 
x 
x 
x 

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2. List of abbreviations 
AC 
AE 
CMR 
eCRF 
CRO 
CRP 
CT 
CTCAE 
CUR 
ECOG 
EF 
ELISA 
ERNA 
FDA 
GCP 
Hb 
Hct 
ICF 
ICRP 
IMP 
ITLC 
IP 
LVEF 
NT-proBNP 
MBq 
MIRD 
MCV 
MedDRA 
PET 
PBS 
PoC 
PS 
PV 
QA 
QC 
RBC 
RCP 
REB 
ROI 
ROS 
 
SAE 
Doxorubicin/cyclophosphamide chemotherapy 
Adverse Event 
Cardiac Magnetic Resonance Imaging 
Electronic Case Report Form 
Clinical Research Organization 
C-Reactive Protein 
Computed Tomography 
Common Terminology Criteria for Adverse Events 
Cardiac Uptake Ratio 
Eastern Cooperative Oncology Group Status 
Ejection Fraction 
Enzyme-Linked Immuno-absorbent Assay 
Equilibrium RadioNuclide Angiography 
Food and Drug Administration 
Good Clinical Practice 
Hemoglobin 
Hematocrit 
Informed Consent Form 
International Commission on Radiological Protection 
Investigational Medicinal Product 
Instant Thin Layer Chromatography 
Investigational Product 
Left Ventricular Ejection Fraction 
N Terminal pro B-type Natriuretic Peptide 
Mega Becquerel 
Medical Internal Radiation Dose 
Mean Corpuscular Volume 
Medical Dictionary For Regulatory Activities 
Positron Emission Tomography 
Phosphate Buffered Saline 
Proof of Concept 
Phosphatidylserine 
Pharmacovigilance 
Quality Assurance 
Quality Control 
Red Blood Cell 
Radiochemical Purity 
Research Ethic Board 
Region of Interest 
Reactive Oxygen Species 
 
Serious Adverse Event 

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SD 
SOP 
SPECT 
SUV 
TBR 
TLC 
WBC 
WHO 
VOI 
Standard Deviation 
Standard Operating Procedure 
Single-Photon Emission Computed Tomography 
Standardized Uptake Value 
Target to background ratio 
Thin Layer Chromatography 
White Blood Cell 
World Health Organization 
Volumes Of Interest 
 
 

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3. Background and Rationale 
The 5-year survival for early stage breast cancer has increased from 79% in 1990 to 88% in 2012 
(Canadian Cancer Statistics 2015. pg 61. www.cancer.ca). However, this improved cancer 
survival due to anthracycline-based chemotherapy is unfortunately associated with an increase 
in cardiovascular events [1]. In patients with breast cancer and surviving five years or longer after 
initial treatment, cardiovascular events represent the second major cause of mortality [2]. The 
incidence of heart failure is directly related to the cumulative dose of doxorubicin and estimated 
at 5%, 16% and 26% for doses of 400, 500 and 550 mg/m2 [3].  Accordingly, clinical protocols 
limit the cumulative dose to 450 mg/m2. Anthracycline therapy may cause cardiac damage in 
lower doses as cardiac biopsy data has shown significant changes in cell morphology with 
cumulative doses as low as 200 mg/m2 [4]. Elevated troponin levels are a marker of myocyte 
necrosis and are elevated in some patients after one cycle of anthracycline therapy [5].  Thus, 
patients vary in terms of sensitivity to anthracycline therapy for myocyte damage and there is no 
safe threshold for all patients. 
 
For many years, the accepted mechanism for anthracycline-induced cardiac toxicity was 
generation of excess reactive oxygen species (ROS) due to electron exchange between oxygen 
molecules and anthracycline [6] or between anthracycline complexes with iron [7].  However, 
antioxidants [8] and iron chelation [9] were ineffective in preventing cardiotoxicity in prospective 
randomized clinical trials. More recently, topoisomerase (Top) 2 was recognized as playing a 
major role in anthracycline-induced cardiotoxicity [10]. Top 2 is present in cardiac myocytes [11] 
and inhibition by anthracycline results in myocyte death. Doxorubicin treatment is associated with 
an increase in p53 phosphorylation and apoptosis [12]. Deletion of p53 or inhibition of the p53 
pathway results in reduced apoptosis with better LV function after doxorubicin therapy [13, 14]. In 
Top2 -/- mice, doxorubicin therapy resulted in minimal changes and this supported the 
hypothesis that Top2 plays a major role in doxorubicin cardiotoxicity. 
 
Primary prevention of anthracycline-induced cardiotoxicity has been pursued in several ways. 
Anthracycline can be administered by continuous infusion with less cardiotoxicity and similar 
tumor response rates [15]. Similarly, liposomal encapsulation has less cardiotoxicity but similar 
anti-tumor efficacy [16]. Alternatively, dexrazoxane can be administered as an effective 
cardioprotective agent [17] with less cardiotoxicity [18] and possibly less anti-tumor efficacy. [19]. 
Presently, dexrazoxane is approved by the FDA for women with metastatic breast cancer 
requiring additional doxorubicin and having received at least 300 mg/m2. Conventional agents 
including betablockers, ACE inhibitors and ARBs have been used for primary prevention, with 
borderline or negative results [20-23]. 
 
Cardiotoxicity due to anthracycline therapy is clinically detected as changes in left ventricular 
ejection fraction (LVEF) measured by equilibrium radionuclide angiography (ERNA) [24], 
echocardiography [25, 26] or magnetic resonance imaging [27].  Cardiotoxicity is characterized 
by a decrease of LVEF from baseline of >5 % in patients with symptoms of heart failure or a 
decrease of LVEF >10% in asymptomatic patients to an EF <54% [28]. Of note, LVEF can vary 
with changes in afterload related to medications or other factors including sepsis, fluid overload 
and other heart disease. LVEF measured by ERNA has an associated exposure to radiation of 5 

AAA-Annexin-05 
 
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to 10 mSv per examination.  Echocardiography has the advantage of no radiation and can provide 
information about valvular and pericardial disease. 2D echocardiography has less optimal 
reproducibility than ERNA with lesser ability to detect small changes in ejection fraction [29]. 
Recent small studies using 3D echocardiography have shown better reproducibility with less inter-
observer variability for LVEF measurement compared to 2D echocardiography [25, 30]. 
 
Cardiac MR can be used to measure LVEF with a high degree of accuracy and reproducibility 
without radiation and also provide information about the pericardium [31].  However, availability 
of cardiac MR is relatively limited and not possible for patients with current cardiac devices 
including pacemakers and internal defibrillators or intracranial metal.  Newer techniques have 
been developed to detect early cardiotoxicity and include global longitudinal strain by 
echocardiography [32, 33] and by cardiac MR [34]. Measurement of strain using 
echocardiography or cardiac MR appears to offer greater sensitivity for detection of small changes 
but is not well established. 
 
Secondary prevention studies using betablocker or ACE inhibitor therapy suggests benefit with 
early initiation of therapy [35, 36]. 
 
Apoptosis is a form of programmed cell death with a series of cellular events including the 
exposure of phospholipid phosphatidylserine on the surface as an early event.  Annexin-V is a 
small protein that binds to phosphatidylserine with high affinity.  Annexin-V can be labeled with 
99m-Tc for apoptosis imaging in heart and lung transplant rejection in animals and humans. [37-
39].  Annexin-V imaging has been used for imaging of apoptosis in rats treated with acute and 
chronic doxorubicin therapy with a dose-dependent increase in tracer uptake and  correlations 
with both histopathologic and immunohistochemical data as well as echocardiographic evidence 
of left ventricular dysfunction [40, 41]. In vivo planar and SPECT / CT imaging in rats 
demonstrated myocardial uptake of Tc-99m labeled annexin V at low doses of doxorubicin prior 
to the decrease in LV ejection fraction measured with echocardiography [41]. 99m-Tc hydrazine-
nicotinamide (HYNIC) annexin-V has been used in patients for detection of acute myocardial 
infarction and endocarditis in cardiac patients and spontaneous and treatment induced apoptosis 
in cancer patients [42]. This approach with 99m-Tc-HYNIC-annexin-V had limitations with high 
uptake in the kidney resulting in large patient radiation dosing and significant abdominal scatter 
and has not advanced past phase II studies. A new annexin derivative, rhAnnexin V-128, has 
been developed permitting direct chelation of 99m-Tc to the protein, with a better biodistribution 
profile and less renal retention [43, 44]. We recently completed a phase I evaluation of 99mTc rh-
Annexin-V 128 in 12 healthy adult volunteers and demonstrated that the radiotracer was a safe 
radiopharmaceutical with low participant radiodosimetry [45]. 
 
The development of cardiotoxicity is a major concern in patients with early stage breast cancer 
and treated with anthracycline therapy. Serial LVEF evaluation can detect cardiotoxicity usually 
after cardiac damage is present and most likely irreversible. Patients vary in cardiac sensitivity to 
anthracyclines. A better monitoring approach may be direct imaging of myocyte damage with 
annexin-V imaging to identify patients developing cardiotoxicity. These patients may benefit from 
changes in chemotherapy with dose alterations or changes to alternative drugs and treatment 

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AAA-Annexin-05 
 
Page 19 of 51 
Study Protocol 
 
Confidential 
Version 7.0, 11 March 2018 
This is a single centre, Proof of Concept (PoC), Phase II study. Patients with histologically 
confirmed early stage (Stage I, II and III) HER-2 negative breast cancer and scheduled to receive 
(neo) adjuvant doxorubicin-based chemotherapy (A- 60 mg/m2; C- 600 mg/m2; every 2 or 3 
weeks  x 4 cycles) to be followed by paclitaxel or docetaxel as per clinical practice [46, 47] will be 
recruited from the Ottawa Hospital Cancer Centre. Participants will be scheduled for cardiac MRI 
and 99mTc-rhAnnexin V-128 imaging prior to initiating doxorubicin-based chemotherapy. 
Participants will also undergo 99mTc-rhAnnexin V-128 imaging and CMRI after the 2nd and the 4th 
cycles of AC treatment and 12 weeks after the last cycle. 
7. End of Study 
The end of study is defined as the completion of all study procedures in the last enrolled 
participant (i.e. last visit, last participant). 
8. Study Population 
Approval for the study will be obtained from the Ottawa Hospital Science Network Research 
Ethics Board (OHSN-REB) and Health Canada. All participants will provide written informed 
consent prior to the initiation of any study procedures. It is foreseen to recruit thirty patients with 
early stage breast cancer. 
8.1 Inclusion criteria 
1. Females  18 years of age with histologically confirmed early stage (Stage I, II or III) HER-
2 negative breast cancer and planned to receive (neo)adjuvant doxorubicin-based (A- 60 
mg/m2; C- 600 mg/m2; every 2 or 3 weeks x 4 cycles) chemotherapy. 
2. Eastern Cooperative Oncology Group Status (ECOG)  2 (see Appendix II) 
3. Able and willing to comply with the study procedures 
8.2 Exclusion criteria 
1. Pregnancy or lactation 
2. Moderate or severe valvular stenosis or regurgitation 
3. History of atrial fibrillation or flutter 
4. History of any disease or relevant physical or psychiatric condition which may interfere 
with the study objectives at the investigator judgment 
5. Know hypersensitivity to the investigational product or any of its components 
6. Prosthetic valve or pacemaker 
7. Claustrophobia or inability to lie still in a supine position 
8. Contraindication(s) to CMRI procedure 
9. Participation in another clinical trial within 4 weeks before study inclusion, except for 
patients who have participated or who are currently participating in a study without any 
study drug administration 
10. Unwillingness to provide consent 
8.3 Source of Study Population 

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AAA-Annexin-05 
 
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Study Protocol 
 
Confidential 
Version 7.0, 11 March 2018 
9. Investigational Product, Dose and Mode of Administration 
The full name of the Investigational Drug is “Kit for the Preparation of Tc-99m Recombinant 
Human Annexin V-128 for Injection”. 
9.1 Description of Investigational Product 
The kit will be prepared, packaged and released according to the manufacturer’s Standard 
Operating Procedures (SOPs), and in compliance with the principles of the Good Manufacturing 
Practice (GMP) guidelines, ICH Good Clinical Practice (GCP) guidelines, and applicable local 
laws/regulations. The IP will be supplied as a sterile, single vial lyophilised kit for reconstitution at 
the clinical site with 99mTc solution eluted from a generator. 
 
A single dose vial contains 0.4 mg of rhAnnexin V-128. The kit contains also stannous chloride 
(reducing agent), sodium -D-Glucoheptonate dihydrate (transchelating agent), gentisic acid 
sodium salt hydrate (radiation stability enhancer), hydroxypropyl--cyclodextrin (solubilizing 
agent), sodium metabisulfite (antioxidant) and trehalose dihydrate (lyoprotectant and cake 
forming agent). Lactic acid is also present as buffering agent. The kit composition details are 
included in the Appendix I. 
9.2 Handling, Preparation and Storage 
The IP must be stored, handled and administered only by qualified/authorized personnel and must 
be prepared in accordance with pharmaceutical quality requirements, and radiation safety 
regulations. 99mTc-rhAnnexin V-128 must be administered at the investigational site. Based on the 
stability tests performed (Appendix I), the Annexin kit can be stored upon receipt at 5°C ± 3°C 
until the expiry date stated on the labels. 
 
A single dose vial containing 0.4 mg of lyophilized rhAnnexin V-128, will be reconstituted with 2 
mL ± 0.2 mL containing 740 MBq ± 74 MBq (20 mCi ± 2 mCi) of 99mTc eluted from the generator. 
Development studies have shown that this amount of radioactivity provides a sufficient amount of 
radioactivity for QC testing and the foreseen 99mTc rhAnnexin V-128 dose of 350 MBq up to 4 h 
after labeling. The administration volume (corresponding to 350 MBq) is calculated according to 
the estimated time of injection, on the basis of the physical decay of the radionuclide (half-life = 
6.02 h). Stability studies performed on the Drug Product have demonstrated radiochemical purity 
at 6 h from labeling greater than 90%, which is in line with current specifications of the Kit for the 
preparation of 99mTc-rhAnnexin V-128 for injection. For the purpose of this study, it is recommended 
to administer the reconstituted solution within 4 hours after completion of the radiolabeling. It is 
also required to determine the amount of radioactivity injected to the patient by measuring the 
radioactivity before and after injection with an appropriate radioactivity calibration system. 
 
The labeling reaction requires 90 minutes and the reconstituted radiolabeled product is stable for 
6 hours. 
 

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AAA-Annexin-05 
 
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10.5 
Immunogenicity Assessments 
Anti-rhAnnexin V-128 IgG and IgM antibodies will be quantified in serum samples by ELISA. For 
this purpose 10 mL blood samples will be collected at screening and 12 weeks after the last dose 
of doxorubicin, before injection of 99mTc-rhAnnexin V-128. Serum will be prepared, divided into six 
aliquots and frozen (-80°C). Three out of six serum samples per time-point will be shipped to the 
central laboratory 
. Remaining samples will be shipped only if 
required for analysis and destroyed at study end if not required. 
10.6 
99mTc-rhAnnexin V-128 Planar and SPECT Imaging and Image Analysis 
Administration of the 99mTc-rhAnnexin V-128 (350 MBq ± 10 %) will be as a single bolus via an 
intravenous catheter in an antecubital vein followed by a saline flush. All images will be acquired 
with a dual head SPECT/CT gamma camera with low-energy high-resolution collimators. The 
energy acceptance window for the 99mTc photopeak will be 140 keV (+/- 10%). A low dose CT 
scan (helical, 120 kVp, 1 mA with 1.9 pitch) will be acquired of the thorax for attenuation 
correction. 
 
Planar imaging will be performed in the anterior view with acquisition using a 256 x 256 matrix, 
an  energy window set for Tc99m  at 140 keV +/- 10% and a  low energy, high resolution (LEHR) 
collimator.    The image will be acquired for 1200s at one and two hours post injection of 
radiotracer. 
 
Reconstruction will be done using iterative reconstruction incorporating CT-based attenuation 
correction and dual-energy-window scatter correction. Planar and SPECT images of the thorax 
will be acquired at 1 and 2 hours post-injection. Acquired images will be stored for off-line analysis 
using a Hermes Gold workstation (Hermes Medical Solutions). Myocardial uptake will be 
measured from regions of interest (ROIs) placed over the myocardium on the SPECT images co-
registered with the corresponding CT images for anatomic delineation. Myocardial uptake will be 
expressed in absolute units (% injected dose/g or as a standardized uptake value (SUV).  As a 
secondary analysis, a simpler approach without attenuation and scatter corrections will also be 
used by determination of a cardiac uptake ratio (CUR) as previously described [41] with a second 
group of ROIs placed over the axillary soft tissues to obtain a value representative of background. 
 
                                        Myocardium (counts/pixel) - Soft tissue (counts/pixel) 
                                                           Soft tissue (counts/pixel) 
 
Inter and intra-observer variability will be determined by repeated analysis of the images of all 
participants. 
10.7 
Cardiac Magnetic Resonance Imaging 
Cardiac MRI will be performed with either a 1.5-T scanner (Siemens, Erlangen, Germany) or a 
3.0-T Scanner (Siemens, Erlangen, Germany).  Transverse images will be acquired with an 
inversion recovery prepared dark blood HASTE sequence (repetition time [TR] 600 ms, echo time 
[TE] 26 ms, 6 mm slice thickness, 1.8 mm interslice gap, matrix 256 x104). Cine bright-blood 
CUR= 

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images in the 4- and 2-chamber and long-axis planes will be performed with a breath-hold 
balanced steady-state free precession sequence (true fast imaging with steady-state precession, 
TR 42 ms, TE 1.2 ms, flip angle 70°, 6 mm slice thickness, matrix 192 x 174). Cine breath-hold 
balanced steady-state free precession short-axis images will be acquired for the entire LV from 
the base to the apex (stack of 10 sequential short-axis slices; TR 64 ms, TE 1 ms, flip angle 80°, 
8 mm slice thickness, 1.6 mm interslice gap, matrix 192x 132) to obtain measurements of  left 
ventricular ejection fraction. 
 
To evaluate for myocardial edema, dark blood T2-weighted turbo spin echo short-axis images will 
be obtained (TR 1,800 to 2,100 ms, TE 74 ms, 8 mm slice thickness, 4 mm interslice gap, matrix 
256 x 175). At each imaging session, a single 5 ml blood sample will be withdrawn for 
measurement of the hematocrit, to be used in conjunction with the T1 measurements to ensure 
accurate estimation of extracellular volume [49]. T1 maps in short-axis oblique and four chamber 
views using a modified Look-Locker inversion recovery, “MOLLI” will acquired before the 
administration of contrast to obtain native T1 values [49]. Late gadolinium enhancement (LGE) 
images will be obtained after 10 min of 0.2 mmol/kg injection of gadolinium (Gadovist®, Bayer 
Inc.) with a T1- weighted inversion recovery-prepared multislice true fast imaging with steady-
state precession sequence with magnitude and phase-sensitive reconstruction. Images will be 
acquired sequentially in the short axis, followed by horizontal and vertical long-axis images (TR 
700 ms, TE 1.0 ms, flip angle 40°, 8 mm slice thickness, 1.6 mm interslice gap, matrix 192 x 144). 
To quantify the myocardial mass of the LGE, the endocardial and epicardial borders of the short-
axis view of the LV will be manually traced. The computer-assisted detection algorithm will be 
used to define LGE as any region with a signal intensity +/- 2 SD above a reference remote 
myocardial region. The LGE mass will be expressed as a percentage of the LV mass. 15 minutes 
post-injection, we will acquire post contrast T1 maps in short-axis oblique and four chamber views. 
All analysis including quantitative will be performed with dedicated computer software (CVI 42, 
Circle Cardiovascular Imaging, Calgary, Alberta, Canada) [48, 49]. 
10.8 
Radiation Risk Assessment 
Participants will receive radiation from 1) 99mTc-rhAnnexin V-128 (350 MBq) for a dose of 3.0 mSv 
(8.1 ± 0.8 µSv/MBq and 2) the CT scan for attenuation correction for a dose of 0.4 mSv. Total 
dose for the 99mTc-rh-Annexin-V 128 and CT will be 3.4 mSv for one imaging study and 13.6 mSv 
for the 4 administrations. 
 
Since the annual background radiation dose at sea level in North America is 2.7 mSv, the total 
effect of dose for this study per patient radiation is equivalent to living 5 years in North America. 
This poses minimal risk to the participant and there are no expected consequences with this 
exposure. 
11. 
Data Monitoring Committee 
The Data Monitoring Committee (DMC) consists of investigators and Sponsor representatives, as 
well as external persons such as independent experts, if deemed necessary by the Sponsor. The 
main function of the committee will be to review the images of the first 10 participants in terms of 
image quality, visual efficacy (uptake) and clinical relevance of the study product, and determine 

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if there is a significant evidence of inadequate technical performance in this study group. The 
DMC will also determine if there is an excess of adverse events. 
The DMC will promptly give recommendations to continue or terminate the study. The DMC report 
will be edited by the Sponsor and sent to the REB and regulatory authorities as required. 
12. 
Statistical methods 
12.1 
Sample size and analysis 
Sample size was estimated for the comparison of 99mTc-rh-Annexin-V 128 uptake in doxorubicin 
treated patients imaged after 2 cycles of doxorubicin versus normals baseline uptake using a 5% 
significance level and power of 95%.  The measured heart uptake in 6 normal females (age 29.5 
+ 4.6 years, mean + SD) was 1.2 +/- 0.2% ID/gm in the Phase 1 study.  Sample size estimations 
were done assuming results in the baseline studies of the patients will be similar to the normal 
females in the Phase 1 study. 
 
For the comparison of 99mTc-rh-Annexin-V 128 uptake using a paired analysis and assuming a 
similar SD of 0.2%, a sample size of 26 patients will allow to detect a change of 0.15% ID/gm with 
a two-sided 5% significance level and a power of 95% (difference between two dependent means, 
G*Power 3.1.3). 
 
For the comparison of left ventricular ejection fraction (LVEF) measured with CMR, a sample size 
of 28 patients will detect an absolute difference of 5% LVEF units with a two-sided 5% significance 
level and a power of 95% using a paired analysis and assuming a SD of 7 (difference between 
two dependent means, G*Power 3.1.3). Assumptions were based on representative CMR data 
for LVEF of 58 +/- 7% from 53 participants with breast cancer, lymphoma, leukemia and 
myelodysplastic syndrome [34]. 
 
The final study population for recruitment size will be 30 patients, allowing for 5 to 10% patient 
attrition or incomplete imaging data. 
12.2 
General statistical considerations 
Continuous variables will be presented as number of non-missing values, mean, standard 
deviation, median, minimum, maximum and quartiles. For categorical variables, descriptive 
statistics will include counts and percentages per category. Confidence intervals will be computed 
when appropriate. Continuous variables will be compared using the most appropriate test such as 
one-way repeated measure ANOVA or Friedman tests with appropriate post-hoc testing if relevant. 
Proportions will be compared using the most appropriate test such as Chi squared test, Fisher 
exact test or McNemar test. Pearson’s or Spearman linear regression analysis will be used to 
calculate the relationship between two data sets as appropriate. A p value less or equal to 0.05 
will be considered significant. 
 
No adjustment for multiplicity will be applied and missing data will not be replaced. 
12.3 
Demographics and Other Participant Characteristics 

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Demographic and other baseline data will be summarized descriptively. All background and 
demographic data will be listed in detail. 
12.4 
Efficacy 
Primary endpoint of PoC: 
Image quality, imaging agent uptake and clinical relevance of apoptosis imaging in the evaluation 
of doxorubicin-induced cardiotoxicity in patients with early stage of breast cancer using 99mTc-
rhAnnexin V-128 will be determined by the DMC (visual image review and consensus). 
 
Primary endpoint of Phase II: 
The ability of 99mTc-rhAnnexin V-128 to detect doxorubicin-induced cardiotoxicity will be assessed 
by repeated analysis of uptake and LVEF compared to baseline using the most appropriate test 
such as one way repeated measures ANOVA or Friedman test, with appropriate post hoc testing 
if relevant. 
 
Secondary endpoints: 
Timing and extent of 99mTc-rhAnnexin V-128 myocardial uptake will be determined by an 
appropriate paired analysis of absolute value or Standardized Uptake Value (SUV) and Cardiac 
Uptake Ratio (CUR) after the 2nd and the 4thcycle of AC treatment and after 12 weeks of the last 
cycle of doxorubicin, compared to baseline. Differences of 99mTc-rhAnnexin V-128 myocardial 
uptake will be compared using the most appropriate test such as one way repeated measures 
ANOVA with post hoc testing  
 
The worsening of LV function will be assessed by comparing CMRI LVEF after the 2nd and the 
4thcycle of AC treatment and after 12 weeks of the last dose of doxorubicin compared to baseline. 
Differences of LV function will be compared using the most appropriate test such as one way 
repeated measures ANOVA with post hoc testing 99mTc-rhAnnexin V-128 uptake changes will be 
correlated with the changes in LVEF and in cardiotoxicity biomarkers using Pearson or Spearman 
correlation test as appropriate. 
12.5 
Safety 
The statistical analysis of safety data will be mainly descriptive in nature. 
 
12.5.1 Adverse Events / Serious Adverse Events 
All original AE/SAE terms will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA). System organ classes and preferred terms will be used in the analyses. Type and 
incidence of AEs/SAEs, as well as severity and relatedness to the IP will be tabulated. 
12.6 
Laboratory Tests 
Descriptive statistics including shift tables will be generated for all laboratory tests performed i.e. 
the actual values and the changes from pre-injection by cross tabulations (with classes for below, 
within, and above normal range). 
 

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AAA-Annexin-05 
 
Page 29 of 51 
Study Protocol 
 
Confidential 
Version 7.0, 11 March 2018 
Investigator should respond in accordance with the reporting procedure for SAEs including 
information regarding the outcome of pregnancy. 
 
 

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AAA-Annexin-05 
 
Page 33 of 51 
Study Protocol 
 
Confidential 
Version 7.0, 11 March 2018 
investigational medication and may be disclosed as deemed necessary by the IP manufacturer 
to other Investigators, other pharmaceutical companies, and to governmental agencies. 
 
The Investigator agrees that before he/she publishes any results or data of this study, including 
preliminary results, he/she shall send the draft manuscripts and copies of the information to be 
presented to the IP manufacturer at least 30 working days before submission to a publisher or 
presentation. The IP manufacturer reserves the right to review these materials before submission 
for publication or presentation. This is not intended to restrict or hinder publication or presentation 
but instead to allow the IP manufacturer to protect proprietary information and to provide 
comments based on information that may not yet be available to the Investigator(s). 
15.5 
Records Related to the Clinical Study and Confidentiality 
The Investigator must retain e-CRFs and source documents of all enrolled participants (i.e. all 
participants who gave consent to be screened for the study), IP disposition, and other documents 
required by regulation, in his/her possession or in an accessible area for at least 25 years after 
the completion of this study. 
 
Individual nominative participant medical information obtained as a result of this study is 
considered confidential and disclosure to third parties is prohibited. Such information may only be 
given to a third party after approval of the participant, such as to the participant’s general 
practitioner or to other appropriate medical personnel responsible for the participant’s well-being. 
 
All individuals and organizations involved in conducting the study and/or processing the study 
data will protect the participants’ privacy with appropriate measures in accordance with the 
applicable local and regional laws. 
15.6 
Protocol Amendment and/or Revision and Protocol Deviations 
Any deviation from the protocol that has not been approved by the Sponsor or designee and by 
the REB/regulatory authority may result in the discontinuation from the trial of the site involved. 
However, in the event of any medical emergency, the Investigator is free to perform any medical 
procedure deemed appropriate. Such events and procedures must be reported promptly to the 
Sponsor. 
 
Any changes to the study, which arise after approval of the protocol, will be documented as 
protocol amendments and/or revisions. Depending on the nature of the amendment and/or 
revision, REB/ Regulatory Authority approval or notification is required. The changes will become 
effective only after the approval of the REB/Regulatory Authority (if applicable). 
15.7 
Qualification of the Investigators and delegation of responsibility 
The Investigator(s) should be qualified by education, training, and experience to assume 
responsibility for the proper conduct of the study. He/she should meet all qualifications specified 
by the applicable regulatory requirements and should provide evidence of such qualifications 
through an up-to-date curriculum vitae (Principal as well as all other Investigators) and/or other 
relevant documentation requested. 

AAA-Annexin-05 
 
Page 34 of 51 
Study Protocol 
 
Confidential 
Version 7.0, 11 March 2018 
 
The Investigator should be thoroughly familiar with the appropriate use of the IP, as described in 
the protocol, the current Investigator’s Brochure, the product information, and other information 
sources provided by the IP manufacturer. 
 
The Investigator should be aware of, and should comply with, ICH-GCP and the applicable 
regulatory requirements. 
 
The Investigator should maintain a list of appropriately qualified persons to whom the Investigator 
has delegated significant study related duties. 
15.8 
Conflict of Interest and Financial Disclosure 
There are no conflicts of interest to declare related to this study. The Principal Investigator is 
receiving financial support and the IP from the manufacturer to cover the cost of conducting this 
study. 
 
Disclosable financial interests will be recorded on the Investigator Financial Disclosure Form. 
 
Any Investigator(s) added as investigational staff must complete the Investigator Financial 
Disclosure Form at the beginning of his/her participation to the study. For any Investigator(s) 
leaving the site prior to study completion, an Investigator Financial Disclosure Form should be 
obtained at the end of his/her participation. 
15.9 
Investigator and Manufacturer Indemnity 
The investigator and the Sponsor will provide appropriate medical treatment and care in the event 
of a study related injury or illness. 
 
The Sponsor has covered this study by means of insurance for the participant according to 
national requirements. The name and the address of the relevant insurance company, the 
certificate of insurance, the policy number, and the sum insured are provided in the Investigator’s 
File. 
 
16. 
References 
1. Du XL, Fox EE, Lai D: Competing causes of death for women with breast cancer and change 
over time from 1975 to 2003. Am J Clin Oncol 2008;31:105-116. 
 
2. Hooning MJ, Botma A, Aleman BM et al: Long-term risk of cardiovascular disease in 10-
year survivors of breast cancer. J Natl Cancer Inst 2007;99:365-375.  
 
3. Swain SM, Whaley FS, Ewer MS: Congestive heart failure in patients treated with 
doxorubicin:  A retrospective analysis of three trials.  Cancer 2003;97:2869-2879. 
 

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4. Ewer MS, Ali MK, Mackay B et al: A comparison of cardiac biopsy grades and ejection 
fraction estimations in patients receiving adriamycin. J Clin Oncol 1984;2:112-117. 
 
5. Cardinale D, Sandri MT, Colombo A et al: Prognostic value of troponin I in cardiac risk 
stratification of cancer patients undergoing high-dose chemotherapy. Circulation 
2004;109:2749-2754. 
 
6. Doroshow JH: Effect of anthracycline antibiotics on oxygen radical formation in rat heart.  
Cancer Res 1983;43:460-472. 
 
7. Link G, Tirosh R, Pinson A et al: Role of iron in the potentiation of anthracycline 
cardiotoxicity: Identification of heart cell mitochondria as a major site of iron-anthracycline 
interaction. J Lab Clin Med 1996;127:272-278. 
 
8. Dresdale AR, Barr LH, Bonow RO et al: Prospective randomized study of the role of N-
acetylcysteine in reversing doxorubicin-induced cardiomyopathy. Am J Clin Oncol 
1982;5:657-663. 
 
9. Hasinoff BB, Patel D, Wu X: The oral iron chelator ICL670A (deferasirox) dose not protect 
myocytes against doxorubicin. Free Radiol Biol Med 2003;35:1469-1479. 
 
10. Zhang S, Liu X, Bawa-Khalfe T et al: Identification of the molecular basis of doxorubicin-
induced cardiotoxicity. Nat Med 2012;18:1639-1642. 
 
11. Capranico G, Tinelli S, Austin CA et al: Different patterns of gene expression of 
topoisomerase II isoforms in differentiated tissues during murine development. Biochim 
Biophys Acta 1992;1132:43-48. 
 
12. Sardão VA, Oliveira PJ, Holy J, Oliveira CR, Wallace KB: Doxorubicin-induced 
mitochondrial dysfunction is secondary to nuclear p53 activation in H9c2 cardiomyoblasts. 
Cancer Chemother Pharmacol 2009;64:811-827. 
 
13. Zhu W, Soonpaa MH, Chen H et al: Acute doxorubicin cardiotoxity is associated with p53-
induced inhibition of the mammalian target of rapamycin pathway. Circulation 2009;119:99-
106. 
 
14. Shizukuda Y, Matoba S, Mian OY, Nguyen T, Hwang PM: Targeted disruption of p53 
attenuates doxorubicin-induced cardiac toxicity in mice. Mol Cell Biochem 2005;273:25-32. 
 
15. Valdivieso M, Burgess MA, Ewer MS et al: Increased therapeutic index of weekly 
doxorubicin in the therapy of non-small cell lung cancer: A prospective, randomized study. 
J Clin Oncol 1984;2:207-214. 
 

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16. Gabizon AA: Stealth liposome and tumor targeting:  One step further in the quest for the 
magic bullet. Clin Cancer Res 2001;7:223-225. 
 
17. Speyer JL, Green MD, Zeleniuch-Jacquotte A et al: IRCF-187 permits longer treatment with 
doxorubicin in women with breast cancer. J Clin Oncol 1992;10:117-127. 
 
18. Swain SM, Whaley FS, Gerber MC et al: Delayed administration of dexrazoxane provides 
cardioprotection for patients with advanced breast cancer treated with doxorubicin-
containing therapy. J Clin Oncol 1997;15:1333-1340. 
 
19. Swain SM, Whaley FS, Gerber MC et al: Cardioprotection with dexrazoxane for doxorubicin-
containing therapy in advanced breast cancer. J Clin Oncol 1997;15:1318-1332. 
 
20. Bosch X, Rovira M, Sitges M et al: Enalapril and carvediolol for preventing chemotherapy-
induced left ventricular systolic dysfunction in patients with malignant hemopathies: The 
OVERCOME trial. J Am Coll Cardiol 2013;61:2355-2362. 
 
21. Kaya MG, Ozkan M, Gunebakmaz O et al: Protective effects of nebivolol against 
anthracycline-induced cardiomyopathy: A randomized control study. Int J Cardiol 
2013;167:2306-2310. 
 
22. Kalay N, Basar E, Ozdogru I et al: Protective effects of carvediolol against anthracycline-
induced cardiomyopathy. J Am Coll Cardiol 2006;48:2258-2262. 
 
23. Georgakopoulos P, Rossou P, Matsakas E et al: Cardioprotective effect of metoprolol and 
enalapril in doxorubicin-treated lymphoma patients: A prospective, parallel-group, 
randomized, controlled study with 36-month follow-up. Am J Hematol 2010;85:894-896. 
 
24. de Geus-Oei LF, Mavinkurve-Groothuis AM, Bellersen L et al: Scintigraphic techniques for 
early detection of cancer treatment-induced cardiotoxicity. J Nucl Med 2011;52:560-571. 
 
25. Walker J, Bhullar N, Fallah-Rad N et al: Role of three-dimensional echocardiography in 
breast cancer: Comparison with two-dimensional echocardiography, multiple-gated 
acquisition scans, and cardiac magnetic resonance imaging. J Clin Oncol 2010;28:3429-
3436. 
 
26. Oreto L, Tadaro MC, Umland MM et al: Use of echocardiography to evaluate the cardiac 
effects of therapies used in cancer treatment: What do we know? J Am Soc Echocardiogr 
2012;25:1141-1152. 
 
27. Vasu S, Hundley WG: Understanding cardiovascular injury after treatment for cancer: An 
overview of current uses and future directions of cardiovascular magnetic resonance. JCMR 
2013;15:66. 
 

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28. Lang RM, Badano LP, Mor-Avi V, et al: Recommendations for cardiac chamber 
quantification by echocardiography in adults: an update from the American Society of 
Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J 
Cardiovasc Imaging. 2015:16(3):233-70. 
29. Pai VB, Nahata MC: Cardiotoxicity of chemotherapeutic agents:  Incidence, treatment and 
prevention. Drug Saf 2000;22:263-302. 
 
30. Thavendiranathan P, Grant AD, Negishi T, Plana JC, Popovic ZB, Marwick TH:  
reproducibility of echocardiographic techniques for sequential assessment of left ventricular 
ejection fraction and volumes: Application to patients undergoing cancer chemotherapy. J 
Am Coll Cardiol 2013;61:77-84. 
 
31. Hundley WG, Bluemke DA, Finn JP et al: ACCF/ACR/AHA/NASCI/SCMR 2010 expert 
consensus document on cardiovascular magnetic resonance: A report of the American 
College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll 
Cardiol 2010;55:2614-2662. 
 
32. Sawaya H, Sebag IA, Plana JC et al: Early detection and prediction of cardiotoxicity in 
chemotherapy-treated patients. Am J Cardiol 2011;107:1375-1380. 
 
33. Stoodley PW, Richards DA, Hui R et al: Two-dimensional myocardial strain imaging detects 
changes in left ventricular systolic function immediately after anthracycline chemotherapy. 
Eur J Echocardiogr 2011;12:945-952. 
 
34. Drafts BC, Twomley KM, D’Agostino R et al:  Low to moderate dose anthracycline-based 
chemotherapy is associated with early noninvasive imaging evidence of subclinical 
cardiovascular disease. JACC: Cardiovasc Imag 2013;6(8):877-885. 
 
35. Cardinale D, Colombo A, Sandri MT et al: Prevention of high-dose chemotherapy-induced 
cardiotoxicity in high-risk patients by angiotensin-converting enzyme inhibition.  Circulation 
2006;114:2474-2481. 
 
36. Cardinale D, Colombo A, Lamantia G et al: Anthracycline-induced cardiomyopathy:  Clinical 
relevance and response to pharmacologic therapy. J Am Coll Cardiol 2010; 55:213-220. 
 
37. Dobrucki LW, Sinusas AJ: Cardiovascular molecular imaging. Semin Nucl Med 2005;35:73-
81. 
 
38. Korngold EC, Jaffer FA, Weissleder R, Sosnovik DE: Noninvasive imaging of apoptosis in 
cardiovascular disease. Heart Fail Rev 2008;13:163-173. 
 
39. Morrison AR, Sinusas AJ: New molecular imaging targets to characterize myocardial 
biology. Cardiol Clin 2009:27:329-344. 

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40. Bennink RJ, van den Hoff MJ, van Hemert FJ et al: Annexin V imaging of acute doxorubicin 
cardiotoxicity (apoptosis) in rats. J Nucl Med 2004;45(5):842-848 
 
41. Lahorte CMM, Vanderheyden J-L, Steinmetz N et al: Apoptosis-detecting radioligands:  
Current state of the art and future perspectives. Eur J Nucl Med Mol Imag 2004;31(6):887-
919. 
 
42. Tait JF, Smith C, Blandenberg FG: Structural requirements for in vivo detection of cell death 
with 99mTc-Annexin V. J Nucl Med 2005;46:807-815. 
 
43. Tait JF, Smith C, Levashova Z et al: Improved detection of cell death in vivo with annexin V 
radiolabeled by site-specific methods. J Nucl Med 2006;47:1546-1553.  
 
44. Gabrielson KL, Mok GSP, Nimmagadda S et al: Detection of dose response in chronic 
doxorubicin-mediated cell death with cardiac technetium 99m Annexin V single-photon 
emission computed tomography. Mol Imag 2008;7(3):132-138. 
 
45. Annexin Phase I Clinical Study Report, August 4, 2015 
 
46. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology, Breast 
Cancer, Vers 1, 2016. 
47. Senkus E. et al. Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, 
treatment and follow-up. Ann Oncol. 2015; 26(Suppl 5): v8-v30. 
48. Moon JC, Messroghli DR, Kellman P, et al: Myocardial T1 mapping and extracellular volume 
quantification: a Society for Cardiovascular Magnetic Resonance (SCMR) and CMR 
Working Group of the European Society of Cardiology consensus statement. J Cardiovasc 
Magn Reson. 2013;15:92. 
 
49. Messroghli DR, Greiser A, Frohlich M et al: Optimization and validation of a fully-integrated 
pulse sequence for modified look-locker inversion-recovery (MOLLI) T1 mapping of the 
heart. J Magn Reson Imag 2007;26:1081-1086. 
 
 

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Appendix I – Radiolabeling procedure of rh-Annexin V-128 and quality controls 
 
Radiolabeling procedure 
 
The Technetium solution to be used for the labeling of rh-Annexin V-128 kit is the solution which 
can be obtained by commercially available Tc Generators compliant with the Ph.Eur. Monograph 
“Sodium Pertechnetate (99mTc) Injection (Fission)” and Tc 99m Injection USP. 
During the product development, the following procedures and conditions have been tested and 
confirmed as adequate: 
a) Radioactive concentration of the Pertechnetate solution added for labelling should be 370 
MBq/mL (the reconstitution volume is 2 mL ± 0.2 mL). 
Labelling at room temperature under slight rotation by introducing the vial in a shielded roller for 
90 min: shorter incubation times may result in inadequate labelling. 
Stability of the Radiolabelled compound up to 6h at room temperature (RCP  90 %). 
Suitability of the Radio TLC method to determine the radiochemical yield and purity by using three 
different eluents: Acetone 100% (99mTcO4-, Rf=1.0); Anticoagulant Citrate Dextrose solution (ACD) 
(99mTc-rhAnnexin V-128, Rf=0.0); PBS (99mTc-Glucoheptonate, Rf=1.0 and 99mTcO2,Rf=0.0). 
 
Labelling takes place through an exchange reaction with 99m-Technetium-Glucoheptonate.  
 
 
Scheme of the exchange reaction between 99mTc-Glucoheptonate (99mTc-GH) and rhAnnexin V-
128. 
 
The instructions for the preparation of the 99mTc-rhAnnexin V-128 are in accordance with the 
following aseptic procedure: 
1) Remove one rhAnnexin V128 Kit reaction vial from refrigerated storage and allow it to 
reach room temperature (from 5 to 10 minutes). 
2) Waterproof gloves should be worn during the preparation procedure. Flip off cap from 
the rhAnnexin V-128 Kit vial and swab the top of the vial closure with an appropriate 
antiseptic to disinfect the surface, and then allow the stopper to dry. 
3) Place the vial in a suitable radiation shield appropriately labelled with date, time of 
preparation, volume and activity. 
4)  Aseptically add 2 mL ± 0.2 mL of Sodium Pertechnetate Tc-99m solution containing 
740 MBq ± 74 MBq (20 mCi ± 2 mCi)  to the vial in the lead shield (Do not shake). 
5) Remove the vial from the lead shield and place it in an appropriately shielded roller. 
Leave the vial under slow rotation for 90 min. 
6) Remove the vial from the shielded roller, inspect visually for the absence of particulate 
matter and discoloration and place it again in a lead shield. 

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Appendix II - Eastern Cooperative Oncology Group (ECOG) Performance 
Status 
 
 
ECOG PERFORMANCE STATUS* 
Grade ECOG 
0 
Fully active, able to carry on all pre-disease performance without restriction 
1 
Restricted in physically strenuous activity but ambulatory and able to carry out work of a 
light or sedentary nature, e.g., light house work, office work 
2 
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up 
and about more than 50% of waking hours 
3 
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 
5 
Dead 
 
 
* As published in Am. J. Clin. Oncol.: 
Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: 
Toxicity And Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 
5:649-655, 1982. 
All rights reserved. 
Revised: July 27, 2006 
 
 

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Appendix III - National Cancer Institute Common Terminology 
Criteria for Adverse Events 
 
 
 
This is an extract of the whole document. For the complete CTCAE guide, version 4.0, please 
refer to the following website: 
http://www.acrin.org/Portals/0/Administration/Regulatory/CTCAE_4.02_2009-09-
15_QuickReference_5x7.pdf 
 
 
 
 
 

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Serious Adverse Event (SAE) Reporting Form 
 
ALL REPORTS MUST BE SIGNED AND DATED BY THE INVESTIGATOR. 
 
Please fax or send by e-mail the form to AAA Global Pharmacovigilance within 24 hours 
from awareness of event. 
 
E-mail: 
 
 
Fax N°: 
 
 
Study Name 
EudraCT N° 
Center N°
Investigator N° 
Country 
 
 
 
 
 
 
TYPE OF REPORT 
 
 Initial 
 
 
 Completion of data 
 
 
 Follow-up 
 
1. PATIENT DATA - DO NOT SEND PATIENT IDENTIFIABLE DATA 
Patient 
Initials 
(first letter of First 
Name and first letter 
of Last Name): 
Last name    
First name    
Patient N°:
Sex:
 
Year 
of 
Birth
(yyyy): 
 
Age at onset of 
event: 
 
 
Weight (kg):
 
Height (cm): 
 
2. EVENT DETAILS 
Date 
of 
onset 
(dd/mm/yyyy): 
 
Diagnosis: 
 
 
Description of SAE (please state date of first use): 
 
 
 
 
 
 
 
 
Seriousness Criteria (check all that are relevant to the event): 
 Participant died                          
 Hospitalisation or prolongation of existing hospitalisation 
 
 Life-threatening                          
 Persistent or significant disability or incapacity 
 
 Congenital anomaly/                  
 Other significant medical events 
            birth defect 
 

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Severity of event:                        
 
Mild                            
 Moderate                               
 
Severe 
3. STUDY TREATMENT 
Drug 
Schedule 
Route of 
administration 
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Causally Related to 
Drug?  
Tick either unrelated or 
possibly related 
Expected  
(Y/N) 
Unrelated 
Possibly 
Related 
1. 
 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
 
 
 
4. NIMPs (Non-investigational medicinal products) 
Are there any additional medications used as part of the protocol?  Such medications are referred to 
as NIMPs 
Yes 
  
 
 
 
 
 
No 
 
If yes, please complete the table below  
NIMP(s) 
Dose/schedule 
Route of 
administration 
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Causally Related to 
NIMP?  
Tick either unrelated or 
possibly related 
Expected  
(Y/N/NA) 
Unrelated 
Possibly 
Related 
1. 
 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
 
 
 
5. CONCOMITANT DRUGS RELEVANT TO THE SAE (do not include therapy used to treat 
the SAE) 
Tick box if no relevant concomitant medication 
Drug name 
Dose/schedule 
Route of 
administration 
Reason 
for use 
Start date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Continued? 
(Y/N) 
1. 
 
 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
 
 
3. 
 
 
 
 
 
 

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4. 
 
 
 
 
 
 
 
 
5. 
 
 
 
 
 
 
 
 
6. 
 
 
 
 
 
 
 
 
6. MEDICAL HISTORY (list relevant medical history): 
Tick box if no relevant medical history 
Condition 
Start Date 
(dd/mm/yyyy) 
End date 
(dd/mm/yyyy) 
Ongoing 
(Y/N)  
Medication required 
Y/N 
1. 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
7. RELEVANT TEST/LABORATORY FINDINGS (include only the results relevant to the SAE 
diagnosis or course of SAE)  
Test/lab 
finding  
Unit  
Date 
(dd/mm/yyyy) 
Value 
Reference range 
1. 
 
 
 
 
 
 
2. 
 
 
 
 
 
 
3. 
 
 
 
 
 
 
4. 
 
 
 
 
 
 
Comment on test/laboratory findings (if none, mark as NA) 
 
 
 
 
 
 
 
 
 

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8. ACTION TAKEN (check all that are relevant to the SAE)  
 No action taken  
 
 Drug 
permanently 
discontinued due to this 
SAE  
 
 
 Concomitant 
medication 
taken  
 Drug 
schedule 
adjusted/temporarily 
interrupted  
 
If multiple drugs used, please 
record which drug(s) have 
been adjusted/interrupted: 
 Non-drug therapy given 
 Hospitalisation/prolonged 
hospitalisation  
9. OUTCOME OF SAE 
 Completely recovered 
Date 
of 
recovery 
(dd/mm/yyyy) 
 
 Condition still present and 
unchanged 
 Recovered with sequelae 
Date (dd/mm/yyyy) 
Describe sequale: 
 
 
 Condition deteriorated 
 
 
 
 Condition improving 
 Death  
Date of death (dd/mm/yyyy) 
 
 
Autopsy:  
Yes 
     No 
     N/A 
 
If Yes, include relevant information: 
 
10. ADDITIONAL INFORMATION  
 
 
 
 
 
 
11. INFORMATION SOURCE 
Name, 
address 
and 
telephone number of PI 
 
 
 
 
 
 
Date 
of 
report 
(dd/mm/yyyy) 
 
 
PI signature 
 
 
 
 

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TO BE COMPLETED BY AAA GLOBAL PV (INTERNAL USE ONLY) 
 
DATE OF RECEIPT: 
(dd/mm/yyyy) 
AAA CASE TRACKING NUMBER: 
 
 
INFORMATION COMPLETE: 
 Yes  
 No  
 
 
Name and signature: 
 
 
FOLLOW-UP REQUESTED:  
 YES 
 
 NO  
Details: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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PREGNANCY REPORTING FORM  
ALL REPORTS MUST BE SIGNED AND DATED BY THE INVESTIGATOR. 
Please fax or send by e-mail the form to AAA Global Pharmacovigilance within 24 hours 
from awareness of event. 
E-mail: 
 
Fax N° : 
 
 
N.B : Fill the applicable fields and refer to Completion Guide of Pregnancy Reporting Form. 
TYPE OF REPORT:      Initial       Completion of data         Follow-up n° ………………       
                                                                       
Study Name 
EudraCT N° 
Center N° 
Investigator N° 
Country 
 
 
 
 
 
 
 
 
 
 
 
 
 
2. PREGNANT WOMAN’S GENERAL MEDICAL HISTORY / BACKGROUND 
BACKGROUND  
PRIOR IMMUNIZATIONS 
Rhesus: 
Smoking: 
Alcohol:  
Drug abuse(s): 
  Unknown    Rh -    Rh + 
  Unknown    No      Yes ….…….……………. (pack-years) 
  Unknown    No      Yes ....….…….…..……. (glasses/day) 
  Unknown    No      Yes ....……….…..…………... (detail) 
Rubella: 
Toxoplasma: 
  Unknown   No    
Yes   
  Unknown   No    
Yes   
MEDICAL HISTORY 
VIRAL SEROLOGY  
Hypertension: 
Diabetes mellitus: 
Epilepsy:  
Psychiatric diseases: 
  Unknown    No      Yes   
  Unknown    No      Yes   
  Unknown    No      Yes   
  Unknown    No      Yes   
HIV: 
Hepatitis: 
  Unknown   No    
Yes   
  Unknown   No    
Yes   
3. PREGNANT WOMAN’S GYNECOLOGICAL & OBSTETRICAL HISTORY 
GYNECOLOGICAL HISTORY 
1. PATIENT INFORMATION 
Patient initials (first letter of Last Name and first letter 
of First Name) 
                       Last name    
               First name   
Patient N°: 
Birthdate (YYYY): 
        
   Age: ……………… 
Weight (kg): 
  
Height (cm):  

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Used contraception: 
Regular menses: 
Infertility treatment: 
  None     Oral    Local    Intra-uterine device    Other   …………………………..…………………………. 
(detail) 
  No        Yes    
  No        Yes   …………………………..……………………………………………………………………….……… 
(detail) 
OBSTETRICAL HISTORY 
Gravidity: 
Parity: 
  No    Yes ………………………….. (detail)  
  No    Yes ………………………….. (detail) 
Abortions:  
 
 
 
 
 
  No    Yes 
If yes, please precise: 
  Spontaneous ……………….…………… 
(detail) 
  Elective …………………….…………….. 
(detail) 
 
 
Therapeutic 
……………….…..…………. (detail) 
In utero demise: 
  No    Yes ………………………….. (detail) 
Number of healthy live offspring:   
Number of death offspring:   
Number of malformated live offspring:  
…………………………   
…………………………   
…………………………   
4. MATERNAL & PATERNAL FAMILY HISTORY 
Malformations: 
Prematurely died children: 
Psychomotor retardation: 
Consanguinity: 
Hereditary disease: 
Other: 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
  Unknown    No    Yes ……………………………………………………………………..….……… (detail) 
……………………………………………………………………..….………………………………………...… (detail) 
5. CURRENT PREGNANCY STATUS AT TIME OF DETECTION 
Last menstrual period: 
    /     /         
 
Gestational age: ……………………. 
Ultrasound-estimated gestational age: …………………… 
 
Polyzygotic pregnancy:  
Ectopic pregnancy :  
 
  No     
Yes 
  No     
Yes 
Estimated date of delivery: 
    /     /         
6. COURSE OF CURRENT PREGNANCY 
DELETERIOUS EXPOSURES DURING PREGNANCY 
PATHOLOGY (IES) DURING PREGNANCY 
Smoker: 
Alcohol:  
Drug abuse(s) : 
Other : 
  No     Yes ……...……………………………..  (pack-years) 
  No     Yes ……………………………………….  (glasses/day) 
  No     Yes ……………………………………….........  (detail) 
…………………………………………………………………………. 
Hypertension : 
Diabetes: 
Infection :  
Other : 
  No     Yes  
  No     Yes  
  No     Yes  
……………………………
. 
MEDICATION RECEIVED AFTER PREGNANCY DETECTION 
Name 
 
Posology 
(with units) 
Administration 
route 
Indication(s)  
Administration dates 
(start/end)  

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1.  
 
 
 
 
2.  
 
 
 
 
3.  
 
 
 
 
4.  
 
 
 
 
5.  
 
 
 
 
MEDICAL FOLLOW-UP 
Hospitalization during pregnancy:  
Intrauterine growth retardation: 
Prenatal diagnosis:  
  No     Yes    ………………………………………...………………………………………...... (reason) 
  No     Yes    ………………………………………...………………………………………........ (detail) 
  No     Yes     
Ultrasound: 
  No     Yes  
If yes, please precise: 
 
 
Date:     /     /         
Date:     /     /         
Date:     /     /         
Results: ………………………………………... 
Results: ………………………………………... 
Results: ………………………………………... 
Invasive method:  
  No     Yes 
If yes, please precise: ………………………………………... (method) 
 
Date:     /     /         
Results: ………………………………………... 
Toxicology screen:    No     Yes 
If yes, please precise: ………………………………………... (drug / body fluid) 
 
Date:     /     /         
Results: ………………………………………... (level) 
7. OUTCOME OF CURRENT PREGNANCY 
Live newborn: 
  No     Yes 
If NO, please precise: 
 
  Spontaneous abortion 
  Elective abortion 
  Therapeutic abortion 
  In utero demise 
Date:     /     /          
Date:     /     /         
Date:     /     /         
 
Term: 
……………………… 
(week) 
Term: 
……………………… 
(week) 
Term: 
……………………… 
(week) 
Term: 
……………………… 
(week) 
Malformations: 
Histopathology: 
  No     Yes  
  No     Yes 
……………………………………………………………...  (detail) 
……………………………………………………………...  (detail) 
8. DELIVERY 
Delivery date: 
    /     /         
  Normal delivery 
  Induced delivery   
  Caesarean section 
Fetal distress:  
Normal placenta: 
Amniotic fluid:  
  No     Yes    (If yes)   Chronic    
Acute 
  No     Yes    Unknown 
  Clear     Turbid 
Gestational age: 
…………………………. (weeks) 

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Postpartum maternal condition: 
Intrapartum medication: 
  Normal         Abnormal     
  Unknown     No     Yes   
…………………………………………………..…….  (detail) 
…………………………………………………..…….  (if yes, detail) 
9. NEWBORN 
Sex :     F     M   
Weight: ………………………..... (unit) 
Length: …………………….….... (unit) 
Cranial perimeter: ………......... (unit) 
Preterm:         No     Yes  
Dysmature:    No     Yes   
Intensive care:    
Malformation :  
Neonatal pathology:  
Breastfeeding: 
  No     Yes    Unknown 
  No     Yes ………………………...  
(detail) 
  No     Yes ………………………...  
(detail) 
  No     Yes   
APGAR score: ……..…. (1 min)    
                          ……..…. (5 min) 
Transfer to NICU / pediatrics:  
Immediate outcome: 
  No    Yes  ….……..  (duration) 
………………………...................... 
Department address:  
Child’s follow-up performed by: 
………………………...…………
……… 
………………………...…………
……… 
10. INITIAL REPORTER 
 
Occupation:  
 
Full name:  
 
Organization/Adress:  
 
Telephone:  
Fax:  
Email:  
 
Date & signature  ______________________________________   
 
If the reporter is a patient or not a Healthcare Professional: 
Has the patient given the authorization to AAA to follow up the 
pregnancy with its treating Doctor?    Yes     No   
Date & signature  __________________________________ 
 
Details of the treating Doctor (if different from the reporter): 
Occupation:  
Full name:  
Organization/Address:  
Telephone/Fax:  
Email:  
 
ADMINISTRATIVE INFORMATION (for internal use only) 
AAA Case #: ……………………………………………. 
TYPE DE RAPPORT:      Initial     Follow up n°: ……………… 
Initial reception by: 
NAME:  
OCCUPATION:  
LOCAL AFFILIATE/COUNTRY:  
DATE:       /     /         
 
 SIGNATURE   _________________________________________ 
Reception date by AAA PV department 
    /     /         
Reception date by a partner 
    /     /         
 
Data collected during a Pharmacovigilance investigation may be stored in a database according to Regulation (UE) no 520/2012, Regulation (CE) no 
726/2004 and directive 2001/83/CE.