Serial [F-18] Fluoroestradiol (FES) PET Imaging to Evaluate Endocrine-targeted Therapy
Phase: PHASE2
Conditions: Estrogen Receptor Positive, Primary or Recurrent Breast Carcinoma, Stage IV Breast Cancer AJCC v6 and v7
Sponsor: University of Washington

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 1 of 31                                                                    Version: 01/15/2016 
 
 
 
FRED HUTCHINSON CANCER RESEARCH CENTER 
UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE 
Current version: 09/25/20  
 Version 1.0  
09/25/2020   
 
 
Title of Protocol: 
Serial [F-18] fluoroestradiol (FES) PET Imaging to Evaluate Endocrine-Targeted Therapy 
 
 
Investigators List: 
Investigator 
Professional Title 
Phone Number 
Hannah Linden, MD FACP 
Professor, Clinical Research Division, FHCRC; Professor of Medicine, 
Division of Medical Oncology, UW 
(206) 606-6710 
Lanell Petersen, PhD 
Research Scientist, Division of Medical Oncology, UW 
(206) 606-2449 
Delphine Chen, MD 
Professor, Department of Radiology, UW; 
Director of Nuclear Imaging, Seattle Cancer Care Alliance 
(206) 606-6342 
Jennifer Specht, MD 
Professor, Clinical Research Division, FHCRC;Associate Professor of 
Medicine, Division of Medical Oncology, UW 
(206) 606-2053 
 
IND #101203 
Sponsor: Delphine Chen 
 
 
Emergency number (24 hours): (206) 598-6190 (paging) for Dr. Linden or the Nuclear Medicine Resident on call 
IRO received 08/23/21

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 2 of 31                                                                    Version: 01/15/2016 
 
ABBREVIATIONS 
 
FES or F18-FES 
[18F]-fluoroestradiol (FES) 
FDG or F18-FDG 
[
18F] -Fluorodeoxyglucose (FDG) 
PI 
Principal Investigator 
PFS 
Progression-free survival 
 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 3 of 31                                                                    Version: 01/15/2016 
 
Table of Contents 
1.0 
GENERAL INFORMATION................................................................................................................................................... 6 
1.1 
Protocol Title ........................................................................................................................................................ 6 
1.2 
Sponsor Information ............................................................................................................................................ 6 
1.3 
Investigator Information ...................................................................................................................................... 6 
1.4 
Contractors and Consultants for the Study (if applicable) .................................... Error! Bookmark not defined. 
2.0 
INTRODUCTION TO THE PROTOCOL .................................................................................................................................. 7 
2.1 
Introduction ......................................................................................................................................................... 7 
2.2 
Preclinical Data..................................................................................................................................................... 8 
2.3 
Clinical Data to Date ............................................................................................................................................. 9 
2.4 
Study Agent ........................................................................................................................................................ 10 
2.5 
Dose Rationale ................................................................................................................................................... 10 
2.6 
Other Agents ...................................................................................................................................................... 10 
2.7 
Risks/Benefits ..................................................................................................................................................... 11 
3.0 
OVERVIEW OF CLINICAL TRIAL ........................................................................................................................................ 11 
3.1 
Study Objectives ................................................................................................................................................ 11 
3.2 
Study Population ................................................................................................................................................ 12 
3.3 
Study Design....................................................................................................................................................... 12 
3.4 
Estimated Accrual .............................................................................................................................................. 15 
4.0 
SAFETY CONSIDERATIONS ............................................................................................................................................... 15 
4.1 
Stopping Rules.................................................................................................................................................... 15 
5.0 
BRIEF DESCRIPTION OF MANUFACTURING PROCESS FOR 18F FES ................................................................................. 15 
7.0 
SUBJECT ELIGIBLITY ......................................................................................................................................................... 15 
7.1 
Inclusion Criteria ................................................................................................................................................ 15 
7.2 
Exclusion Criteria ................................................................................................................................................ 15 
8.0 
SUBJECT REGISTRATION .................................................................................................................................................. 16 
9.0 
TREATMENT PLAN ........................................................................................................................................................... 16 
9.1 
Treatment Plan Overview .................................................................................................................................. 16 
9.2 
Administration of IP or Placebo ......................................................................................................................... 17 
9.3 
Concomitant Medication and Supportive Care Guidelines ................................................................................ 18 
9.4 
Duration of Therapy ........................................................................................................................................... 18 
9.5 
Duration of Follow-Up........................................................................................................................................ 18 
9.6 
Dosing Delays/Dose Modifications .................................................................................................................... 18 
9.7 
End of Treatment (EOT) Visit Schedule and Procedures .................................................................................... 18 
9.8 
Emergency Unblinding Procedures (if applicable) ................................................ Error! Bookmark not defined. 
10.0 
SUBJECT EVALUATION ..................................................................................................................................................... 18 
10.1 
On-Study Clinical Evaluations ............................................................................................................................. 18 
10.2 
Immunological Studies .......................................................................................... Error! Bookmark not defined. 
11.0 
TOXICITY MONITORING ................................................................................................................................................... 19 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 4 of 31                                                                    Version: 01/15/2016 
 
12.0 
SUBJECT DISCONTINUATION OF ACTIVE TREATMENT .................................................................................................... 19 
13.0 
CONCOMITANT MEDICATIONS ....................................................................................................................................... 19 
14.0 
ADVERSE EVENTS ............................................................................................................................................................ 19 
14.1 
Adverse Event .................................................................................................................................................... 20 
14.2 
Serious Adverse Event ........................................................................................................................................ 20 
14.3 
Unexpected Adverse Event ................................................................................................................................ 20 
14.4 
Monitoring and Recordings Adverse Events ...................................................................................................... 20 
14.5 
Grading Adverse Event Severity ......................................................................................................................... 21 
14.6 
Attribution of an Adverse Event ........................................................................................................................ 21 
14.7 
Adverse Event Recording Period ........................................................................................................................ 21 
14.8 
Adverse Event Reporting Requirements ............................................................................................................ 21 
15.0 
CRITERIA FOR ENDPOINT EVALUATIONS......................................................................................................................... 22 
15.1 
Disease Assessment Prior to Enrollment .............................................................. Error! Bookmark not defined. 
15.2 
Definition of Progression After Enrollment........................................................... Error! Bookmark not defined. 
15.3 
Time to Tumor Progression ................................................................................... Error! Bookmark not defined. 
15.4 
Survival Time ......................................................................................................... Error! Bookmark not defined. 
15.5 
Comparison of Performance Status - between active agent and placebo ............ Error! Bookmark not defined. 
16.0 
DATA AND SAFETY MONITORING PLAN .......................................................................................................................... 24 
17.0 
ASSESSMENT OF EFFICACY ................................................................................................. Error! Bookmark not defined. 
17.1 
Efficacy Parameters............................................................................................... Error! Bookmark not defined. 
17.2 
Method and Timing ............................................................................................... Error! Bookmark not defined. 
17.3 
Other Response Parameters ................................................................................. Error! Bookmark not defined. 
18.0 
DATA MANAGEMENT/CONFIDENTIALITY ....................................................................................................................... 24 
19.0 
STATISTICAL CONSIDERATIONS ....................................................................................................................................... 25 
20.0 
INVESTIGATOR OBLIGATIONS ......................................................................................................................................... 26 
21.0 
ADMINISTRATIVE AND REGULATORY CONSIDERATIONS ................................................................................................ 26 
21.1 
Pre-Study Documentation .................................................................................................................................. 26 
21.2 
Study Site Training ............................................................................................................................................. 26 
21.3 
Documentation .................................................................................................................................................. 26 
21.4 
Access to Source Data ........................................................................................................................................ 27 
21.5 
Data Collection ................................................................................................................................................... 27 
21.6 
Protocol Interpretation and Compliance ........................................................................................................... 27 
21.7 
Study Monitoring and Data Collection ............................................................................................................... 27 
21.8 
Disclosure of Data/Publication........................................................................................................................... 27 
21.9 
Ethical Considerations ........................................................................................................................................ 27 
21.10 
Informed Consent .............................................................................................................................................. 28 
21.11 
Institutional Review Board/Ethics Committee ................................................................................................... 28 
21.12 
Subject Privacy ................................................................................................................................................... 28 
22.0 
STOPPING THE STUDY ........................................................................................................ Error! Bookmark not defined. 
23.0 
REFERENCES .................................................................................................................................................................... 28 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 5 of 31                                                                    Version: 01/15/2016 
 
24.0 
APPENDICES ....................................................................................................................... Error! Bookmark not defined. 
24.1 
[SAMPLE APPENDIX A: Study Calendar] ................................................................ Error! Bookmark not defined. 
 
 
 
 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 6 of 31                                                                    Version: 01/15/2016 
 
1.0 
GENERAL INFORMATION 
 
This is a clinical research protocol and will be conducted under appropriate IRB review. Research procedures will follow all 
applicable sections of the Code of Federal Regulations, including CFR 21 Part 312. 
 
This clinical study will investigate the utility of [18F]FES in patients with estrogen receptor (ER) positive, primary, recurrent or 
metastatic, breast carcinoma. [18F]FES PET has been validated as a measure of estrogen receptor expression. This trial is also 
designed to test the safety of [18F]FES.  In addition, this study will obtain data on the value of [18F]FES to predict and evaluate 
response to endocrine-targeted therapies as a measure of ER expression in this patient population. [ 18F]-fluoroestradiol (FES) is 
a sterile injectable radiopharmaceutical designed for imaging estradiol binding to estrogen receptors (ERs) in vivo. FES is 
currently approved for detection of estrogen-receptor-positive lesions.  
 
Patients with primary, recurrent or metastatic breast cancer from an ER+ primary tumor who will be undergoing endocrine-
targeted therapy will be imaged with [F-18]-16-fluoroestradiol. All patients will undergo a pre- and post-therapy FES PET or FES 
PET/CT scan (hereafter FES PET will be used to denote both FES PET and FES PET/CT unless specifically noted). In some patients 
receiving non-interfering medications such as aromatase inhibitors, scans may be performed with patients already on a 
treatment who are to start an alternative or additional endocrine targeted treatment. FDG PET and CT will be used as staging 
tests for this study and FDG will also serve as a comparator for tumor localization with the FES imaging.  
 
After the FES and FDG baseline imaging (see schematic below), the patients will start or change therapy, typically within 30 days, 
and be followed clinically for up to 20 years. FES and FDG images will be spatially co-registered and tumor regions will be drawn 
on the FDG images and transferred to the FES images for quantitative analysis of FES uptake in both ER positive and ER negative 
tumors. 
 
The FES uptake from images will be analyzed qualitatively by visual assessment and quantitatively using a standard uptake value 
(SUV). ER, PR and HER2 assays will allow determination of hormone receptor status and whether HER2 over-expression indicates 
estrogen-independent growth in some treatment studies, however, there may not be pathologic correlates in all studies. 
 
Patients with metastatic or recurrent disease may consent to optional research biopsies performed prior to start of the selected 
endocrine-targeted therapy, and after 1-12 weeks on therapy. Obtained tissues will be analyzed for expression of prognostic 
markers and/or for intra-tumor steroid hormone concentrations to evaluate correlations between results of imaging and histo-
pathological studies and to enhance understanding of mechanisms of response and resistance in the context of tumor 
microenvironment. 
 
We anticipate that the imaging measure of receptor density will predict the likelihood that a patient will respond to hormone 
targeted therapy, evaluate subsequent changes in this measure as the patient undergoes therapy and that eventually [18F]FES 
imaging will help us design therapeutic trials for better treatment outcomes.  We also expect that repeat [18F]FES PET imaging 
shortly after the start of endocrine-targeted therapy will reflect the pharmacodynamics of endocrine targeted therapy. 
 
1.1 
Protocol Title 
Serial [F-18] fluoroestradiol (FES) PET Imaging to Evaluate Endocrine-Targeted Therapy 
1.2 
Sponsor Information 
Delphine L Chen, MD 
Seattle Cancer Care Alliance 
Department of Radiology/Division of Nuclear Medicine 
1144 Eastlake Avenue E, #LG2-200 
Seattle, Washington 98109 
Telephone: (206) 606-2449 
dlchen7@uw.edu 
1.3 
Investigator Information 
Hannah M Linden, MD 
University of Washington School of Medicine 
Department of Medicine/Division of Medical Oncology 
825 Eastlake Avenue E, G3-200 
Seattle, Washington 98109 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 7 of 31                                                                    Version: 01/15/2016 
 
Telephone: (206) 606-6710 
Fax: (206) 606-2054 
hmlinden@uw.edu 
 
2.0 
INTRODUCTION TO THE PROTOCOL 
 
2.1 
Introduction 
 
This clinical study will investigate the utility of [18F]FES in patients with  estrogen receptor (ER) positive, primary, recurrent or 
metastatic, breast carcinoma. [18F]FES PET has been validated as a measure of estrogen receptor expression. This trial is also 
designed to test the safety of [18F]FES.  In addition, this study will obtain data on the value of [18F]FES to predict and evaluate 
response to endocrine-targeted therapies as a measure of ER expression in this patient population.  If promising, these data will 
be used to design a phase II multi-center clinical trial.  
 
2.2 
Background 
 
This single-site study will investigate the ability of [18F]FES to quantify changes in ER expression and estradiol binding in vivo in 
patients with breast cancer for whom endocrine-targeted therapy has been chosen based on clinical presentation or as part of 
therapeutic clinical trial. The results of this trial will help evaluate the effect of ER-directed therapies on ER expression and 
estrogen binding to ER, and secondarily whether the FES PET measures of estrogen receptor function, and changes with 
treatment, predict response to endocrine targeted therapy in patients with known ER+ primary or metastatic breast cancer as 
measured by immunohistochemistry (IHC) of biopsy material. The primary goal is to gain insight into the efficacy of ER-targeted 
therapies, especially novel therapies, on ER expression and estrogen binding to ER. For example, serial FES PET imaging could be 
used to test the efficacy of an ER antagonist in blocking estradiol binding, or the ability of an agent directed at altering ER 
expression to change ER expression levels in tumors. Such in vivo measures of the pharmacodynamics of ER-directed therapy 
have traditionally required serial biopsy and have been quite challenging. FES PET presents a non-invasive alternative to measure 
the effects of ER-directed therapy. 
 
Invasive breast carcinoma: Each year, invasive breast cancer will be diagnosed in over 250,000 women and account for over 
40,000 deaths in the United States (1). Advances in diagnosis and therapy have resulted in increased survival for early breast 
cancer (1-3). This increase in breast cancer survival may result in more patients diagnosed with advanced or metastatic breast 
cancer. Individualized medicine tailoring therapy to patients shows promise to care for this disease (4). 
 
Invasive breast carcinoma and hormone receptors: The incidence of hormone receptor positive disease is approximately 79% (1, 
2). Physicians generally choose endocrine-targeted therapies as first-line treatments for patients with ER+ advanced disease due 
to improved tolerability as well as ease of administration. Nonetheless, chemotherapy is frequently offered to patients without 
proof of superior outcomes. Measurement of tumor hormone receptor expression, both estrogen receptor (ER) and 
progesterone receptor (PgR) at the time of primary diagnosis is standard of clinical care (5). Knowledge of hormone receptor 
 
Treatment of breast carcinoma: Treatment selection for breast cancer poses several challenges. Not all patients will respond to 
first-line endocrine targeted therapy due to intrinsic endocrine-therapy resistance mechanisms as well as tumor heterogeneity. 
Heterogeneity is a challenge in management of breast cancer, especially for locally advanced or metastatic disease. In cases 
where tissue sampling is feasible, the expression of ER may be heterogeneous. Not all metastatic breast cancer cells will have the 
same level of estrogen receptor (ER) expression) and ER expression at one site does not guarantee expression at all sites (6).  In 
addition, there are no current methods in standard practice to inform on either of these. This presents significant practical 
challenges for assessing ER expression in breast cancer. The potential for misidentification of patients appropriate for endocrine 
therapy is significant. While ER expression predicts measurable tumor regression (objective response) in 30% to 77% of patients 
with a new diagnosis of breast cancer, response rates are more typically 7% to 21% in patients with recurrent disease and prior 
breast cancer treatment (7). A predictive assay of hormone sensitivity capable of assessing ER expression at all sites of disease 
would be highly valuable for selection of which patients are more likely to benefit from endocrine therapy. 
 
Recent advances in endocrine therapy: A significant advance in the management of ER+ metastatic breast cancer was the 
introduction of aromatase inhibitors (AI) (8-10). These agents are more effective and result in a longer time to progression than 
previous therapies, and have therefore displaced tamoxifen as first-line treatment for metastases and adjuvant therapy (8, 10-

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 8 of 31                                                                    Version: 01/15/2016 
 
12). In addition, Fulvestrant, a selective estrogen receptor down-modulator (SERD, given IM) is active in metastatic disease and 
may have a particular benefit in de novo disease (13-15). Oral SERDs are in development, with the assistance of FES for 
pharmacodynamic imaging (16).  
 
The synergistic addition of CDK 4/6 inhibitors and other molecularly targeted agents (mTOR, PARP inhibitors, PI3K inhibitors) has 
resulted in improved response, duration of response and survival in first and second line settings (17-20). FES measures ER 
expression, and could measure cross talk (21). 
 
Endocrine therapy for breast carcinoma: The optimal management of patients who experience progression of disease while on 
adjuvant aromatase inhibitor treatment, and of premenopausal patients, remains under investigation. There is evidence to 
support the usefulness of irreversible steroidal AIs (exemestane) for treating patients who progress on nonsteroidal AIs (22). 
Clinical experience suggests a primary role for this strategy in patients who have a significant disease-free interval on a hormonal 
adjuvant therapy. For post-menopausal women with advanced or metastatic hormone receptor positive (HR+) disease, whose 
disease is considered treatable but not curable, the initial standard of care treatment is aromatase inhibitors (AIs), with or 
without CDK (cyclin-dependent kinase) 4/6 inhibition (23). Upon progression, salvage endocrine therapy with molecularly 
targeted agents, or chemotherapy is indicated (24). Recent Phase III trials combining later-line endocrine therapy with a targeted 
agent, such as palbociclib, alpelisib or everolimus, have demonstrated considerable improvement in outcome (17, 25, 26) over 
endocrine therapy alone. Clinical studies have shown promising results when combining endocrine therapy with HDACi, including 
exemestane with entinostat (27), tamoxifen with vorinostat (28) and a randomized phase III study (E2112) of endocrine therapy 
plus entinostat/placebo in patients with hormone receptor-positive advanced breast cancer (29). Currently active investigational 
protocols will determine the optimal management of premenopausal women with hormonal therapy. Our study will test the 
value of FES PET for predicting the effectiveness of endocrine therapy, with the eventual goal of selecting patients with primary 
or metastatic disease most likely to benefit from this expanding choice of agents for endocrine therapy. In addition, our 
hypothesis is that FES PET will be useful as a predictive assay for those patients who have failed one endocrine therapy agent and 
are being considered for an alternative endocrine treatment. 
 
2.2.1 
Preclinical Data 
 
Nonclinical Pharmacology of FES and Estradiol: The extensive body of literature on the pharmacology and toxicity of 
fluoroestradiol and of estradiol is summarized below. Estradiol is a naturally occurring substance with biochemical and 
pharmacologic properties nearly identical to FES. It is important to interpret toxicity data for FES relative to reported toxicity for 
estradiol in the context of the intended use of FES as a single-dose-administration agent for diagnostic imaging. In this setting, 
FES reaches physiologic levels (i.e., greater than post-menopausal levels) only on a transient basis. This must be viewed in the 
context of many years of exposure to physiologic levels of estradiol in most women. 
 
Pharmacokinetics and Metabolism of FES in Animals: The pharmacology of FES has been studied in rats. In rats, FES is rapidly 
metabolized to more polar species19. By 60 minutes after injection, less than 15% of circulating radioactivity is due to [18F]FES; 
the remainder is metabolites. Injection of blood from rats obtained 2 hours after injection into different rats showed that the 
metabolites did not accumulate in ER-rich tissues, such as the uterus, that could be blocked by estradiol19. This suggests that the 
metabolites are conjugates or other species that do not bind to ER, as compared to unconjugated oxidation products such as the 
estrone, which would be expected to bind to ER.  
 
Immature Sprague-Dawley female rats received a single injection of [18F]FES and were sacrificed at 30, 60, and 120 min after 
injection. The results of tissue distribution assays are presented in Table 4.1 as percent injected dose per gram13. [18F]FES was 
found to have high binding selectivity to target estrogen receptor rich tissues. 
 
Nineteen mature female rats with 7,12-dimethylbenz[a]anthracene (DMBA) induced mammary tumors received a single injection 
of [18F]FES, and tissue and tumor uptake was measured at 3 hours post injection as % injected dose per gram of tissue and 
tumor to blood and tumor to non-target tissue ratios. The correlation between [18F]FES and ER content at 3 hours was poor19. 
However, VanBrocklin et20 al studied 69 female SpragueDawley rats age 22 – 30 days that were injected with 50 µCi of [ 18F]FES 
and sacrificed at one-hour post injection to measure alphafetoprotein (AFP) serum concentration and determine the effects of 
AFP binding on blood activity levels of [18F]FES. A strong positive correlation was seen between serum AFP concentration and 
[18F]FES blood activity levels, suggesting that the anticipated correlation between uptake of the tracer and ER content may be 
compromised by the presence of unbound metabolites in the blood and by endogenous molecules that possess high affinity 
binding sites for phenolic steroids including estrone and estradiol, such as AFP in rats or SHBG in humans20. Time activity curves 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 9 of 31                                                                    Version: 01/15/2016 
 
for animal models are not directly applicable to human uptake for [ 18F]FES due to the lack of sex hormone binding globulin 
(SHBG) in rats. 
 
Toxicology: Multiple studies support the role of estradiol and its catechol estrogen metabolites as weak mutagens and 
carcinogens in in vivo and in vitro experiments. However, these data, combined with the recent preclinical toxicology and 
mutagenicity work reported above, also suggest a low frequency of mutagenic events related to estradiol, even with high 
concentrations and repeated exposures. [18F]FES is therefore extremely unlikely to pose a mutagenic or carcinogenic threat in 
single-dose exposures such as those required in FES PET. Studies have detected low level alterations to DNA; however, these 
changes occurred with chronic exposure to estradiol concentrations of 25 µg/ml or greater. This level is 2 – 3 orders of 
magnitude greater than FES levels encountered in PET, and exposure for PET imaging is transient. The mass of drug used in the 
FES imaging studies is well below any levels where genotoxicity was observed. 
 
2.2.2 
Clinical Data to Date 
 
Imaging of ER with [18F]FES: PET ER imaging using [18F]-fluoroestradiol (FES) poses an attractive possibility to meet this clinical 
need. Previous work evaluating the ER binding, radiation dosimetry, blood clearance and protein interactions of FES in women 
with hormone receptor positive breast cancer has shown that uptake correlates with in vitro assay of expression in breast cancer 
tissue samples (30-32). FES-PET evaluates multiple tumor sites simultaneously and, thus, demonstrates the tumors' ability to 
concentrate estrogen over the entire body. Furthermore FES positron emission tomography (with either PET or PET/CT) 
measures the heterogeneity of ER expression and function in metastatic disease (33-35). Prior studies have shown that the level 
of FES uptake predicts the response of advanced breast cancer to hormonal therapy; these therapies were predominantly 
tamoxifen (36). We also showed that the level of FES uptake as an in vivo indicator of ER function predicted response to 
endocrine therapy with selective ER modulators (SERMs) or aromatase inhibitors (Als) in first-line therapy or salvage settings (37-
40). Typically, a higher tumor SUV was noted in responders compared with non-responders. FES uptake, like IHC, identifies 
patients with tumors that lack ER expression. This is helpful in distinguishing ER+ tumors that may respond to endocrine therapy 
from those that do not benefit from such therapy. Serial FES-PET studies show the persistence or loss of ER expression over time 
in vivo, a potentially useful biomarker to determine when endocrine therapy is likely to be ineffective at controlling tumor 
growth, and are less invasive, more comprehensive than repeated tissue sampling. In this study we will test FES predictive 
capability in patients undergoing endocrine therapy of breast cancer, and also to test the impact of endocrine treatments on ER 
expression and/or ER blockade. 
 
We have examined the role of FES in 47 heavily pretreated patients (39): Initial FES uptake was measured and correlated with 
subsequent tumor response to 6 months of hormonal treatment. In this study, 11/47 (23%) patients had an objective response. 
Quantitative FES uptake and response were significantly associated; 0/15 patients with initial FES SUV<1.5 responded to 
hormonal therapy, compared to 11/32 (34%) with FES SUV 1.5 (p < .01). In the subset of patients whose tumors did not over-
express HER2/neu, 11/24 (46%) of patients with SUV  1.5 responded. These pilot results support the further evaluation of the 
predictive capability of FES PET. 
 
FES uptake predicted a greater likelihood of response to endocrine therapy: Patients with low or absent FES uptake were 
unlikely to manifest a response to treatment, yet FES did not help to distinguish which patients would experience a clinical 
benefit, defined as stable disease. Several factors may have contributed to this finding. Stable disease over 6 months included 
patients with disease that may have progressed slowly, independent of treatment, as well as patients with rapidly progressive 
disease in whom therapy slowed but did not abrogate tumor growth. The study was not designed to distinguish between these 
two outcomes. In addition, we identified PgR (progesterone receptor) expression as contributing to likelihood of response, and 
noted that elevated estradiol levels and HER2 expression were associated with non-response. In this new study we propose to 
document tumor characteristics including quantitative ER mRNA levels measured by PCR and semi-quantitative levels of ER, PgR, 
AR and HER2 by IHC, molecular targets including PI3K and ESR1 mutations. Gathering these indices as part of the proposed study 
may help to enhance the predictive value of PET FES, allow understanding of mechanism of resistance to endocrine therapy, and 
potentially determine which patients are likely to appreciate clinical benefit as a result of endocrine therapy, even in the absence 
of an objective response. 
 
In prior observational imaging trials (unpublished data): we have measured regional estrogen-ER binding using FES PET before 
and after treatment with estrogen depleting therapies, Aromatase inhibitors (AI), and estrogen blocking therapies, Tamoxifen 
(TAM), or fulvestrant (FUL) in 30 metastatic breast cancer patients. As expected, tumor FES uptake declined markedly on ER 
blockers TAM and FUL (average 54% decline), but less than 15% on average on estrogen-depleting AIs (p<0.001). All 5/5 patients 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 10 of 31                                                                    Version: 01/15/2016 
 
taking TAM showed complete tumor blockade (FES SUV ≤ 1.5 after treatment), compared to 4/11 of FUL patients (p=0.009). 
Other studies have also shown that FES PET can measure estrogen receptor suppression (16). We concluded that molecular 
imaging can assess the in vivo pharmacodynamics of targeted agents, and may give insight into the activity of established 
therapeutic agents. 
 
Phase II trial: Twenty-three patients with ER+/HER2- metastatic breast cancer with prior clinical benefit from endocrine therapy 
but later progression on aromatase inhibitor (AI) therapy were included in a Phase II trial of vorinostat to restore endocrine 
sensitivity in ER+/HER2- metastatic breast cancer, with molecular imaging correlates. 18F-FES PET and 18F-Fluorodeoxyglucose 
(18F-FDG) PET scans were performed at baseline, week 2, and week 8. Simultaneous HDACi and AI dosing in patients with 
cancers resistant to AI alone was promising with clinical benefit (6+ months without progression) in 4 of 10 evaluable patients. 
Higher 18F-FES-PET uptake identified patients likely to benefit from combination therapy, but vorinostat did not appear to 
change ER expression (results submitted for publication). 
 
2.3 
Study Agent 
The [ 18F]fluoroestradiol is a sterile, IV injectable solution with a volume of ≤ 20 ml containing 0.15 M phosphate buffered saline: 
< 15% ethanol (v:v). The injected dose of [ 18F]FES is generally 6 mCi (185 MBq) with an allowable range of 3 to 6 mCi of [ 
18F]fluoroestradiol. The drug product solution is stored at room temperature in a gray butyl septum sealed, sterile, pyrogen-free 
glass vial with an expiration time of 8 hours. The mass of injected drug is ≤ 5 µg (≤ 17 nmol) of FES. 
 
Chemically, FES is [18F]16α-fluoro-3,17β-diol-estratriene-1,3,5(10). The molecular weight is 289.37, and the structural formula is: 
 
 
 
FES is a sterile, clear, colorless solution for intravenous injection, with an osmolarity of 340 mOsm. Its pH ranges between 4.5 to 
7.0. The composition of the final product in 40 mL solution is fluoroestradiol no more than 5 µg, fluoroestradiol F 18 148 MBq/mL 
to 3,700 MBq/mL (4 mCi/mL to 100 mCi/mL), sodium ascorbate 0.44% w/v in sodium chloride 0.9% w/v, and ethanol no more 
than 3.2% w/v. 
 
2.4 
Dose Rationale 
The suggested dose is 220 MBq. 222 MBq is the maximum recommended dose in the IB and has been demonstrated to be well-
tolerated in terms of toxicity, while providing an accurate image.   
 
2.5 
Other Agents 
18F-Fluorodeoxyglucose (18F-FDG) Injection is a positron emitting radiopharmaceutical that is used for diagnostic purposes in 
conjunction with positron emission tomography (PET) imaging. The active ingredient 2-deoxy-2-[18F]fluoro-D-glucose has the 
molecular formula of C6H11 18FO5 with a molecular weight of 181.26, and has the following chemical structure:  
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 11 of 31                                                                    Version: 01/15/2016 
 
 
 
Fludeoxyglucose F 18 Injection is provided as a ready to use sterile, pyrogen free, clear, colorless citrate buffered solution. FDG 
scans are used as a comparator for this trial. Patients will have a clinical FDG PET scan prior to the start of treatment as part of 
their standard care. A second FDG PET scan will be done as a study procedure concurrent with the FES PET timing stipulated by 
treatment regimen (this may vary from 1 to 12 weeks post treatment start depending on regimen).  
 
Risks: Hypersensitivity reactions with pruritus, edema and rash have been reported in the postmarketing setting. FDG will 
increase the risk of secondary cancer. 
 
2.6 
Risks/Benefits 
Very few adverse events been reported for diagnostic [18F]FES administration at the strength described for this study in 267 
patients studied at the University of Washington. Patients have experienced pain and bruising at the injection site, and one 
patient reported a temporary slight change in taste. Thus few adverse effects are expected as a result of the administration of 
[18F]FES, except for discomfort at the injection site. The [18F]FES dose is slightly less than recommended safe oral dose assuming 
an oral conjugated estrogen dose of 2.5 mg in one day.  
 
The IB also identifies potential risks, which have not been observed in patients receiving FES, but are theoretically possible based 
on the chemistry and pharmacology of FES: Tissue Injury, infection, extravasation of dose, allergic reaction, nausea, vomiting, 
anorexia, uterine bleeding, and secondary cancers due to radiation exposure. 
 
FDG PET, blood draws, and biopsies are standard-of-care procedures. FDG PET has additional risks of pruritus, edema, and rash, 
occurring in less than 1% of patients. The blood draw may briefly cause patients to feel faint, lightheaded, nauseated, mild pain, 
bleeding, bruising and infection at the site of the needle insertion. Biopsies may cause pain, bleeding at the biopsy site, 
tenderness, scarring, or infection. 
 
Carcinogenesis has not been observed in animal or clinical trials. Synthetic estrogens such as 2- fluoroestradiol and 4-
fluoroestradiol are poor carcinogens in the same animal model systems because the fluorine blocks metabolism when 
substituted in these positions. [ 18F]FES is labeled with fluorine at the 16 position of the estradiol. Administration of [ 18F]FES as 
described herein, for up to four PET scan procedures, results in intermittent and vastly reduced overall estrogenic exposure 
compared to regimens known to cause cancer in animals.   
 
FES imaging will not be used to direct therapy. It is not expected that patients on this trial will derive a benefit, this trial is 
intended only to expand the body of knowledge on FES imaging. The contribution to the body of knowledge for the use of FES is 
expected to far outweigh the minor risks of FES administration. 
 
3.0 
OVERVIEW OF CLINICAL TRIAL 
 
3.1 
Study Objectives 
 
3.1.1 
Primary Objectives 
Measure the effect of endocrine targeted therapy on ER expression and estradiol binding to the receptor using serial FES PET and 
FDG PET. 
3.1.2 
Secondary Objectives 
Document the safety profile of FES PET in patients with breast cancer. 
  

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 12 of 31                                                                    Version: 01/15/2016 
 
Examine associations between FES PET results and serial measurements of hormone or other levels in peripheral blood, as 
related to efficacy of endocrine-targeted therapy. Correlate FES PET uptake measures with histopathological assays and tumor 
microenvironment studies on biopsy specimens, if relevant to specific treatment regimen. 
 
3.2 
Study Population 
This study focuses on patients with estrogen receptor (ER) positive, primary, recurrent or metastatic, breast carcinoma. Further 
detail on the subject population can be found in the inclusion and exclusion criteria listed under section 7. 
 
The population for this study will be recruited from patient rosters in other studies that require a FES scan as a research 
procedure. 
 
3.3 
Study Design 
This clinical study will investigate the utility of [18F]FES in patients with  estrogen receptor (ER) positive, primary, recurrent or 
metastatic, breast carcinoma. [18F]FES PET has been validated as a measure of estrogen receptor expression. This trial is also 
designed to test the safety of [18F]FES.  In addition, this study will obtain data on the value of [18F]FES to predict and evaluate 
response to endocrine-targeted therapies as a measure of ER expression in this patient population.  If promising, these data will 
be used to design a phase II multi-center clinical trial.  
 
We anticipate that the imaging measure of receptor density will predict the likelihood that a patient will respond to hormone 
targeted therapy, evaluate subsequent changes in this measure as the patient undergoes therapy and that eventually [18F]FES 
imaging will help us design therapeutic trials for better treatment outcomes.  We also expect that repeat [18F]FES PET imaging 
shortly after the start of endocrine-targeted therapy will reflect the pharmacodynamics of endocrine targeted therapy. 
 
Briefly, patients with primary, recurrent or metastatic breast cancer from an ER+ primary tumor who will be undergoing 
endocrine-targeted therapy will be imaged with [F-18]-16-fluoroestradiol. All patients will undergo a pre-therapy FES PET or FES 
PET/CT scan (hereafter FES PET will be used to denote both FES PET and FES PET/CT unless specifically noted). In some patients 
receiving non-interfering medications such as aromatase inhibitors, scans may be performed with patients already on a 
treatment who are to start an alternative or additional endocrine targeted treatment. Patients will undergo a repeat FES PET and 
FDG PET on study after starting the endocrine-targeted therapy.  The exact timing of the repeat scans may vary depending on the 
treatment regimen.  In the repeat studies, we will be testing the ability of FES PET and FDG PET to measure the pharmacologic 
effect of endocrine-targeted therapy and early measures that may help predict response to such targeted agents. In patients on 
selective estrogen receptor degrader (SERD) therapies, where repeat FES PET is used primarily to evaluate residual ER availability 
rather than tumor response, repeat FDG PET may be omitted, as determined by requirements of the co-enrolling companion 
therapeutic protocol. A subset of patients may undergo a third FES PET at a later time point determined by the treatment 
regimen.  
 
FDG PET and CT will be used as staging tests for this study and FDG will also serve as a comparator for tumor localization with the 
FES imaging. Patients will have a clinical FDG PET scan prior to the start of treatment as part of their standard care; their treating 
physician will order this. In rare cases where an FDG PET has recently been performed at an outside medical facility but the scan 
has inadequate image quality or insufficient quantitative information, or for patients who would not be ordered as a standard 
part of the patient’s care, a baseline FDG scan will be done as part of this protocol. A second FDG PET scan will be done as a study 
procedure concurrent with the FES PET timing stipulated by treatment regimen (this may vary from 1 to 12 weeks post treatment 
start depending on regimen). In the subset of patients undergoing a third FES PET scan there may also be a research FDG PET 
done at the same time point if indicated by the treatment regimen. 
 
After the FES and FDG baseline imaging (see schematic below), the patients will start or change therapy, typically within 30 days, 
and be followed clinically for up to 20 years. Lesion location will be identified using clinical FDG scans with reference to clinical CT 
for metastatic disease or ultrasound, mammography, and/or breast MRI for primary tumors in patients presenting with 
metastatic or recurrent disease that still have a primary breast lesion. FES and FDG images will be spatially co-registered and 
tumor regions will be drawn on the FDG images and transferred to the FES images for quantitative analysis of FES uptake in both 
ER positive and ER negative tumors.  For FDG studies, SUVs will be generated. 
 
The FES uptake from images will be analyzed qualitatively by visual assessment and quantitatively using a standard uptake value 
(SUV). Serial measurements of hormone levels in peripheral blood may be used with some treatment regimens to allow 
determination of efficacy of endocrine therapy. ER, PR and HER2 assays will allow determination of hormone receptor status and 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 13 of 31                                                                    Version: 01/15/2016 
 
whether HER2 over-expression indicates estrogen-independent growth in some treatment studies, however, there may not be 
pathologic correlates in all studies. 
 
We emphasize that this is an observational study in that [18F]FES PET will not be used to direct therapy. Treatment regimens are 
chosen by the referring oncologist prior to the [18F]FES PET study on the basis of clinical criteria or participation in experimental 
treatment protocols.  While patients and referring physicians will not be blinded to [18F]FES PET results, treatment choices will 
be made prior to the entry of the patient into the study and will not be altered because of the FES PET results. 
 
Patients with metastatic or recurrent disease may consent to optional research biopsies performed prior to start of the selected 
endocrine-targeted therapy, and after 1-12 weeks on therapy. Obtained tissues will be analyzed for expression of prognostic 
markers and/or for intra-tumor steroid hormone concentrations to evaluate correlations between results of imaging and histo-
pathological studies and to enhance understanding of mechanisms of response and resistance in the context of tumor 
microenvironment. 
 
Below is an outline for this schema: 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 14 of 31                                                                    Version: 01/15/2016 
 
 
3.3.1 
Primary Endpoint 
The primary endpoints will be quantitative and qualitative measures of FES uptake, and measures of change in FES uptake 
between pre-therapy and post-therapy scans 
3.3.2 
Secondary Endpoint  
Progression-free survival. 
 
Begin endocrine targeted therapy 
Diagnostic FDG PET or PET/CT  
Primary or Metastatic Breast Cancer Patients (with history of ER+ Primary) 
Planning a Course of Endocrine-Targeted Therapy.  Patients may be co-enrolled on 
other studies using FES PET imaging 
FES PET or PET/CT  
 (in a small number of patients FES PET may precede the FDG PET or PET/CT) 
Evaluation of disease-free/progression-free survival (for up to 20 years post-Rx) 
Repeat FDG and FES PET  
(timing of repeat imaging may vary from 1 week to 12 weeks post treatment start 
depending on the treatment regimen) 
Repeat FDG and FES PET  
(if indicated by treatment protocol time points  
or to evaluate ER status at time of progression) 
Obtain metastatic or recurrent tumor tissue from an FDG and/or FES avid site 
(optional biopsy – baseline) 
Obtain metastatic or recurrent tumor tissue (optional biopsy – early response) 
(Timing may vary from 1 to 12 weeks post treatment start; a sample should be 
obtained after the completion of imaging, from the same site as the baseline 
sample whenever possible) 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 15 of 31                                                                    Version: 01/15/2016 
 
3.4 
Estimated Accrual 
We anticipate that we will enroll up to 20 patients in this pilot study. 
 
 
4.0 
SAFETY CONSIDERATIONS 
 
4.1 
Stopping Rules 
Participant involvement will be concluded if any AEs possibly related to the IP occur. The principal investigator will exercise their 
discretion in determining which AEs may be related to the IP. This excludes mild pain, bruising, or controllable bleeding at the 
injection site, which is a common and expected risk for IV imaging products. 
 
5.0 
BRIEF DESCRIPTION OF MANUFACTURING PROCESS FOR F-18 FES 
This product is manufactured under IND# 101203. The chemical precursor for [18F]FES is provided in house or by Advanced 
Biological Compounds in single-use, 2 mg vials that are delivered to the custody of Dr. Steven Shoner, the lead radiochemist for 
this project. They are stored in a controlled temperature freezer in a locked and secure room and they are inventoried with a 
chain of custody maintained from the time of receipt. Each radiosynthesis is assessed by a radiochemist for quality. The quality 
control tests that must be passed prior to release of the product [18F]FES for injection include the pH, radioactive purity, 
radiochemical purity, specific activity, sterilizing filter integrity, tests for Kryptofix, acetonitrile, endotoxins and particulates. 
Acceptance criteria are detailed in the CMC document. The [18F]FES dose is drawn up into a syringe, assayed for mCi at time of 
injection, labeled and administered to the research subject. 
 
6.0 
SUBJECT ELIGIBLITY 
6.1 
Inclusion Criteria  
 
Adult, non-pregnant patients with biopsy-proven or clinically obvious primary, recurrent or metastatic breast cancer  
 
Breast cancer from ER+ primary that is seen on other imaging tests. Tumor ER expression must have been confirmed by 
immunohistocytochemistry of primary tumor or recurrent disease. 
 
At least one site of disease 1.5 cm or greater is needed to meet the spatial resolution limits of PET imaging.  
 
Patients must have been off tamoxifen or other estrogen receptor blocking agents for at least 6 weeks and off 
chemotherapy for 3 weeks for the initial baseline FES.  
 
Patients must be selected for an endocrine targeted therapy regimen for treatment of their breast cancer by the 
referring oncologist. Selected treatments may be part of experimental treatment protocols for which the patient would 
be separately consented.  
 
Patients must be willing to undergo serial imaging procedures.  
 
Patients must agree to allow access to clinical records regarding response to treatment and long term follow up.  
 
Ability to understand and the willingness to sign a written informed consent document. 
 
6.2 
Exclusion Criteria 
o 
An inability to lie still for the tests  
o 
Individuals weighing more than 300 lb. (this is the weight limit of the scanner table) 
o 
Pregnant or lactating. Women of childbearing potential with either a positive or no pregnancy test at baseline are 
excluded.  
o 
Any other life-threatening illness (e.g. serious, uncontrolled concurrent infection or clinically significant cardiac disease – 
congestive heart failure, symptomatic coronary artery disease, cardiac arrhythmia not well controlled with medication). 
o 
Use of tamoxifen, faslodex, DES or any other ER blocking agent < 6 weeks or chemotherapy < 3 weeks prior to imaging 
scan.  
o 
Unwillingness or inability to give informed consent. 
o 
Uncontrolled diabetes mellitus (fasting glucose > 200 mg/dL) 
o 
Adult patients who require monitored anesthesia for PET scanning. 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 16 of 31                                                                    Version: 01/15/2016 
 
7.0 
SUBJECT REGISTRATION 
 
Subjects will be registered by the Fred Hutch/UW Study Coordinator and entered into the Clinical Trials Management System 
(CTMS). A complete, signed, study consent and HIPAA consent are required for registration. 
 
8.0 
TREATMENT PLAN 
 
Treatment will be administered on an outpatient basis. Reported adverse events are described in section 13.0 and potential risks 
are described in section 2.6. There will be no dose modifications for FES administration. No investigational or commercial agents 
or therapies will be administered in this protocol with the intent to treat the patient’s malignancy. 
 
8.1 
Treatment Plan Overview 
 
Figure 6.1 Outline (Schema) of the [18F]FES Study Protocol. a) FDG PET is not required for primary breast cancer patients unless 
required for localization or requested by treating physician. b) Where available and medically appropriate, a clinical or research 
biopsy that involved sampling of a relevant lesion within 6 months prior to the enrollment may be utilized in place of the baseline 
optional biopsy. c) Repeat FDG PET may be omitted in patients on SERD therapies. 
 
Initial visits prior to [18F]FES PET: Patients who are identified as potential candidates for the [18F]FES PET study will be 
approached to explain the nature of the study and to obtain their written informed consent to be enrolled in the protocol. Heart 
rate and blood pressure will be recorded at the time of clinic visit where study is considered or at the time of consent. The 
patient will have a clinical FDG PET/CT scan if a recent FDG scan has not already been obtained. The FDG PET/CT scan should be 
obtained close to the time of FES PET/CT, typically within 14 days of the [18F]FES PET/CT scan. An additional FDG PET/CT scan 
may be done as a research scan if the patient has undergone a recent PET scan at an outside institution or if they are unable to 
obtain a clinical PET scan as part of their clinical care. The research FDG PET/CT scan in this instance will be identical in procedure 
to a clinical FDG scan. The following additional patient data will be obtained: histological diagnosis, age at radiologic diagnosis, 
weight, gender, ECOG score and other treatment modalities used. Correlative radiology including CT, MRI, or bone scan, and 
laboratory tests measuring renal, blood and liver function will also be collected, for values within 30 days of the FES PET/CT scan. 
For patients referred from outside the UW health system, patient records, and biopsy material and imaging as necessary, will be 
reviewed to determine eligibility for the study. Patients without a clinical evaluation in the last 30 days are unexpected; in these 
instances a clinical evaluation will be completed. 
 
Day of [18F]FES PET/CT Scan: After the FES injection and rest period (section 6.6.1), the patient will be positioned supine in the 
PET/CT scanner. A low dose CT scan (60 mA) will provide attenuation correction data using non-contrast CT. The PET image 
acquisition sequence will be the same as that used for clinical FDG scans. This consists of a torso survey series of five-minute 
images acquired over 15 cm survey fields of view (FOVs) extending from the base of the skull to the mid thigh (5 to 7 FOVs in 
total). The images will be corrected for radioactive decay of the tracer and normalized to the injected dose and body weight. This 
results in regional standardized uptake values (SUVs) whole-body image sets.  
 
Prior to injection, a whole blood sample may be taken for determination of albumin, estradiol and testosterone levels, heart rate 
and blood pressure will be recorded. A known quantity of nonradioactive FES will be added to plasma (from blood collected prior 
to injection) to determine binding to sex steroid binding protein (SBP). For patients in whom a second venous access line is 
feasible and has been placed, venous blood samples may be collected at 5, 20 and 60 minutes after injection of the [18F]FES for 
metabolite analysis in selected patients. Heart rate and blood pressure will be measured after the FES injection.  
 
After the [18F]FES PET Scan: A follow up phone call will be made by study staff within 24 hours after the FES PET scan to ask 
about any signs of adverse effects. Patients will typically start the selected hormone targeted therapy within 30 days of the FES 
PET scan. Patients who have started aromatase inhibitors prior to [18F]FES PET will be permitted to enter the study, if an 
additional endocrine targeted treatment is planned. 
 
In patients who consent to optional biopsies, a baseline tumor sample will be obtained after completion of the baseline PET 
imaging but prior to starting the selected endocrine targeted therapy. Where available and medically appropriate, a clinical or 
research biopsy that involved sampling of a relevant lesion within 6 months prior to the enrollment may be utilized in place of 
the baseline optional biopsy.  

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 17 of 31                                                                    Version: 01/15/2016 
 
 
In some patients undergoing biopsies, a whole blood sample will be collected prior to starting the therapy, to allow correlation of 
steroid hormone levels in serum and biopsy tissue. 
 
Repeat FES PET scan and FDG PET scan: Patients will undergo a second FES PET and FDG PET scan after starting endocrine 
targeted therapy to assess the effect of therapy on ER expression and estradiol binding to the receptor. Exact timing of the 
second FES and FDG scans, will depend upon the endocrine targeted regimen and dosing, but typically will be 1 – 12 weeks after 
starting therapy. 
 
The repeat FDG PET may be omitted in patients on SERD therapies, where repeat FES PET is used primarily to evaluate residual 
ER availability rather than tumor response. This will be determined by requirements of the co-enrolling companion therapeutic 
protocol. 
 
Optional Biopsy: In patients who consent to optional biopsies, an early response tumor sample will be obtained 1-12 weeks after 
starting the selected therapy. This biopsy should take place after completion of the repeat PET imaging and should target the 
same tumor site as the baseline biopsy. A whole blood sample may be drawn for correlation of steroid hormone levels in serum 
and biopsy tissue.  
 
Week 1 to 20 years after [18F]FES PET Scan: Clinical follow-up will continue for up to 20 years, time of progression and date of 
death will be recorded. For some patients, especially those receiving two endocrine-directed treatments, a third FES PET scan 
and additional research FDG PET scan may also be obtained 1-12 weeks after the second FES PET scan. For each patient, a 
maximum of 3 FES PET and 3 FDG PET scans would be done.  
 
A study calendar is included in Appendix A. 
 
8.1 
Administration of IP (FES PET) 
FES will be administered in the PET imaging suite at the University of Washington Medical Center or at the Seattle Cancer Care 
Alliance (SCCA). The [18F]FES for injection will be prepared as described in section 6.6.2, Study Procedures and Schedule of 
Events. Upon arrival, the patient will have an opportunity to have questions answered regarding the procedure. The patient will 
have an intravenous line placed prior to [18F]FES administration. A dose of nominally 220 MBq (6 mCi with a range of 110 to 220 
MBq = 3 to 6 mCi) of [18F]FES will be administered intravenously by a physician. The injection will be infused over approximately 
2 minutes and followed by a saline flush. The infusion and imaging procedure will be terminated in any patient who exhibits 
anaphylaxis, physical signs of significant hypotension, significant dyspnea or chest pain. We do not expect to observe any of 
these effects as no events have been reported in more than 300 scans performed with this compound at our institution to this 
date. The patient will then be allowed to rest comfortably in a prep room prior to being positioned in the PET scanner to 
commence the image acquisition at 60 +/- 10 minutes post FES injection. 
 
 
 
 
Heart rate and blood pressure will be recorded pre- and post-FES dosing, and will continue to be monitored after injection until 
baseline is achieved.  
  
Patients will be monitored for adverse events, potentially related to the administration of [18F]FES, from the time of the initial 
injection to 10 hours post injection. Any adverse events will be recorded and reported according to FDA requirements (see 
section 13.0, Adverse Events). 
 
8.2 
Administration of FDG PET 
In most cases, a standard clinical diagnostic FDG PET or PET/CT scan will be obtained prior to the [18F]FES PET scan. The FDG PET 
or PET/CT scan serves to help identify active sites of breast cancer and is used to help determine sites on the FES PET scan where 
estradiol binding would be expected. At least one site of measurable disease outside of the liver, where quantification of FES 
uptake can be difficult because of normal biodistribution, must be evident on the FDG PET scan and CT or MRI. FDG PET imaging 
will be completed close to the time of the FES PET scan. In select cases where the baseline FDG PET is being repeated at our 
institution for the purposes of this study it may be completed after the FES PET. The FDG PET will be a clinical 5 axial field-of-view 
(AFOV) scan from skull base to mid-thigh. Maximum SUV of identified lesions will be calculated and recorded as per standard 
clinical procedure. 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 18 of 31                                                                    Version: 01/15/2016 
 
For FDG PET or PET/CT, all patients will fast for at least 4 hours before PET scanning. All patients must have a medical history 
negative for diabetes and/or a pre-scan serum glucose level less than 200 mg/dL. A dose of 260-370 MBq (7-10 mCi) of FDG will 
be injected into a peripheral intravenous or central venous catheter. Patients will rest comfortably in a supine position prior to 
scanning. Imaging will be performed with a commercially made PET/CT scanner operating in the high sensitivity mode. Imaging 
will consist of a torso survey covering five adjacent 15-cm axial fields of view (FOVs). For the PET/CT device, a low dose CT scan 
beginning at approximately 60 minutes after FDG injection provides attenuation data for attenuation correction using a non-
contrast CT. Emission data will be collected for all five axial FOVs, typically five minutes per FOV.  
 
Emission data will be reconstructed according to standard protocols. Images will be corrected for radioactive decay of the tracer 
and normalized to the injected dose and body weight, which results in regional standardized uptake values (SUVs): as defined in 
section 6.10.3.  
 
We emphasize that the baseline FDG PET or PET/CT is part of standard clinical care of metastatic and recurrent breast cancer and 
will be performed as part of routine clinical care in the vast majority of patients participating in the study. Methodology for FDG 
PET is included in this section for reference purposes. In some cases, FDG PET or PET/CT will have already been performed at an 
outside center at the time of enrollment. On rare occasions when patients have been referred to the study with a recent FDG PET 
scan already completed at an outside site that is unavailable or of insufficient detail for our study, or the patient is unable to 
obtain a PET scan as part of standard clinical management, we will repeat the FDG PET at the University of Washington as a 
research scan, however, the imaging procedure will not vary from that of a standard clinical scan. 
 
Patients will undergo a second (and potentially a third in a subset of patients) FDG PET following the same imaging procedure as 
part of the research study. This second scan will be performed at a time point stipulated by the treatment regimen and may vary 
from 1 to 12 weeks post therapy start. 
 
8.3 
Concomitant Medication and Supportive Care Guidelines 
Because interaction of < 5 µg of [18F]FES with other concomitantly administered drugs through the cytochrome P450 system or 
other pathways is extremely unlikely, this section is not applicable. The infusion and imaging procedure will be terminated in any 
patient who exhibits adverse reactions as described in section 4. 
 
8.4 
Duration of Therapy 
As this is an observational study, the results of [18F]FES PETs and repeat FDG PETs are not used to direct therapy, and the 
duration of therapy is determined on the basis of clinical grounds by the referring physician, and is not influenced by the FES 
study. 
8.5 
Duration of Follow-Up 
Patients will be followed up to 20 years after [18F]FES PET. Patients removed from study for unacceptable adverse events will be 
followed until resolution or stabilization of the adverse event. 
 
8.6 
Dosing Delays/Dose Modifications 
As this is a trial of a diagnostic imaging agent to be administered before endocrine therapy, dosing delays and dose modifications 
are not relevant to this protocol. FES administration will be stopped if there are any signs of toxcicity. 
8.7 
End of Treatment (EOT) Visit Schedule and Procedures 
EOT visits will not be used on this trial. 
9.0 
SUBJECT EVALUATION 
 
9.1 
On-Study Clinical Evaluations 
To establish a baseline, this study plans to pull data from recent clinic visits for patients matching the eligibility criteria, if the 
visits occurred within the last 30 days. If one is not available, clinical evaluations will take place proceeding both the first and 
second FES scans (and the third, if applicable). These visits should occur as close to the FES scan as possible but must be within 
30 days (+/-) of the FES scan. The following tests and procedures would be completed, although not all tests may be done at each 
visit;  
 
Physical Examination 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 19 of 31                                                                    Version: 01/15/2016 
 
 
Vitals 
 
Labs: 
o 
Hematology: CBC, differential, platelets 
o 
Serum Chemistries: including calcium, magnesium, SGOT, SGPT, alkaline phosphatase, LDH, total bilirubin, BUN, 
creatinine, electrolytes, and glucose 
 
Prior to FES administration, the following are completed: 
 
A whole blood sample may be taken (10mL) (optional) 
o 
A known quantity of nonradioactive FES will be added to plasma (from blood collected prior to injection) to 
determine binding to sex steroid binding protein (SBP). 
 
Heart rate and blood pressure 
Following FES Administration, the following are completed: 
 
For patients able to have a second venous access, venous blood samples may be collected at 5, 20, and 60 minutes after 
collection. 
 
Heart rate and blood pressure 
 
10.0 TOXICITY MONITORING 
Both acute and chronic toxicities are recorded and reported to the Sponsor, or its designee, and will be reviewed by the 
independent DMC at scheduled meetings. Monitoring for acute toxicity takes place during and immediately following IP 
administration for a period of 2 hours at the study site. Subjects are observed for the development of an immediate localized 
allergic reaction or anaphylactic reaction during this time. Chronic toxicity is evaluated describe here. Describe acceptable or 
unacceptable toxicity treatments here. 
 
11.0 SUBJECT DISCONTINUATION OF ACTIVE TREATMENT 
Subjects may be removed from this study at any time at their discretion. Subjects may also be removed from this protocol if they 
develop any untoward side effects from the imaging product. 
If a subject withdraws consent to participate in the study or aspects of the study, attempts should be made to obtain permission 
to record survival data up to the protocol-described end of the subject follow-up period. Survival data are important to the 
integrity of the final study analysis. Documentation in the medical record should state that the subject is withdrawing from the 
study and what, if any, selected data the subject will permit the investigator to obtain. 
 
An explanation for discontinuing treatment is recorded for each subject discontinuing treatment in the study source. The Sponsor 
must be notified immediately if a subject discontinues treatment. All subjects, irrespective of treatment status, will continue to 
be followed for survival. Treatment in this study must be discontinued for any of the following reasons: 
 
if the Sponsor decides to stop the study; 
 
at Investigator’s discretion; 
 
at the subject’s request; 
 
if the subject enrolls in a trial of another investigational agent; 
 
Any adverse event possibly related to the IP, excluding mild pain, bruising, or controllable bleeding at the injection site 
 
pregnancy 
12.0 CONCOMITANT MEDICATIONS 
Because interaction of < 5 µg of [18F]FES with other concomitantly administered drugs through the cytochrome P450 system or 
other pathways is extremely unlikely, this section is not applicable. 
 
The infusion and imaging procedure will be terminated in any patient who exhibits adverse reactions as described in section 4. 
 
13.0 ADVERSE EVENTS 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 20 of 31                                                                    Version: 01/15/2016 
 
13.1 
Adverse Event  
According to ICH guidelines (Federal Register. 1997; 62(90):25691-25709) and 21 CFR 312.32, IND Safety Reports, and ICH E2A, 
Definitions and Standards for Expedited Reporting, an adverse event is defined as follows: 
 
An adverse event is any untoward medical occurrence in a clinical investigation subject administered a medicinal product and 
which does not necessarily have a causal relationship with this treatment. An AE can therefore be any unfavorable and 
unintended sign (including an abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal product, whether or not considered related to the medicinal product. 
 
Abnormal laboratory values for laboratory parameters specified in the study should not be recorded as an adverse event unless 
an intervention is required (repeat testing to confirm the abnormality is not considered intervention), the laboratory abnormality 
results in a serious adverse event or the adverse event results in study termination or interruption/discontinuation of study 
treatment. 
 
Medical conditions present at screening (i.e., before the study treatment is administered) are not adverse events and should not 
be recorded on adverse event pages of the CRFs.  These medical conditions should be adequately documented on the subject 
chart.  However, medical conditions present at baseline that worsen in intensity or frequency during the treatment or post-
treatment periods should be reported and recorded as adverse events. 
  
13.2 
Serious Adverse Event  
An adverse event should be classified as an SAE if it meets one of the following criteria: 
 
Table 13.1: SAE Criteria 
Fatal 
Adverse event results in death. 
Life threatening:  
The adverse events placed the subject at immediate risk of death. This classification 
did not apply to an adverse event that hypothetically might cause death if it were 
more severe.  
Hospitalization:  
It required or prolonged inpatient hospitalization. Hospitalizations for elective 
medical or surgical procedures or treatments planned before enrollment in the 
treatment plan or routine check-ups are not SAEs by this criterion. Admission to a 
palliative unit or hospice care facility is not considered to be a hospitalization.  
Disabling/incapacitating  
Resulted in a substantial and permanent disruption of the subject’s ability to carry 
out normal life functions.  
Congenital anomaly or birth 
defect:  
An adverse outcome in a child or fetus of a subject exposed to the molecule or 
treatment plan regimen before conception or during pregnancy.  
Medically significant:  
The adverse event did not meet any of the above criteria, but could have 
jeopardized the subject and might have required medical or surgical intervention to 
prevent one of the outcomes listed above.  
 
13.3 
Unexpected Adverse Event 
An unexpected adverse event is defined as an event that has a nature or severity, or frequency that is not consistent with the 
applicable investigator brochure, or the prior medical condition of the subject or other treatment given to the subject.  
“Unexpected,” as used in this definition, refers to an adverse drug experience that has not been previously observed and 
reported in preclinical or clinical studies rather than an experience that has not been anticipated based on the pharmacological 
properties of the study drug. 
 
13.4 
Monitoring and Recording Adverse Events 
All AEs will be assessed by the investigator or qualified designee and recorded in the source documentation. The investigator 
should attempt to establish a diagnosis of the event on the basis of signs, symptoms and/or other clinical information. In such 
cases, the diagnosis should be documented as the adverse event and/or serious adverse event and not described as the 
individual signs or symptoms. The following information should be recorded: 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 21 of 31                                                                    Version: 01/15/2016 
 
 
Description of the adverse event using concise medical terminology 
 
Description as to whether or not the adverse event is serious, noting all criteria that apply  
 
The start date (date of adverse event onset) 
 
The stop date (date of adverse event resolution) 
 
The severity (grade) of the adverse event  
 
A description of the potential relatedness of the adverse event to study drug, a study procedure, or other causality  
 
The action taken due to the adverse event 
 
The outcome of the adverse event 
 
Because adverse events are not expected for this IP, and have not been seen in our experience with FES, patients with AEs 
possibly related to the IP will be discontinued. The principal investigator will exercise their discretion in determining the 
attribution of AEs. 
 
Patients who discontinue the study will be asked if follow-up via telephone is acceptable. If they agree to receive communication 
from us, we will follow-up with them 30 days following administration of the IP. If any unexpected risks are discovered which 
may affect patients more than 30 days following administration, all previous participants will be informed.  
 
13.5 
Grading Adverse Event Severity 
All AEs will be graded in severity according to the NCI Common Terminology Criteria for Adverse Events (CTCAE) Version 4.0. If a 
CTCAE criterion does not exist, the investigator should use the grade or adjectives: Grade 1 (mild), Grade 2 (moderate), Grade 3 
(severe), Grade 4 (life-threatening), or Grade 5 (fatal) to describe the maximum intensity of the adverse event.  
 
13.6 
Attribution of an Adverse Event 
Association or relatedness to the study agent will be assessed by the investigator as follows: 
 
Definite: The event follows a reasonable temporal sequence from exposure to the investigational agent, has been 
previously described in association with the investigational agent, and cannot reasonably be attributed to other factors 
such as the subject’s clinical state, other therapeutic interventions or concomitant medications; AND the event 
disappears or improves with withdrawal of the investigational agent and/or re-appears on re-exposure (e.g., in the event 
of an infusion reaction). 
 
Probable: The event follows a reasonable temporal sequence from exposure to the investigational agent and has been 
previously been described in association with the investigational agent OR cannot reasonably be attributed to other 
factors such as the subject’s clinical state, other therapeutic interventions or concomitant medications. 
 
Possible: The event follows a reasonable temporal sequence from exposure to the investigational agent, but could be 
attributable to other factors such as the subject’s clinical state, other therapeutic interventions or concomitant 
medications. 
 
Unlikely: Toxicity is doubtfully related to the investigational agent(s).  The event may be attributable to other factors 
such as the subject’s clinical state, other therapeutic interventions or concomitant medications. 
 
Unrelated: The event is clearly related to other factors such as the subject’s clinical state, other therapeutic interventions 
or concomitant medications. 
 
For general AE assessment, an AE is considered related if it is assessed as definitely, probably, or possibly related; unrelated if it is 
assessed as unlikely related or unrelated.  
 
13.7 
Adverse Event Recording Period 
AEs will be monitored and recorded in study-specific case report forms (CRFs) from the time of first exposure to an 
investigational product in this study. Patients will be contacted 24 hours following IP administration to evaluate for signs of AEs. 
AEs with an onset date prior to the first exposure to an investigational product will not be recorded, except in the case of 
clinically significant worsening of the AE during the specified AE monitoring time frame.  
 
13.8 
Adverse Event Reporting Requirements  
Expedited AE reporting for this study will be completed with the FDA and as required by FDA MedWatch, and the IND 
sponsor. These requirements are briefly outlined in the table below. 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 22 of 31                                                                    Version: 01/15/2016 
 
All life-threatening adverse reactions reports are submitted to the  sponsor, and to all participating investigators. The 
sponsor will report all attributable, unexpected life-threatening or otherwise serious AEs to the FDA. A copy of the report is 
kept on file. If a new risk is identified to be attributable to FES, it will also be reported to the IRB as a protocol and consent 
change within 10 days. 
 
Table 13.2  Reporting Requirements 
 
Unexpected 
Expected 
 
Adverse Reaction 
(known or suspected attributable to 
the use of [18F]FES)
AE not 
attributable to 
[18F]FES
AE, AR 
 
Serious including 
life-threatening (or 
death) 
Nonserious 
Life-Threatening or 
serious or not 
serious 
Not 
applicable to 
[18F]FES 
Reporting 
Time 
Requirement 
to the FDA
Sponsor report to 
FDA ASAP and 
within 7 days of 
discovery of event 
Annual 
Continuation 
Review 
submission 
Annual Continuation 
Review submission 
Not 
applicable to 
[18F]FES 
Reporting 
Form for the 
FDA
IND Safety report of 
potentially serious 
risk  
Annual Reports / 
Case reports  
Annual Reports / 
Case reports 
Not 
applicable to 
[18F]FES 
Reporting 
Time 
Requirement 
to the local 
IRB 
Report to IRB 
ASAP within 10 
days of discovery 
of event (suspected 
is defined as 50% 
probability 
attributable to 
[18F]FES study) this 
also includes any 
increased risks with 
the study even 
without an AE 
At continuation 
review time 
At continuation 
review time 
Not 
applicable to 
[18F]FES 
Reporing 
form for the 
IRB 
Expedited Reporting 
Form for 
Unanticipated 
Problems or 
Noncompliance and 
Adverse Event 
Reporting Form 
Form for 
Unanticipated 
Problems or 
Noncompliance, 
Case reports on 
continuation 
form, Data Saety 
Monoring 
Reports 
Form for 
Unanticipated 
Problems or 
Noncompliance, 
Case reports on 
continuation form, 
Data Safety 
Monitoring Reports 
Not 
applicable 
to [18F]FES 
 
14.0 CRITERIA FOR ENDPOINT EVALUATIONS 
For the purposes of this study, the outcome measured will be the change in FES and FDG PET measures between the serial sets of 
scans. Response evaluations will not be evaluated as part of this study, though the information may be recorded if it is collected 
for treatment studies the patient may be participating. Patients may also be followed for up to 20 years for disease progression 
and overall survival. 
 
The FES PET scan will be assessed with: 
 
 
Qualitative FES uptake:  all known disease sites positive vs. heterogeneous or absent FES uptake. 
 
Quantitative FES uptake:  SUVs in all lesions measured at baseline and repeat scan (and at third scan if indicated)  
 
Quantitative change in FES uptake:  percentage and SUV unit change in SUV between baseline and repeat FES PET scan 
 
Qualitative Visual Assessment 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 23 of 31                                                                    Version: 01/15/2016 
 
 
Qualitative (visual) assessment of level of uptake in sites of recurrent breast cancer is performed for all studies. In this analysis, 
trained observers determine whether FES uptake is present above background at sites of breast cancer. Active disease sites are 
identified by the FDG PET scan performed close to the time of FES PET, in conjunction with conventional imaging such as CT, MRI, 
and bone scan. Active sites of disease are defined as sites with (1) abnormal uptake on FDG PET and (2) either biopsy 
confirmation or unequivocal correlative findings on at least one other modality. For each site of active disease, two trained 
observers blinded to the clinical data, but with any available FDG PET and correlative imaging, will determine whether FES above 
background levels is present or absent. Differences between observers will be resolved by consensus. 
 
Quantitative Assessment 
 
FES static survey images will undergo region of interest (ROI) analysis as follows: Lesion location will be identified using FES scans 
along with FDG scans with reference to CT or ultrasound. All patients will have undergone clinically motivated FDG PET scans for 
staging prior to FES imaging. CT, MRI, ultrasound or bone scan will be available on all patients with suspected metastatic disease. 
Although FES and FDG imaging will be performed on separate days, studies will be performed with the patient in the same 
position and images will be co-registered using common anatomic landmarks such as the lung outline, cardiac blood pool, liver 
contour, and body outline. In this way, regions can be drawn on the FDG images and transferred to the FES images for 
quantitative analysis which is important in identifying tumor locations, especially in ER-negative tumors which are not visualized 
on FES imaging. For each disease site, a set of 1.5 cm diameter regions on three adjacent planes with the highest lesion FES 
uptake will be drawn to determine maximal FES uptake. Up to the 10 largest sites seen on the static torso survey will be 
quantified. Partial-volume correction will not be used because only sites 1.5 cm or greater diameter will be included in 
quantitative analysis.  
 
FES uptake will be quantified using the standard uptake value (SUV, defined below). For each site, we will record the average and 
maximum SUV within the ROI set for each site of disease.  
 
For each subject, we will calculate the average and range of FES uptake values for active disease sites. The FES uptake will be 
compared with subsequent response to endocrine therapy and TTP. 
 
FDG studies will also be quantified for uptake in a similar fashion. On FDG studies, simple SUVs will be generated using the 
average tissue activity over the imaging period, which are typically 45 and 75 minutes after injection. We will record the 
maximum FDG SUV for each site of disease. Uptake at tumor sites using the standardized uptake value (SUV) is calculated as:  
 
SUV =
Ct
ID / wt
 
 
 
  
where Ct is the average tumor uptake after injection for the period of the static imaging for torso surveys (MBq/mL), ID is the 
injected dose (GBq) and wt is the patient’s weight (kg). Note that either standard or metric units can be used to calculate SUV as 
long as only one type of unit is used for each calculation.  
 
Biologic Correlates 
 
Optional blood sample may be collected at the time of the FES PET scan procedure for determination of serum hormone levels 
(estradiol, estrone, follicle-stimulating hormone, sex hormone binding globulin, testosterone, free testosterone) and liquid 
biopsy. 
  
Patients participating in this study will have undergone clinical biopsy of the primary tumor and/or metastasis for which ER, PgR, 
and HER2 expression will be determined by IHC. Clinical records of these assays will be reviewed, and the assays themselves may 
be reviewed as needed. 
 
On patients for whom archival biopsy material can be obtained, additional assays may be performed, and may include repeat and 
standardized ER, PR, and HER2 assays.  
 
Patients with metastatic or recurrent disease may consent to optional research biopsies of the tumor performed at the baseline, 
i.e. prior to start of the selected endocrine targeted therapy, and after 1-12 weeks on therapy. Obtained tissues will be analyzed 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 24 of 31                                                                    Version: 01/15/2016 
 
for a baseline expression and post-therapy changes in protein and genomic expression including ER, PgR, and HER2, using IHC 
methods and PI3K and ESR1 using Oncoplex. Some samples will be assayed for intra-tumor steroid hormone levels (estradiol, 
estrone, testosterone, dihydrotestosterone) using IHC and/or mass spectrometry techniques.  
 
In some patients undergoing biopsy, a whole blood sample will be drawn during the same time point to allow correlation of 
steroid hormone levels in serum with levels in biopsy tissue.  
 
Assays for ER and PgR will be read using the Allred scoring system, which provides a semi-quantitative and qualitative assessment 
of tumor expression levels (Harvey, 1999). IHC is the primary assay methodology for HER2. Scoring of HER2 is done by assessing 
intensity of the membranous stain (0, 1+, 2+, 3+). Scores of 0 and 1+ are considered negative and score of 3+ is considered 
positive. Score of 2+ is considered indeterminate and will be validated by fluorescence in situ hybridization (FISH) (HER-2 DNA 
probe kit; Abbott Molecular Inc., Des Plaines, IL)(Yaziji, 2004). Analysis of HER2 will be done using information from the IHC 
assays and the FISH confirmation when required.  
  
Measurement of these tumor-associated indices may enhance the predictive value of PET FES, provide information to better 
understand mechanisms of resistance to endocrine therapy, and eventually determine which patients are likely to appreciate 
clinical benefit as a result of endocrine therapy, even in the absence of an objective response. 
 
 
Time to progression (Progression-free survival): Time to progression (and progression-free survival) will be measured as the 
time from the start of endocrine therapy to the time the patient is first recorded as having disease progression. If a patient never 
progresses while being followed, the patient will be censored at the time he/she terminates follow-up or by date of disease 
progression or death. 
 
15.0 DATA AND SAFETY MONITORING PLAN 
 
Institutional support of trial monitoring will be in accordance with the FHCRC/University of Washington Cancer Consortium 
Institutional Data and Safety Monitoring Plan.  Under the provisions of this plan, FHCRC Clinical Research Support (CRS) 
coordinates data and compliance monitoring conducted by consultants, contract research organizations, or FHCRC employees 
unaffiliated with the conduct of the study.  Independent monitoring visits occur at specified intervals determined by the assessed 
risk level of the study and the findings of previous visits per the institutional DSMP.  
 
In addition, protocols are reviewed at least annually and as needed by the Consortium Data and Safety Monitoring Committee 
(DSMC), FHCRC Scientific Review Committee (SRC) and the FHCRC/University of Washington Cancer Consortium Institutional 
Review Board (IRB).  The review committees evaluate accrual, adverse events, stopping rules, and adherence to the applicable 
data and safety monitoring plan for studies actively enrolling or treating subjects.  The IRB reviews the study progress and safety 
information to assess continued acceptability of the risk-benefit ratio for human subjects.  Approval of committees as applicable 
is necessary to continue the study. 
 
The trial will comply with the standard guidelines set forth by these regulatory committees and other institutional, state and 
federal guidelines. 
 
16.0 DATA MANAGEMENT/CONFIDENTIALITY 
 
Source data will include all signs collected during this research. This includes: 
 
 
All imaging data, including scan images 
 
Vitals and physical exams collected at clinic visits 
 
Labs: 
o 
Hematology: CBC, differential, platelets 
o 
Serum Chemistries: including calcium, magnesium, SGOT, SGPT, alkaline phosphatase, LDH, total bilirubin, BUN, 
creatinine, electrolytes, and glucose 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 25 of 31                                                                    Version: 01/15/2016 
 
The imaging will be stored on an encrypted hard drive and treated as source. Only the appropriately delegated staff will be given 
the password to access this data. 
 
The investigator will ensure that data collected conform to all established guidelines. Each subject is assigned a unique subject 
number to protect subject confidentiality. Subjects will not be referred to by this number, by name, or by any other individual 
identifier in any publication or external presentation. The licensed medical records department, affiliated with the institution 
where the subject receives medical care, maintains all original inpatient and outpatient chart documents. 
 
17.0 STATISTICAL CONSIDERATIONS 
 
 
Analysis Plan 
 
The primary application will be pilot studies with enrollment of about 20 patients, in which the in vivo effects of endocrine-
targeted therapy are measured by serial FES PET. The primary endpoints will be quantitative and qualitative measures of FES 
uptake, and measures of change in FES uptake between pre-therapy and post-therapy scans (Section 6.10.2). Additionally, 
patients will be followed for disease progression. Associations among FES and FDG PET measures, progression, and biological 
correlates (Section 6.10.3) may be examined in descriptive analyses. 
 
An expected primary analysis is to examine whether FES uptake changed on average between serial assessments. This may be 
assessed by a one-sample test of the percent change in FES SUV. For example, a one-sided test at the 0.05 level of significance 
could evaluate whether the average percent change in FES SUV was greater than 20%, considered a biologically significant 
change. In serial FES SUV measurements of heavily-pretreated breast cancer patients, change in FES SUV was approximately 
normally distributed with a standard deviation of about 25 percentage points, for both patients treated with blocking therapy 
(tamoxifen or fulvestrant) or non-blocking therapy (aromatase inhibitor). Using this standard deviation and n=20 to test whether 
the average change was greater than 20%, the power would be 0.97 if the true change is 40%, and 0.85 if the true change is 35%. 
To conclude only that the average percentage change was different from zero (using a two-sided test at the 0.05 level of 
significance), power would be 0.95 to detect a true average change of 20% (and 0.85 if the true standard deviation were 30 
percentage points). 
 
Other analyses for pilot studies could examine what proportion of patients experienced a threshold in percentage change, or 
surpassed a targeted follow-up FES SUV value. These percentages will be reported using a 90% Wilson score binomial confidence 
interval. Width of these confidence intervals for pilot studies of n=20, n=25, and n=30 are given in Table 6.3 for a range of 
observed percentages. 
 
Table 17.1:  90% Wilson score binomial confidence intervals (CIs) by percent observed and sample size. 
 
observed 
percentage (CI) for 
n=20 
observed 
percentage (CI) 
for n=25 
observed 
percentage (CI) for 
n=30 
0.1 (0.03, 0.26) 
0.12 (0.05, 0.27) 
0.1 (0.04, 0.23) 
0.2 (0.09, 0.38) 
0.20 (0.10, 0.36) 
0.2 (0.11, 0.34) 
0.3 (0.16, 0.48) 
0.32 (0.19, 0.48) 
0.3 (0.18, 0.45) 
0.4 (0.24, 0.58) 
0.40 (0.26, 0.56) 
0.4 (0.27, 0.55) 
0.5 (0.33, 0.67) 
0.48 (0.33, 0.64) 
0.5 (0.36, 0.64) 
 
 
Breast cancer is a disease of adults with low frequency of incidence in males. We have not excluded males from participation in 
our studies and will continue this policy but anticipate that none will enroll due to the rarity of presentation. 
 
 
Table 6.4.  Planned Enrollment.  
Ethnic Category 
 
 
Sex/Gender 
 
Females 
Males 
Total 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 26 of 31                                                                    Version: 01/15/2016 
 
Hispanic or Latino 
3 
0 
3 
Not Hispanic or Latino 
17 
0 
17 
Ethnic Category Total of All Subjects 
20 
0 
20 
 
Racial Categories 
American Indian/Alaska Native 
0 
0 
0 
Asian 
3 
0 
3 
Native Hawaiian or Other Pacific Islander 
0 
0 
0 
Black or African American 
1 
0 
1 
White 
16 
0 
16 
Racial Categories: Total of All Subjects  
20 
0 
20 
 
Males will not be excluded; however, breast cancer is rare in males. 
 
Patients will be recruited from participants in other studies requiring [18F]FES PET. Over the course of this study, more studies will 
be added requiring [18F]FES PET, possibly increasing the enrollment target. The IRB will be made aware of changes to enrollment 
targets. 
 
18.0 INVESTIGATOR OBLIGATIONS 
The PI is responsible for the conduct of the clinical trial at the site and is responsible for personally overseeing the treatment of 
all study subjects. The PI must assure that all study site personnel, including sub-Investigators and other study staff members, 
adhere to the study protocol and to all applicable regulations and guidelines regarding clinical trials both during and after study 
completion. 
 
All subjects are informed of the nature of the program, its possible hazards, and their right to withdraw at any time, and each 
subject signs a form indicating their consent to participate prior to receiving any study-related procedures (see Appendices XXX). 
 
19.0 ADMINISTRATIVE AND REGULATORY CONSIDERATIONS 
 
19.1 
Pre-Study Documentation 
The following documentation required by the FDA must be received by the Sponsor, or its designee, prior to initiation of the trial: 
FDA Form 1572; curricula vitae of the PI and all Sub-Investigators; signed Protocol Agreement; copy of the correspondence from 
the IRB indicating approval of the protocol and Informed Consent Forms, signed by the IRB chairperson or designee; an IRB 
membership list containing the names and occupations of the IRB members; copy of the Informed Consent Forms that were 
reviewed and approved by the IRB. 
 
19.2 
Study Site Training 
Before initiation of the study, the Sponsor, or its designated representatives will review and discuss the following items with the 
Investigator and clinic staff: the protocol, study procedures, record keeping and administrative requirements, drug 
accountability, AE reporting, Good Clinical Practice guidelines, CRF/eCRF completion guidelines, monitoring requirements, and 
the ability of the site to satisfactorily complete the protocol. Additional documents with instructions for study compliance and 
CRF/eCRF completion will be provided. 
 
19.3 
Documentation 
The documentation of clinical data must be stored by the Sponsor according to legal requirements. The PI and study staff has 
responsibility for maintaining a comprehensive and centralized filing system containing all study-related documentation. These 
files must be suitable for inspection by the Sponsor, the FDA, and/or other applicable regulatory agencies/competent authorities 
at any time, and should consist of the following elements: subject files (complete medical records, laboratory data, supporting 
source documentation, and the Informed Consent); study files (the protocol with all amendments, copies of all pre-study 
documentation, and all correspondence between the Competent Authorities, IRB, site, and Sponsor); and drug accountability 
files, containing a complete account of the receipt and disposition of the study drug. 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 27 of 31                                                                    Version: 01/15/2016 
 
19.4 
Access to Source Data 
The PI will permit the Sponsor's representatives to monitor the study as frequently as the Sponsor deems necessary to determine 
that protocol adherence and data recording are satisfactory. The CRF/eCRF and related source documents will be reviewed in 
detail by the Sponsor’s representative at each site visit. Only original source documents are acceptable for review. This review 
includes inspection of data acquired as a requirement for participation in this study and other medical records as required to 
confirm information contained in the CRF/eCRF, such as past history, secondary diagnoses, and concomitant medications. Other 
study records, such as correspondence with the Sponsor and the Competent Authorities, and IRB and screening and drug 
accountability logs will also be inspected. All source data and study records must also be available for inspection by 
representatives of the FDA or other regulatory agencies. 
 
19.5 
Data Collection 
Describe how data will be collected. 
Electronic case report forms must be completed and submitted for each subject enrolled in the study. Any changes or corrections 
made to the CRF/eCRF must be subsequently reviewed and signed by the PI. All data fields in the CRF/eCRF must be completed 
to avoid queries. 
 
19.6 
Protocol Interpretation and Compliance 
The procedures defined in the protocol are carefully reviewed by the PI and his/her staff prior to the time of study initiation to 
ensure accurate representation and implementation. Protocol amendments, if any, are reviewed and implemented promptly 
following IRB and relevant Competent Authorities approval. The Sponsor is responsible for submitting protocol amendments to 
the FDA as described in 21 CFR § 312.30 (Protocol Amendments) and other regulatory agencies according to national, state or 
local requirements. The Sponsor, or its designee, is always available to answer protocol- or subject-related questions. 
 
19.7 
Study Monitoring and Data Collection 
A representative from the Sponsor will visit the study center periodically to monitor adherence to the protocol, applicable FDA 
regulations and/or other regulatory agencies national, state or local requirements, and the maintenance of adequate and 
accurate clinical records. Electronic case report forms are reviewed to ensure that key safety and efficacy data are collected and 
recorded as specified by the protocol. The Sponsor or its designee is permitted to access subject medical records, laboratory data 
and other source documentation as needed to appropriately monitor the trial. 
 
19.8 
Disclosure of Data/Publication 
Individual subject medical information obtained as a result of this study is considered confidential and disclosure to third parties 
other than those noted below is prohibited. Such medical information may be given to the subject’s personal physician or to 
other appropriate medical personnel responsible for the subject’s welfare. Data generated as a result of this study are to be 
available for inspection on request by the FDA or other regulatory agencies, the Sponsor or its designee and by the IRB. 
It is anticipated that the final results of this study will be submitted to a peer-reviewed scientific journal. Authorship on such a 
paper will be acknowledged with customary scientific practice. As such, without the expressed permission of the Sponsor, only 
clinical Study data relating the Study as a whole will be published. If permission is granted by Sponsor for publication of ancillary 
data from individual sites, prior to submission for publication of any manuscript or presentation of any poster, presentation, 
abstract or other written or oral material that describes the results of Study, Institution and/or PI shall provide Sponsor at least 
60 days (or as otherwise specified in the sites executed Clinical Trial Agreement) to review any such materials. Such materials 
shall not divulge any of Sponsor’s Confidential Information, and Institution and/or PI shall promptly remove any Confidential 
Information as requested by Sponsor. If requested by Sponsor, the PI and Institution shall delay the submission of any publication 
or presentation up to 60 days from the date of Sponsor’s request for such a delay. In addition, Sponsor has the right to require 
that any publication or presentation concerning the Study will acknowledge Sponsor’s support. 
 
19.9 
Ethical Considerations 
The Investigator agrees to conduct this study in accordance with applicable United States FDA clinical trial regulations and 
guidelines, applicable United States FDA clinical trial regulations and guidelines, the ICH (E6) GCP guidelines, n, the IRB and local 
legal requirements and with the Declaration of Helsinki (1989). The Investigator will conduct all aspects of this study in 
accordance with all national, state, and local laws of the applicable regulatory agencies. 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 28 of 31                                                                    Version: 01/15/2016 
 
19.10 Informed Consent 
The PI assumes the responsibility of obtaining written Informed Consent for each subject before any study-specific procedures 
are performed. 
Subjects meeting the criteria set forth in the protocol will be offered the opportunity to participate in the study. To avoid 
introduction of bias, the Investigator must exercise no selectivity with regard to offering eligible subjects the opportunity to 
participate in the study. Subjects or parents/legal guardians of all candidate subjects will receive a comprehensive explanation of 
the proposed treatment, including the nature of the therapy, alternative therapies available, any known previously experienced 
adverse reactions, the investigational status of the study drug, and other factors that are part of obtaining a proper Informed 
Consent. Subjects will be given the opportunity to ask questions concerning the study, and adequate time to consider their 
decision to or not to participate. 
Informed Consent will be documented by the use of a written Consent Form that includes all the elements required by FDA 
regulations and ICH guidelines. The Sponsor or designee will review the informed consent prior to submission to the IRB. The 
form is to be signed and dated by the subject and by the person who administers the consent process. A copy of the signed form 
will be given to the person who signed it, the original signed Consent Form will be filed with the subject’s medical records, and 
copy maintained with the subject’s study records. The date and time of time of the Informed Consent must be recorded in the 
source documents. 
If an amendment to the protocol changes the subject participation schedule in scope or activity, or increases the potential risk to 
the subject, the Informed Consent Form must be amended. Any amended Informed Consent must be reviewed by the Sponsor or 
designee and approved by the IRB prior to use. The revised Informed Consent Form must be used to obtain re-consent from any 
subjects currently enrolled in the study if the subject is affected by the amendment, and must be used to document consent 
from any new subjects enrolled after the approval date of the amendment. 
 
19.11 Institutional Review Board/Ethics Committee 
The PI will assure that an appropriately constituted IRB that complies with the requirements of 21 CFR Section 56 or written 
assurance of compliance with ICH (E6) guidelines will be responsible for the initial and continuing review and approval of the 
clinical study. Before initiation of the study, the PI or designee will forward copies of the protocol and Consent Form to be used 
for the study to the IRB for its review and approval. A photocopy of the IRB notification of approval must be forwarded to the 
Sponsor or its designee before any investigational supplies will be shipped to the PI. 
The PI or designee will also assure that all changes in the research activity and all unanticipated problems involving risks to 
human subjects or others will be reported promptly to the IRB, and that no changes will be made to the protocol without prior 
Sponsor and IRB approval, except where necessary to eliminate apparent immediate hazards to human subjects. 
Copies of all study-related correspondence between the Investigator and the IRB must be provided to the Sponsor, or its 
designee, by the Investigator. The PI or designee must promptly notify the IRB of any SAE occurring at the site and of any safety 
reports (e.g., IND Safety Reports) received from the Sponsor, or its designee, and must copy the Sponsor, or its designee on that 
correspondence. 
The Investigator or designee will be responsible for submitting periodic progress reports to the IRB at intervals appropriate to the 
degree of subject risk involved in the study, but not less than once per year and at the completion or termination of the study. 
 
19.12 Subject Privacy 
The Sponsor and the Investigator affirm and uphold the principle of the subject's right to privacy. The Sponsor, it’s designates 
and the Investigator shall comply with applicable national and local privacy laws. 
 
To verify compliance with this protocol, the Sponsor, or its designee, will require that the Investigator permit the Sponsor, or its 
designee’s monitor to review the subject's original medical records. Should access to such medical records require a waiver or 
authorization separate from the statement of Informed Consent, the Investigator will obtain such permission in writing from the 
subject before the subject is entered into the study. 
 
 
20.0 REFERENCES 
1. 
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019;69: 7-34. 
2. 
DeSantis CE, Ma J, Gaudet MM, et al. Breast cancer statistics, 2019. CA Cancer J Clin 2019;69: 438-51. 
3. 
Munoz D, Near AM, van Ravesteyn NT, et al. Effects of screening and systemic adjuvant therapy on ER-specific US breast 
cancer mortality. J Natl Cancer Inst 2014;106. 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 29 of 31                                                                    Version: 01/15/2016 
 
4. 
Greenwalt I, Zaza N, Das S, Li BD. Precision Medicine and Targeted Therapies in Breast Cancer. Surg Oncol Clin N Am 
2020;29: 51-62. 
5. 
Carlson RW, Anderson BO, Cox C, et al. Breast Cancer Clinical Practice Guidelines in Oncology.  2004  [cited 2004 
11/21/04]; 1.2004:[Available from: http://www.nccn.org 
6. 
Macfarlane R, Seal M, Speers C, et al. Molecular alterations between the primary breast cancer and the subsequent 
locoregional/metastatic tumor. Oncologist 2012;17: 172-8. 
7. 
Lonning PE, Taylor PD, Anker G, et al. High-dose estrogen treatment in postmenopausal breast cancer patients heavily 
exposed to endocrine therapy. Breast Cancer Res Treat 2001;67: 111-6. 
8. 
Mouridsen H, Gershanovich M, Sun Y, et al. Superior efficacy of letrozole versus tamoxifen as first-line therapy for 
postmenopausal women with advanced breast cancer: results of a phase III study of the International Letrozole Breast Cancer 
Group. J Clin Oncol 2001;19: 2596-606. 
9. 
Nabholtz JM. Steroidal side effects of exemestane. J Clin Oncol 2001;19: 2107-8. 
10. 
Winer EP, Hudis C, Burstein HJ, et al. American Society of Clinical Oncology technology assessment on the use of 
aromatase inhibitors as adjuvant therapy for postmenopausal women with hormone receptor-positive breast cancer: status 
report 2004. J Clin Oncol 2005;23: 619-29. 
11. 
Carlson RW, McCormick B. Update: NCCN breast cancer Clinical Practice Guidelines. J Natl Compr Canc Netw 2005;3 
Suppl 1: S7-11. 
12. 
Nabholtz JM, Buzdar A, Pollak M, et al. Anastrozole is superior to tamoxifen as first-line therapy for advanced breast 
cancer in postmenopausal women: results of a North American multicenter randomized trial. Arimidex Study Group. J Clin Oncol 
2000;18: 3758-67. 
13. 
Ellis MJ, Llombart-Cussac A, Feltl D, et al. Fulvestrant 500 mg Versus Anastrozole 1 mg for the First-Line Treatment of 
Advanced Breast Cancer: Overall Survival Analysis From the Phase II FIRST Study. J Clin Oncol 2015;33: 3781-7. 
14. 
Mehta RS, Barlow WE, Albain KS, et al. Overall Survival with Fulvestrant plus Anastrozole in Metastatic Breast Cancer. N 
Engl J Med 2019;380: 1226-34. 
15. 
Robertson JF, Llombart-Cussac A, Rolski J, et al. Activity of fulvestrant 500 mg versus anastrozole 1 mg as first-line 
treatment for advanced breast cancer: results from the FIRST study. J Clin Oncol 2009;27: 4530-5. 
16. 
Wang Y, Ayres KL, Goldman DA, et al. (18)F-Fluoroestradiol PET/CT Measurement of Estrogen Receptor Suppression 
during a Phase I Trial of the Novel Estrogen Receptor-Targeted Therapeutic GDC-0810: Using an Imaging Biomarker to Guide Drug 
Dosage in Subsequent Trials. Clin Cancer Res 2017;23: 3053-60. 
17. 
Andre F, Ciruelos E, Rubovszky G, et al. Alpelisib for PIK3CA-Mutated, Hormone Receptor-Positive Advanced Breast 
Cancer. N Engl J Med 2019;380: 1929-40. 
18. 
Finn RS, Crown JP, Lang I, et al. The cyclin-dependent kinase 4/6 inhibitor palbociclib in combination with letrozole 
versus letrozole alone as first-line treatment of oestrogen receptor-positive, HER2-negative, advanced breast cancer (PALOMA-
1/TRIO-18): a randomised phase 2 study. Lancet Oncol 2015;16: 25-35. 
19. 
Hortobagyi GN, Stemmer SM, Burris HA, et al. Ribociclib as First-Line Therapy for HR-Positive, Advanced Breast Cancer. 
N Engl J Med 2016;375: 1738-48. 
20. 
Johnston S, Martin M, Di Leo A, et al. MONARCH 3 final PFS: a randomized study of abemaciclib as initial therapy for 
advanced breast cancer. NPJ Breast Cancer 2019;5: 5. 
21. 
Bosch A, Li Z, Bergamaschi A, et al. PI3K inhibition results in enhanced estrogen receptor function and dependence in 
hormone receptor-positive breast cancer. Sci Transl Med 2015;7: 283ra51. 
22. 
Lonning PE, Bajetta E, Murray R, et al. Activity of exemestane in metastatic breast cancer after failure of nonsteroidal 
aromatase inhibitors: a phase II trial. J Clin Oncol 2000;18: 2234-44. 
23. 
Hanamura T, Hayashi SI. Overcoming aromatase inhibitor resistance in breast cancer: possible mechanisms and clinical 
applications. Breast Cancer 2018;25: 379-91. 
24. 
National Comprehensive Cancer N. NCCN Guideline update: Breast Cancer Version 1.2004. J Natl Compr Canc Netw 
2004;2: 183-4. 
25. 
Piccart M, Hortobagyi GN, Campone M, et al. Everolimus plus exemestane for hormone-receptor-positive, human 
epidermal growth factor receptor-2-negative advanced breast cancer: overall survival results from BOLERO-2dagger. Ann Oncol 
2014;25: 2357-62. 
26. 
Turner NC, Ro J, Andre F, et al. Palbociclib in Hormone-Receptor-Positive Advanced Breast Cancer. N Engl J Med 
2015;373: 209-19. 
27. 
Yardley DA, Ismail-Khan RR, Melichar B, et al. Randomized phase II, double-blind, placebo-controlled study of 
exemestane with or without entinostat in postmenopausal women with locally recurrent or metastatic estrogen receptor-
positive breast cancer progressing on treatment with a nonsteroidal aromatase inhibitor. J Clin Oncol 2013;31: 2128-35. 
28. 
Munster PN, Thurn KT, Thomas S, et al. A phase II study of the histone deacetylase inhibitor vorinostat combined with 
tamoxifen for the treatment of patients with hormone therapy-resistant breast cancer. Br J Cancer 2011;104: 1828-35. 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 30 of 31                                                                    Version: 01/15/2016 
 
29. 
Yeruva SLH, Zhao F, Miller KD, et al. E2112: randomized phase iii trial of endocrine therapy plus entinostat/placebo in 
patients with hormone receptor-positive advanced breast cancer. NPJ Breast Cancer 2018;4: 1. 
30. 
Mankoff DA, Dunnwald LK, Gralow JR, et al. Blood flow and metabolism in locally advanced breast cancer: relationship 
to response to therapy. J Nucl Med 2002;43: 500-9. 
31. 
Mankoff DA, Peterson LM, Tewson TJ, et al. [18F]fluoroestradiol radiation dosimetry in human PET studies. J Nucl Med 
2001;42: 679-84. 
32. 
Mintun MA, Welch MJ, Siegel BA, et al. Breast cancer: PET imaging of estrogen receptors. Radiology 1988;169: 45-8. 
33. 
Kurland BF, Peterson LM, Lee JH, et al. Between-patient and within-patient (site-to-site) variability in estrogen receptor 
binding, measured in vivo by 18F-fluoroestradiol PET. J Nucl Med 2011;52: 1541-9. 
34. 
Mankoff DA, Peterson LM, Petra P, et al. Factors affecting the level and heterogeneity of uptake of [F-18] fluoroestradiol 
(FES) in patients with estrogen receptor positive (ER+) breast cancer. J Nucl Med 2002;43: 287P. 
35. 
Dehdashti F, Mortimer JE, Siegel BA, et al. Positron tomographic assessment of estrogen receptors in breast cancer: 
comparison with FDG-PET and in vitro receptor assays. J Nucl Med 1995;36: 1766-74. 
36. 
Mortimer JE, Dehdashti F, Siegel BA, Trinkaus K, Katzenellenbogen JA, Welch MJ. Metabolic flare: indicator of hormone 
responsiveness in advanced breast cancer. J Clin Oncol 2001;19: 2797-803. 
37. 
Dehdashti F, Mortimer JE, Trinkaus K, et al. PET-based estradiol challenge as a predictive biomarker of response to 
endocrine therapy in women with estrogen-receptor-positive breast cancer. Breast Cancer Res Treat 2009;113: 509-17. 
38. 
Linden HM, Kurland BF, Peterson LM, et al. Fluoroestradiol positron emission tomography reveals differences in 
pharmacodynamics of aromatase inhibitors, tamoxifen, and fulvestrant in patients with metastatic breast cancer. Clin Cancer Res 
2011;17: 4799-805. 
39. 
Linden HM, Stekhova SA, Link JM, et al. Quantitative fluoroestradiol positron emission tomography imaging predicts 
response to endocrine treatment in breast cancer. J Clin Oncol 2006;24: 2793-9. 
40. 
Peterson LM, Kurland BF, Schubert EK, et al. A phase 2 study of 16alpha-[18F]-fluoro-17beta-estradiol positron emission 
tomography (FES-PET) as a marker of hormone sensitivity in metastatic breast cancer (MBC). Mol Imaging Biol 2014;16: 431-40. 
41. 
Kiesewetter DO, Kilbourn MR, Landvatter SW, Heiman DF, Katzenellenbogen JA, Welch MJ. Preparation of four fluorine- 
18-labeled estrogens and their selective uptakes in target tissues of immature rats. J Nucl Med 1984;25: 1212-21. 
42. 
Tewson TJ, Mankoff DA, Peterson LM, Woo I, Petra P. Interactions of 16alpha-[18F]-fluoroestradiol (FES) with sex steroid 
binding protein (SBP). Nucl Med Biol 1999;26: 905-13. 
43. 
Lim JL, Zheng L, Berridge MS, Tewson TJ. The use of 3-methoxymethyl-16 beta, 17 beta-epiestriol-O-cyclic sulfone as the 
precursor in the synthesis of F-18 16 alpha-fluoroestradiol. Nucl Med Biol 1996;23: 911-5. 
44. 
Koleva-Kolarova RG, Greuter MJ, van Kruchten M, et al. The value of PET/CT with FES or FDG tracers in metastatic breast 
cancer: a computer simulation study in ER-positive patients. Br J Cancer 2015;112: 1617-25. 
45. 
Peterson LM, Mankoff DA, Lawton T, et al. Quantitative imaging of estrogen receptor expression in breast cancer with 
PET and 18F-fluoroestradiol. J Nucl Med 2008;49: 367-74. 
 
21.0 Appendix 
 
Appendix A: Study Calendar 
 
Baseline evaluations are to be conducted prior to administration of protocol therapy, typically within 30 days. Baseline FDG 
PET/CT scan will be obtained near the time of the [18F]FES-PET/CT scan, typically within 14 days. Procedures are outlined below: 
 
 
Pre-
Study 
Imaging 1 
Rx 
1 
Imaging 
25 
 
Rx 
2 
Imaging 
36 
Follow up 
Informed Consent 
X 
 
 
 
 
 
 
Demographics 
X 
 
 
 
 
 
 
Pregnancy Test1 
X 
 
 
 
 
 
 
Vital Signs2 
 
X 
 
X 
 
X 
 
Research lab tests3 
 
X 
 
X 
 
X 
 
ER, PgR, HER24 
X 
 
 
 
 
 
 
FDG PET/CT5,6,7
X 
 
 
X 
 
X 
 
[18F]FES injection and 
PET5,7 
 
X 
 
X 
 
X 
 

10465  
 
 
 
 
 
RG1007834 
 
 
00323 Consortium Solid Tumor Protocol Template         
           Page 31 of 31                                                                    Version: 01/15/2016 
 
Collect serum hormone 
levels8 
 
X 
 
X 
 
X 
 
Adverse Event 
Evaluation 
 
X (0-24hr) 
 
X (0-24hr) 
 
X (0 -24hr) 
 
Optional tumor tissue 
biopsy and blood draw9 
 
X 
 
X 
 
 
 
 
1 If patient is pre-menopausal, and birth control use is not confirmed 
2 Vital signs include heart rate and blood pressure 
3Additional blood tests to measure hormone levels (e.g. estradiol, estrone, testosterone, DHT, SHBG) or other hormone related 
measures might be performed in some patients depending on the treatment regimen.  
4 Pathology results from primary or metastatic biopsy will be reviewed and additional pathology tests may be performed on some 
patients depending on the treatment regimen.  
5 FES PET/CT and FDG PET/CT will be done at 1-12 weeks after the Imaging 1 time point depending on the treatment regimen.  
6 Repeat FDG PET may be omitted in patients on SERD therapies. 
7 FES PET/CT and FDG PET/CT may be done at 1-12 weeks after the Imaging 2 time point depending on the treatment regimen. 
8 Optional blood sample for estradiol, estrone, follicle-stimulating hormone, sex hormone binding globulin, testosterone and free 
testosterone serum levels.  
9 In patients consented to optional biopsies, obtain metastatic or recurrent tumor tissue from an FDG and/or FES avid site after 
completion of PET imaging but prior to start of the endocrine targeted therapy. Repeat the biopsy from the same site after 1-12 
weeks on treatment. (Where available and medically appropriate, a clinical or research biopsy that involved sampling of a 
relevant lesion within 6 months prior to the enrollment may be utilized in place of the baseline optional biopsy.) A blood draw 
done during the same time point will accompany some biopsies.