sdAb-based Targeted Radionuclide Therapy of Multiple Myeloma: a Feasibility Study
Phase: NA
Conditions: Multiple Myeloma
Sponsor: Universitair Ziekenhuis Brussel

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 1 of 23 
 
 
 
 
 
 
 
Study Protocol 
 
 
 
 
 
sdAb-based targeted radionuclide therapy of 
multiple myeloma: a feasibility study 
UZBRU_ MUM 
 
 
 
Author: 
M. Keyaerts and M. D’Huyvetter 
 
 
 
 
Date: 
 
30/01/2019 
Signature: 
 
Protocol UZBRU_ MUM 
 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 2 of 23 
 
 
 
Version history 
 
 
Version 
Date 
Changes vs previous version 
1.0 
29/08/2017 
Not applicable 
2.0 
30/03/2018 
Two exclusion criteria removed 
Part 1 of the study (50 patients) split up in a prospective part 
(15 patients) and a retrospective analysis (35 patients). Two 
observations (demographics & medical history) moved to 
contact 2 instead of contact 1 
2.1 
30/01/2019 
The inclusion/exclusion criteria of part 2 were modified: 
removal of  exclusion criterion “patients treated for multiple 
myeloma in the past.  
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 3 of 23 
 
 
Table of contents 
 
Table of contents 
2 
Abbreviations 
3 
1. Study administrative structure 
6 
2. Introduction 
7 
3. Study objectives 
10 
4. Study design 
10 
5. Investigational plan 
10 
   5.1 Overall study design 
10 
   5.2 Study Groups 
10 
   5.3 Time schedule 
11 
   5.4 Selection and withdrawal of subjects 
12 
   5.5 Clinical Laboratories, Technical Department(s), Institution(s) Providing 
         Clinical Study Services 
14 
   5.6 Potential risks and benefis to human subjects 
16 
   5.7 Outcome measures of safety, tolerability and tumor targeting 
16 
           5.7.1 Primary outcome measures for part I 
   16 
           5.7.2 Primary outcome measures for part II 
           5.7.3 Secondary outcome measure for part II 
5.8 Statistical methods planned 
17 
17 
17 
          5.8.1 Sample size justification 
          5.8.2 Paraprotein-targeting evaluation 
17 
17 
    6. Data handling and record keeping 
17 
    7. Direct access to sources 
17 
          7.1 Source data and documents 
18 
          7.2 Direct access to source data and document 
18 
    8. Quality control 
19 
           8.1 Audits and inspections  
                                                                      19 
    9. Ethics                                                                                                                     19 
           9.1 Ethics Committee Approval                                                                          19  
           9.2 Ethical and scientific conduct of the clinical study  
 
 
     20             
    10. Financing and insurance 
 
 
 
 
 
 
 
     20             
          10.1 Financing 
 
 
 
 
 
 
 
 
     20 
10.2 Insurances 
 
 
 
 
 
 
 
 
     20 
    11. Reference list        

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 4 of 23 
 
 
 Abbreviations 
ASCT 
BM 
CR 
CEA 
CRF 
ELISA 
EGFR 
Ga 
GCP 
GMP 
ICH 
MM 
PET 
PSMA 
SdAb 
SPECT 
Autologous stem cell transplantation 
Bone marrow 
Complete remission 
Carcinoembryonic Antigen 
Case Report Form 
Enzyme-Linked Immuno Sorbent Assay 
Epidermal growth factor receptor 
 
Galium 
Good Clinical Practice 
Good Manufacturing Practice 
The International Conference on Harmonisation  
Multiple myeloma 
Positron Emission Tomography 
Prostate Specific Membrane Antigen 
Single domain antibodies 
Single Photon Emission Computed Tomography 
mAb 
Monoclonal antibody 
MFI 
Mean Fluorescence Intensity 
MMR 
MRD 
Macrophage Mannose Receptors 
Minimal residual disease 
TRNT 
Targeted radionuclide therapy 
HER2 
Human epidermal growth factor receptor type 2 
HPLC 
High Performance Liquid Chromatography 
kDa 
VIB 
VUB 
Kilodalton 
Vlaams Instituut voor Biotechnologie 
Vrije Universiteit Brussel 
ml 
Milliliter 
 
 
 
 
 
 
 
 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 5 of 23 
 
 
Title: 
 
“UZBRU_MUM” study 
 
 
Document version: 
2.1 
 
Date of version: 
 
30/01/2019 
Project No: 
 
UZBRU_ MUM 
Sponsor: 
 
UZ Brussel 
 
 
CONFIDENTIALITY STATEMENT 
The information provided in this document is strictly confidential and is available for 
review to investigators, potential investigators and appropriate Ethics Committees and 
authorities only. No disclosure should take place without the written authorization from 
VUB Technology Transfer, except to the extent necessary to obtain informed consent 
from potential patients. 
 
 
sdAb-based targeted radionuclide therapy of multiple myeloma: a feasibility 
study 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 6 of 23 
 
 
1. 
STUDY ADMINISTRATIVE STRUCTURE 
 
 
University Hospital: 
UZ-Brussel 
Department of Nuclear Medicine 
Laarbeeklaan 101  
1090 Jette 
Belgium 
Phone: +32 2 477 50 20 
Fax: +32 2 477 50 17 
 
Principal 
Investigator: 
 
 
 
 
 
 
 
 
 
Leading Ethical 
committee: 
Marleen Keyaerts, MD, PhD 
Department of Nuclear Medicine 
Laarbeeklaan 101  
1090 Jette 
Belgium 
Phone: +32 2 476 31 13 
Mobile: +32 472 81 12 14 
e-mail: mkeyaerts@gmail.com 
 
 
Commissie Medische Ethiek UZ Brussel 
Laarbeeklaan 101 
1090 Jette 
Belgium 
 
 
 
 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 7 of 23 
 
 
2. 
INTRODUCTION 
 
 
Multiple myeloma (MM) is an incurable cancer caused by malignant plasma cells in bone 
marrow (BM). Anti-myeloma drugs target either the myeloma cells directly or remodel the 
microenvironment of the tumor cell (1,2). By combining novel agents (e.g. proteasome 
inhibitors such as bortezomib or immunomodulatory drugs such as thalidomide and 
lenalidomide) with corticosteroids, followed by high dose chemotherapy and autologous stem 
cell transplantation (ASCT), high rates of survival and complete remission (CR) are currently 
achieved (3-4). CR is defined as the absence of monoclonal protein in serum and urine, less 
than 5% BM plasma cells, no increase of lytic bone lesions and disappearance of all pre-
existing soft tissue plasmocytomas. However, disease recurrence is most often observed, due 
to the expansion of minimal residual disease (MRD) and the regrowth of chemo-resistant 
cancer cells in BM (5). Therefore, novel therapeutic strategies are warranted. 
Due to their plasma cell origin, the hallmark of MM cells is the production of paraprotein (M-
component), a monoclonal antibody (mAb) that is regularly secreted into the bloodstream. 
Upon diagnosis, the paraprotein is expressed on the surface of plasma cells in about 35% of 
MM patients (6-7). Each paraprotein sequence is unique for the patient's MM. It is defined by a 
unique antigen-binding site, which is frequently referred to as the 'idiotype'. Highly specific, 
anti-idiotype compounds might therefore be ideal tumor- and patient-specific vehicles for tumor 
imaging and therapy. Recently, Leung-Hagesteijn et al. reported a direct relation between 
bortezomib-resistance and the maturation stage of MM cells, whereby bortezomib-resistant 
malignant cells after MRD-regrowth are characterized by a more dedifferentiated phenotype 
and a concomitant expression of idiotype on their cell surface (8). This study provides further 
rationale to target MM cells in a MRD-setting with anti-idiotype vehicles since it provides a 
rescue strategy to eliminate cells that have otherwise become untreatable. However, the 
generation of truly anti-idiotypic vehicles is challenging because the few variable structures that 
give the M-component its unique nature are admixed within a large conserved framework. 
 
Targeted radionuclide therapy (TRNT) is the technology in which peptides, mAbs or Ab 
fragments are coupled with therapeutic radionuclides. These vehicles interact with tumor-
associated proteins that are expressed on the cancer cell surface. TRNT has become an 
attractive therapeutic application as it has the ability to target both the primary tumor site as 
well as disseminated disease. To date, only two agents are approved for commercial use, the 
radiolabeled anti-CD20 mAbs 90Y-ibritumomab and 131I-tositumomab to treat B cell non-
Hodgkin lymphoma (blood-borne cancers). Due to the long blood half-life of mAbs, the 
systemic administration of radiolabeled mAbs is characterized by a prolonged presence of 
radioactivity in blood and highly perfused organs. Not surprisingly, myelotoxicity as a result of 
mAb-based TRNT is a well-known phenomenon and often a dose-limiting factor (9). Moreover, 
the dose delivered to carcinomas is often inadequate, due to limited penetration of mAb-based 
vehicles. Consequently, inadequate dose estimations often lead to inefficient treatment of 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 8 of 23 
 
 
target lesions in clinical trials, limiting their success.   
The integration of diagnostic testing (molecular imaging) for the presence of a molecular target 
is of interest to predict successful TRNT. This so-called “theranostic approach” aims to improve 
personalized treatment based on the molecular characteristics of cancer cells. Moreover, this 
strategy offers new insights in predicting the dose needed to treat and provides appropriate 
tools to monitor therapy responses. Due to their long circulation time, mAbs and most of their 
related fragments are not ideal for imaging, as it takes days before target-expressing lesions 
become visible.  
 
Single domain antibodies or SdAb may solve some of the issues related to the use of mAbs for 
imaging and TRNT of cancer. SdAb are small (15 kDa) antigen-binding fragments derived from 
heavy-chain-antibodies of Camelidae. They are the smallest antibody-derived antigen-binding 
fragments and have superior characteristics compared to classical mAbs and their derived 
fragments for in vivo cell targeting (10). In the past, we have pioneered the successful 
evaluation of sdAb as in vivo diagnostic tracers (11). In terms of molecular imaging of cancer, 
sdAb have been directed to a variety of membrane-bound cancer cell biomarkers, such as 
CEA, EGFR, HER2, and PSMA. Because of their exceptional specificity of targeting, and the 
fact that they show to be functional after labeling with radionuclides, sdAb became valuable 
vehicles for nuclear imaging and TRNT (11,12). A first-in-human PET study with 68Ga-labeled 
anti-HER2 sdAb for breast cancer imaging was recently finalized in our university hospital 
(13,14), and a second PET study is planned for 2017, using an intratumoral macrophage-
targeting anti-MMR sdAb.  
More recently, we endeavored the use of sdAb as vehicles for TRNT in preclinical cancer 
models, through the therapeutic --particle-emitting radionuclide Lutetium-177 (177Lu).  These 
in vitro and in vivo proof-of-concept studies were very promising and showed strong signs of 
efficient and specific tumor treatment with absence of toxicity in non-target tissues (15-17). 
Crucial for the success of these therapy experiments were the measures that were taken to 
reduce renal retention of the radiolabeled sdAb, which could otherwise lead to kidney-related 
toxicities. This was partially successful by removal of the sdAb’ hexahistidine tag and the 
coinfusion with the plasma expander Gelofusin (17,18). For instance, we recently described 
the use of a 177Lu-labeled anti-HER2 sdAb for TRNT (17). SdAb-based targeted TRNT in 
mice bearing small subcutaneous HER2+ tumors led to a complete blockade of tumor growth 
and a significant difference in survival between the treated and the control. Similar exciting 
findings were recorded for a 177Lu-labeled sdAb to treat residual disease in a mouse model of 
MM (16). These preliminary data demonstrate for the very first time successful TRNT in 
preclinical cancer models using sdAb, and therefore suggest a potential of radiolabeled sdAb 
as a valuable adjuvant therapy candidate to treat residual and micrometastatic disease. In 
terms of TRNT, a low dose first-in-human biodistribution with therapeutic 131I-labeled anti-
HER2 sdAb is planned for 2016 to assess safety, tolerability and biodistribution.  
 
Our research group recently described, as proof-of-principle, the generation, characterization 
and use of anti-idiotypic sdAb as tools for specific targeting of MM cells in the 5T2MM murine 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 9 of 23 
 
 
model (16). This model is reminiscent of the clinical situation where paraprotein is produced 
and expressed on the cancer cell membrane, CR is achieved after chemotherapy but the 
disease eventually recurs. After immunizing a dromedary with 5T2MM M-component/idiotype 
(5T2MMid) we identified high-affinity anti-idiotypic sdAb and demonstrated their anti-idiotypic 
nature and 5T2MM cancer-targeting properties in ELISA, BIAcore and FACS assays. 
Biodistribution studies and SPECT/micro-CT scans using 99mTc-labeled sdAb revealed specific 
in vivo targeting of the 5T2MMid. Treatment of 5T2MM mice in an MRD-like stage with 177Lu-
labeled sdAb resulted in significant signs of reduced tumor load. This study shows that anti-
idiotypic sdAb are a new, sensitive, specific and non-invasive tool for imaging and therapeutic 
purposes and provides a rationale for their clinical evaluation as a personalized treatment 
option for MM patients expressing surface paraprotein.  
 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 10 of 23 
 
 
3. 
STUDY OBJECTIVES 
 
Part I  
Primary objective of the clinical study: 
Quantify the relative amount of patients that have expression of the paraprotein on the surface 
of multiple myeloma cells and determine a relevant threshold to select patients in part II of the 
study for anti-paraprotein sdAb generation 
 
Part II  
Primary objective of the clinical study: 
Generate anti-paraprotein sdAb directed against the idiotype for 5 multiple myeloma patients, 
selected to have sufficient expression of paraprotein on the surface of their multiple myeloma 
cells 
4. 
STUDY DESIGN 
 
Single center, observational study that will be conducted prospectively for part I and II, and 
retrospectively for part III 
 
5. 
INVESTIGATIONAL PLAN 
 
5.1 Overall Study Design 
Single center, observational 
 
5.2 Study Groups 
 
This study will be conducted in 2 parts, 50 patients in part I and 50 patients in part II, with a 
maximum of 100 patients for the entire study.  
 
Part I will consist of: 
o Part IA (15 patients): an additional laboratory analysis performed on excess 
material of bone marrow samples of multiple myeloma patients. The sampling 
will be performed in clinical routine and only excess materials (left over after 
samples for routine analysis are taken) will be used for study purposes. No 
additional sampling will be necessary for study purposes. 
o Part IB (35 patients): a retrospective analysis of results of patients who 
underwent bone marrow biopsy between May 2009 and December 2017. 
Patients who were diagnosed with at least 10% malignant plasma cells and 
whose sample was analyzed for immunoglobulin phenotyping of both plasma 
cells and B lymphocytes will be included for further analysis. 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 11 of 23 
 
 
 
 
Part II will consist of  
- 
an additional laboratory analysis performed on excess material of bone marrow 
samples of multiple myeloma patients. The sampling will be performed in clinical routine 
and only excess materials (left over material after all samples for routine analysis are 
taken) will be used for study purposes. No additional bone marrow sampling will be 
necessary for study purposes. 
- 
A blood sampling of maximally 10 ml by venous puncture (white serum tube), that will 
be used for study purposes  
 
5.3 Time schedule  
 
First patient: November 2017 
 
Last patient: December 2031 
 
5.3.1 Part IA 
 
The individual patient schedule will be: 
 
Contact 1:  
 
Informed consent 
 
Inclusion / exclusion criteria 
 
Contact 2:  
 
Demographics 
 
Medical history 
 
Bone marrow sampling performed in clinical routine /as standard of care 
The clinical procedures will be performed as standard of care. There will be no additional 
study-related procedures.  
The bone marrow sample will be analyzed as standard of care. Only leftover bone marrow 
material will be used for study purposes.  
The following tests will be performed on leftover material: staining of membrane-bound 
paraprotein using anti-kappa and anti-lambda monoclonal antibodies for flow cytometry on 
non-permeabilized multiple myeloma cells (identified as positive using anti-CD38 staining) 
and analysis of binding using flow cytometry equipment.  
 
Based on the results of part I, a threshold will be determined for the selection of patients in 
part II of the study. 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 12 of 23 
 
 
Contact 1 and 2 can be performed at the same time, but the subject has to sign the 
informed consent prior to the performance of contact 2. 
  
 
5.3.2 Part IB 
This part will be conducted retrospectively. Informed consent by the patient is not required 
for this retrospective analysis. 
 
5.3.3 Part II 
 
The individual patient schedule will be: 
 
Contact 1:  
 
Informed consent 
 
Inclusion / exclusion criteria 
 
Demographics 
 
Medical history 
 
Contact 2: bone marrow sampling performed in clinical routine 
 There will be no additional study-related procedures at contact 2.  
The bone marrow sample will be obtained and analyzed in clinical routine. Only left-over 
bone marrow material will be used for study purposes. Procedures will be identical to those 
in part I of the study. 
 
After contact 2, the investigator will interpret the results of the bone marrow analysis for 
expression of the paraprotein on the membrane of multiple myeloma cells and compare the 
result with the threshold, to be determined after part I of the study. If the patient has a value 
above the threshold, the patient will be selected to continue the study. 
 
Contact 3: A blood sampling of maximally 10 ml  (white serum tube) will be obtained from the 
patient by puncture of a peripheral vein. 
 
Subsequent contacts (if applicable): in case additional bone marrow samplings are performed 
as a standard of care procedure in the 10 years following inclusion, and in case there is 
leftover material (not needed for routinely performed tests) this leftover material could be used 
for study purposes. 
 
The patient medical file will be checked on a regular basis to note any myeloma-related 
treatment, treatment response, time-to-relapse and time to next treatment.  
 
 
5.4 Selection and withdrawal of subjects 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 13 of 23 
 
 
5.4.1 Part IA 
Inclusion Criteria: 
Patients will only be included in the study if they meet all of the following criteria: 
- 
Patients who have given informed consent 
- 
Patients at least 18 years old 
- 
Patient scheduled to undergo bone marrow sampling in clinical routine because of a 
clinically suspected or pathologically confirmed multiple myeloma. 
 
Exclusion Criteria 
Patients will not be included in the study if one of the following criteria applies: 
- 
Patients who are unwilling and/or unable to give informed consent 
 
Withdrawal of patients 
The patient may withdraw from the study at any time without giving reasons and without any 
disadvantageous consequences for his/her subsequent medical care. 
 
The investigator may withdraw a patient from the study at any time in case of intercurrent 
illness, adverse event, therapeutic procedure or as a general rule if further participation in the 
study is believed to be to the patient’s detriment. 
 
Any patient withdrawn from the study before the scheduled completion of the study procedures 
will be considered an early withdrawal, regardless of the reason for withdrawal.  
 
Patients withdrawn from the study will be replaced. 
 
A patient participating in part I of the study has completed his study participation at the end of 
contact 2.  
 
5.4.1 Part IB 
Inclusion Criteria: 
Patients who underwent bone marrow biopsy between May 2009 and December 2017 and: 
- 
who were diagnosed with at least 10% malignant plasma cells in the bone marrow 
sample 
- 
whose sample was analyzed for immunoglobulin phenotyping of both plasma cells and 
B lymphocytes  
 
Exclusion Criteria 
Patients will not be included in the study if no immunofixation analysis was performed on blood 
samples 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 14 of 23 
 
 
5.4.2 Part II 
Inclusion Criteria: 
Patients will only be included in the study if they meet all of the following criteria: 
- Patients who have given informed consent 
- Patients at least 18 years old 
- Patients scheduled to undergo bone marrow sampling in clinical routine because of a 
clinically suspected or pathologically confirmed multiple myeloma. 
 
Exclusion Criteria 
Patients will not be included in the study if one of the following criteria applies: 
- Patients who cannot communicate reliably with the investigator 
- Patients who are unlikely to cooperate with the requirements of the study 
- Patients who are unwilling and/or unable to give informed consent 
- Patients at increased risk of death from a pre-existing concurrent illness 
- Patients who participated already in part I of this study 
 
Withdrawal of patients 
The patient may withdraw from the study at any time without giving reasons and without any 
disadvantageous consequences for his/her subsequent medical care. 
 
The investigator may withdraw a patient from the study at any time in case of intercurrent 
illness, adverse event, therapeutic procedure or as a general rule if further participation in the 
study is believed to be to the patient’s detriment. 
 
Any patient withdrawn from the study before the scheduled completion of the study procedures 
will be considered an early withdrawal, regardless of the reason for withdrawal.  
 
Patients withdrawn from the study will be replaced. 
 
A patient participating in part II of the study has completed his study participation 10 years after 
inclusion (additional per-protocol analysis on left-over bone marrow sample are allowed until 
10 years after inclusion).  
 
 
5.5 Clinical Laboratories, Technical Department(s), Institution(s) 
Providing Clinical Study Services 
The local department of clinical chemistry and hematology will perform the study related 
laboratory testing of bone marrow samples for part IA and part II of the study. Also the 
retrospective analysis of part IB will be performed by this department. For part IA, an additional 
immunoglobulin phenotyping analysis on left-over bone marrow sample will be performed 
using both cytoplasmatic and membrane staining using flow cytometry. For part IB, 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 15 of 23 
 
 
retrospectively results of patients who underwent bone marrow biopsy with such flow cytometry 
analysis will be reanalyzed to determine membrane expression of the paraprotein. This will be 
possible if a relatively high amount of malignant plasma cells is present in the sample (10% as 
a threshold is used). In that case, we will assess if these plasma cells can be distinguished on 
the scatter plots because of their typical forward and side scatter characteristics. If this 
population is overlapping with other cell populations on flow cytometry, the sample will be 
excluded for further analysis. Mean fluorescence intensity (MFI) of membrane-bound 
immunoglobulins (IgM, IgD, IgG, IgA, kappa and lambda) on the plasma cells will be quantified 
using isotype control staining as a reference. Also the cytoplasmatic expression of 
immunoglobulins on plasma cells will be quantified on the available flow cytometry data. The 
obtained data will be correlated to the blood-based immunofixation assay that was performed 
in the selected patients. This allows to identify the type of immunoglobulin that was secreted in 
the blood of the patient, and to distinguish irrelevant fluorescent signal produced by non-
secreted immunoglobulins from the relevant signal produced by membrane-bound paraprotein 
immunoglobulin. Because this method can only be performed in patients who had a high 
number of malignant plasma cells in their sample, and since interference of other cells cannot 
be entirely excluded using this method, we will further confirm these results using the 
prospectively collected bone marrow samples of part IA of this study. 
 
The In vivo cellular and molecular imaging laboratory of the VUB will process the blood sample 
drawn via venous puncture of the patient. The patient-specific M-component will be purified 
through chromatography procedures. Next, sdAbs will be generated against the purified 
patient-specific paraprotein in collaboration with the VIB Nanobody Core located at the VUB. In 
short, a sdAb-library is generated after immunization of a dromedary with the paraprotein. 
Peripheral blood lymphocytes are collected, followed by an amplification of the RNA encoding 
for the variable parts of the specific heavy-chain-only antibodies (= single-domain antibodies, 
sdAbs). These sequences are ligated into phagemid vectors, introduced into bacterial cells and 
the resulting sdAb library is phage-displayed. Paraprotein-targeting sdAbs are obtained via 
biopannings of the sdAb-phage library on immobilized paraprotein in the presence of normal 
human serum and sequencing of the obtained clones.  
 
The anti-idiotypic nature and affinity towards paraprotein, and the stability in human serum of 
the selected sdAbs are then characterized, using techniques like ELISA, BIAcore and HPLC. 
Gamma-HPLC profiles of 99mTc-labeled sdAbs added to normal human serum that is spiked 
with increasing concentrations of paraprotein will provide surrogate measurements of 
specificity and affinity for the patient’s idiotype. The in vivo behavior of the different sdAbs will 
be evaluated in animal models. Binding of sdAbs to the membrane of patient-derived malignant 
plasma cells (cytospin of BM aspirates) will be monitored via immunohistochemistry or flow 
cytometry if such cells are available as left-over material of routinely performed bone marrow 
sampling. Based on these results, a lead sdAb will be selected. 
 
The selected lead sdAb from will be radiolabeled with the therapeutic radionuclide 177Lu using 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 16 of 23 
 
 
a functionalized bifunctional chelator through previously established procedures, but now 
translated into a GMP-procedure together with the Nuclear Medicine department of the UZ 
Brussel. After radiolabeling, binding on immobilized paraprotein will be evaluated through 
radioligand binding studies, as well as stability in human serum. Binding towards paraprotein in 
patient blood samples at different disease stages will be analyzed through HPLC. 
At the end of this experimental part, we aim to deliver a pure and functional radiolabeled 
patient-specific anti-idiotype sdAb, which is completely characterized and will be ready for 
personalized therapy. The obtained HPLC results, circulating paraprotein levels, membrane 
paraprotein-positivity and other clinical parameters (including BM Giemsa stainings) will 
provide us with detailed information on the fraction of patients that would be eligible for sdAb-
based TRNT and the time-frame in which they should ideally be treated in a future clinical trial. 
 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 17 of 23 
 
 
 
5.6 Potential risks and benefits to human subjects 
 
Potential Risks 
The bone marrow sampling is performed in clinical routine and does not induce additional risks 
as compared to patient care outside of this study. 
The puncture of a vein for blood sampling, performed in patients participating in part II of the 
study, is performed for study purposes. This procedure might (rarely) cause pain, bleeding, 
bruising or infection localized around the injection site. Similarly, some subjects might feel 
dizzy or even faint during the procedure. The clinical team that will perform this procedure will 
do all they can to keep these discomforts to a minimum. 
Benefits 
For the cancer patients participating in part II of the study, there is the potential that a sdAb 
against their paraprotein is developed. It is not the primary goal of the study to use this sdAb to 
treat the patient. If however available and if ethically and clinically acceptable, it might be 
considered as an individualized therapy in a future clinical trial.   
The information obtained thanks to this study can contribute to the development of a new 
therapeutic for the patient-specific treatment of multiple myeloma patients. 
 
5.7 Outcome measures of safety, tolerability and tumor targeting 
5.7.1 Primary outcome measures for part I 
 
Using flow cytometry analysis on leftover bone marrow samples, the following outcome 
measures will be reported: 
 
Amount of patients that shows membrane expression of the paraprotein (or part of the 
paraprotein) on a subset or all of their multiple myeloma cells in the bone marrow 
sample  
 
Fraction of multiple myeloma cells within a the sample of one patient that has 
membrane expression of the paraprotein  
 
Variation in intensity (expression level) of paraprotein expression in such membrane-
expressing multiple myeloma cells 
 
Based on these observations, a cutoff value for sufficient expression of paraprotein on the 
membrane of multiple myeloma cells will be determined. 
 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 18 of 23 
 
 
5.7.2 Primary outcome measures for part II 
 
Fraction of patients (n=5) for whom a sdAb could be generated that binds to the 
idiotype of the paraprotein 
 
Amount of paraprotein-targeting sdAbs generated per patient and amount of sdAb 
families identified 
 
Affinities of generated paraprotein-targeting sdAbs using BIAcore technology 
 
Affinities of generated paraprotein-targeting sdAbs using ELISA techniques 
 
5.7.3 Secondary outcome measure for part II 
 
Binding of paraprotein-targeting sdAb to membrane-expressed paraprotein of multiple 
myeloma cells, obtained as leftover material from routinely performed bone marrow 
sampling in the 10 years after inclusion of the study subject 
 
5.8 Statistical methods planned 
5.8.1 Sample size justification 
This study is of exploratory nature and is intended to generate a proof-of-concept that 
paraprotein-targeting sdAbs can be generated for paraprotein derived from human subjects. 
The sample size was chosen based on the available budget for nanobody generation 
 
5.8.2 Paraprotein-targeting evaluation 
 
Classical descriptive statistics for categorical variables (N, n and %) will be used. Obtained 
sdAbs will be evaluated in normal mice for normal biodistribution and results will be analyzed 
using two-way Anova. 
 
 
6. 
DATA HANDLING AND RECORD KEEPING 
 
A paper CRF will be completed for each screened subject. This CRF will include specific 
pages for inclusion and exclusion criteria conclusions, for reporting each visit and the reporting 
of biological results. The investigator will review, approve and validate each completed CRF; 
the investigator’s signature (validation) serving as attestation of the investigator’s responsibility 
for ensuring that all clinical and laboratory data entered on the CRF are complete, accurate 
and authentic.  
7. 
 DIRECT ACCESS TO SOURCES 
 
7.1 Source data and documents 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 19 of 23 
 
 
Source data are all the information in original records and certified copies of original records of 
clinical findings, observations, or other activities in the study, which are necessary for the 
reconstruction and evaluation of the study. Source data are contained in source documents 
(originals or certified copies).  
All information recorded on the CRFs for this study must be consistent with the subject’s 
source documentation. The source documents (i.e. hospital records) must contain the first, 
middle (where applicable) and the last name of the subject, the date of birth, the information 
that the informed consent was signed and dated prior to the study, the date of entry in the 
study, the date of the visits, the code number of the subject, and the date of completion of the 
study.  
Source records should be preserved for the maximum period of time permitted by local 
requirements (30 years in Belgium). For each subject enrolled, the investigator will indicate in 
the source record(s) that the subject participates in this study, and record the following 
information: subject number, identification of the subjects (name, address, etc.), and main 
reason for discontinuation, if applicable.  
7.2 Direct access to source data and documents 
Secret must be respected regarding the identity of persons participating in a clinical study and 
all information of a personal or medical nature concerning these subjects. Any information 
which might permit identification of subject must be kept confidential. This confidentiality must 
be guaranteed to all subjects participating in the study.  
In all reports involving the subjects included in the study, each subject will be identified only by 
a subject number with four characters and the birthday year. The investigator will ensure that 
the confidentiality of subjects' data will be preserved. On CRFs or any other documents, the 
subjects will not be identified by their names, but by an identification system, which consists of 
their number in the study. Documents that identify the names of participants against their study 
number, i.e. the confidential subject identification log will be maintained by the investigator in 
strict confidence.  
The investigator will be personally responsible for the updating of a subject identification log 
which relates subject numbers to the names and means of contact of each subject in the study. 
This log will be kept in the investigator's file so that the investigator can contact the subjects. 
The confidentiality of these data will be preserved in accordance with the applicable national 
and/or local laws and regulations on personal data protection.  
Monitors, auditors and other authorized agents will be granted direct access to study subject’s 
original medical records for verification of clinical study procedures and/or data, without 
violating the confidentiality of the subjects, to the extent permitted by the law and regulations. 
In any presentations of the results of this study at meetings or in publications, the subjects’ 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 20 of 23 
 
 
identity will remain confidential.  
8. 
QUALITY CONTROL 
 
The investigator will permit direct access of the study monitors and appropriate regulatory 
authorities to the study data and to the corresponding source data and documents to verify the 
accuracy of this data.  
The investigator agrees to allow the monitor access to any or all of the study materials needed 
for the monitor to properly review the study progress. The investigator (or deputy) agrees to 
assist the monitor in resolving any problem that may be detected during the monitoring visit. 
Monitor should write a monitoring report of visit performed on investigator sites and a 
monitoring letter to the visited investigator.  
8.1 Audits and inspections 
The investigator should understand that source documents for this study should be made 
available to appropriately qualified personnel from the Sponsor, Quality Assurance Unit or its 
designees, or to Health Authority Inspectors after appropriate notification. The investigator's 
site, facilities and all data (including source data) and documentation could be made available 
for audit by an independent quality assurance unit and for EC or regulatory authorities 
according to the guideline of the international conference on harmonization (ICH)-good clinical 
practice (GCP). The investigator agrees to co-operate with the auditor during his/her visit and 
will be available to supply the auditor with CRFs or other files necessary to conduct that audit. 
Any findings will be strictly confidential. The main purposes of an audit or inspection are to 
confirm that the rights and well-being of the subjects have been adequately protected, and that 
all data relevant for the evaluation of the investigational product have been processed and 
reported in compliance with GCP and applicable regulatory requirements. The verification of 
the CRF data must be done by direct control of source documents.  
9. 
ETHICS 
 
9.1 Ethics Committee Approval 
The investigator will obtain, from the Ethics Committee of UZ Brussel a prospective approval of 
the clinical study protocol and corresponding informed consent form(s); modifications to the 
protocol and corresponding informed consent form(s), and advertisements (i.e., directed at 
potential research subjects) for study recruitment.  
The Ethics Committee of UZ Brussel operates in compliance with European regulations and in 
conformance with applicable ICH-GCP guideline.  
In the event that the Ethics Committee requires, as a condition of approval, substantial 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 21 of 23 
 
 
changes to the clinical protocol, or in the event of a decision to modify the previously accepted 
clinical protocol, the investigator will submit (i.e., in advance of implementing the change) a 
Protocol Amendment describing any change to the clinical protocol that significantly affects the 
safety of the subjects. For changes that do not affect critical safety assessments, the revisions 
to the clinical protocol will be notified to the Ethics Committee(s).  
9.2 Ethical and scientific conduct of the clinical study 
The clinical study will be conducted in accordance with the current Ethics committee-approved 
clinical study protocol; Declaration of Helsinki principles; ICH Guidelines on GCP; and relevant 
policies, requirements, and regulations.  
10. 
FINANCING AND INSURANCES 
 
10.1 Financing 
The study is financed by Vrije Univeristeit Brussel, through a grant provided by stichting tegen 
kanker  
10.2 Insurances 
The subjects taking part in this study will be covered by the insurance taken by the UZ Brussel, 
if they were to suffer any prejudice as a result of taking part in the study and according to ICH-
GCP requirements, the institution has taken out personal liability insurance with an Insurance 
company following the Belgian regulations. This insurance was taken out with Ethias NV. 
11. 
REFERENCE LIST 
 
1. Hideshima T, Richardson PG, Anderson KC; Mechanism of action of proteasome inhibitors 
and deacetylase inhibitors and the biological basis of synergy in multiple myeloma. Mol 
Cancer Ther, 2011. 10(11): p. 2034-42. 
2. Adams J; The proteasome: a suitable antineoplastic target. Nat Rev Cancer, 2004. 4(5): p. 
349-60. 
3. Avet-Loiseau H, Leleu X, Roussel M, Moreau P, Guerin-Charbonnel C, Caillot D, Marit G, 
Benboubker L, Voillat L, Mathiot C, Kolb B, Macro M, Campion L, Wetterwald M, Stoppa 
AM, Hulin C, Facon T, Attal M, Minvielle S, Harousseau JL. Bortezomib plus 
dexamethasone induction improves outcome of patients with t(4;14) myeloma but not 
outcome of patients with del(17p). J Clin Oncol, 2010. 28(30): p. 4630-4. 
4. Kumar SK, Rajkumar SV, Dispenzieri A, Lacy MQ, Hayman SR, Buadi FK, Zeldenrust SR, 
Dingli D, Russell SJ, Lust JA, Greipp PR, Kyle RA, Gertz MA. Improved survival in multiple 
myeloma and the impact of novel therapies. Blood, 2008. 111(5): p. 2516-20. 
5. Kawano M. Progress in the field of hematology in the last 100 years: Medical history of 
multiple myeloma. Nihon Naika Gakkai Zasshi, 2002. 91(7): p. 2106-13. 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 22 of 23 
 
 
6. Ghosh N, Matsui W. Cancer stem cells in multiple myeloma. Cancer Lett, 2009. 277(1): p. 
1-7. 
7. Ocqueteau M, San Miguel JF, González M, Almeida J, Orfao A. Do myelomatous plasma 
cells really express surface immunoglobulin? Haematologica 1996; 81: 460–463. 
8. Leung-Hagesteijn C, Erdmann N, Cheung G, Keats JJ, Stewart AK, Reece DE, Chung KC, 
Tiedemann RE. Xbp1s-negative tumor B cells and pre-plasmablasts mediate therapeutic 
proteasome inhibitor resistance in multiple myeloma. Cancer Cell. 2013 Sep 9;24(3):289-
304. 
9. Hicks DG, Kulkarni S. HER2 breast cancer: review of biologic relevance and optimal use of 
diagnostic tools. Am J Clin Pathol 2008; 129: 263–27 
10. Hamers-Casterman C, Atarhouch T, Muyldermans S. Naturally occurring antibodies devoid 
of light chains. Nature. 1993;363:446–448 
11. De Vos J, Devoogdt N, Lahoutte T, Muyldermans S. Camelid single-domain antibody-
fragment engineering for (pre-) clinical in vivo molecular imaging applications: adjusting the 
bullet to its target. Expert Opin Biol Ther 2013;13(8):1149-60 
12. D'Huyvetter M, Xavier C, Caveliers V, Lahoutte T, Muyldermans S, Devoogdt N. 
Radiolabeled nanobodies as theranostic tools in targeted radionuclide therapy of cancer. 
Expert Opin Drug Deliv. 2014 Jul 18:1-16 
13. Xavier C, Vaneycken I, D’huyvetter M, Heemskerk J, Keyaerts M, Vincke C, Devoogdt N, 
Muyldermans S, Lahoutte T, Caveliers V. Synthesis, preclinical validation, dosimetry and 
toxicity of 68Ga-NOTA-Anti-HER2 Nanobodies for immuno-PET imaging of HER2 receptor 
expression in cancer, J Nucl Med, 2013, 54:1-9  
14. Keyaerts M, Xavier C, Heemskerk J, Devoogdt N, Everaert H, Ackaert C, Vanhoeij M, 
Duhoux FP, Gevaert T, Simon P, Schallier D, Fontaine C, Vaneycken I, Vanhove C, De 
Greve J, Lamote J, Caveliers V, Lahoutte T. Phase I Study of 68Ga-HER2-Nanobody for 
PET/CT Assessment of HER2 Expression in Breast Carcinoma. J Nucl Med. 2016 
Jan;57(1):27-33. 
15. D’Huyvetter M, Aerts A, Xavier C, Vaneycken I, Devoogdt N, Gijs M, Impens N, Baatout S, 
Ponsard B, Muyldermans S, Caveliers V, Lahoutte T. Development of 177Lu-nanobodies 
for radioimmunotherapy of HER2-positive breast cancer: evaluation of different bifunctional 
chelators, Contrast Media Mol I, 2012,7(2): 254-64 
16. Lemaire, M, D'Huyvetter, M, Lahoutte, T, Van Valckenborgh, E, Menu, E, De Bruyne, E, 
Kronenberger, P, Wernery, U, Muyldermans, S, Devoogdt, N, Vanderkerken, K. (2014) 
Imaging and radioimmunotherapy of multiple myeloma with anti-idiotypic Nanobodies. 
Leukemia 28 , 444-447 
17. D'Huyvetter M, Vincke C, Xavier C, Aerts A, Impens N, Baatout S, De Raeve H, 
Muyldermans S, Caveliers V, Devoogdt N, Lahoutte T, Targeted Radionuclide Therapy with 
a 177Lu-labeled Anti-HER2 Nanobody, Theranostics, 2014, 4:708-720 
18. Gainkam LO, Caveliers V, Devoogdt N, Vanhove C, Xavier C, Boerman O, Muyldermans 
S, Bossuyt A, Lahoutte T. Localization, mechanism and reduction of renal retention of 
technetium-99m labeled epidermal growth factor receptor-specific nanobody in mice. 
Contrast Media Mol Imaging 2011;6(2):85-92 

 
Study protocol 
version 2.1 
 
 
 
NUCLEAR MEDICINE 
 
 
 
UZ BRUSSEL 
Laarbeeklaan 101 
B1090 Brussel 
www.uzbrussel.be 
 
Nuclear Medicine – Dr. M. Keyaerts 
TEL 02 476 31 13 
FAX 02 477 50 17 
mkeyaerts@gmail.com 
 
SECRETARIAAT 
TEL 02 477 50 20 
Page 23 of 23 
 
 
19. Dekempeneer Y, Keyaerts M, Krasniqi A, Puttemans J, Muyldermans S, Lahoutte T, 
D'Huyvetter M, Devoogdt N.Targeted alpha therapy using short-lived alpha-particles and 
the promise of nanobodies as targeting vehicle. Expert Opin Biol Ther. 2016 May 19:1-13. 
20. Pruszynski M, Koumarianou E, Vaidyanathan G, Revets H, Devoogdt N, Lahoutte T, 
Zalutsky MR. Targeting breast carcinoma with radioiodinated anti-HER2 Nanobody. Nucl 
Med Biol 2013;40(1):52-9 
21. Pruszynski M, Koumarianou E, Vaidyanathan G, Revets H, Devoogdt N, Lahoutte T, Lyerly 
HK, Zalutsky MR. Improved tumor targeting of anti-HER2 nanobody through N-succinimidyl 
4-guanidinomethyl-3-iodobenzoate radiolabeling. J Nucl Med. 2014 Apr;55(4):650-6 
22. Broisat A, Hernot S, Toczek J, De Vos J, Riou LM, Martin S, Ahmadi M, Thielens N, 
Wernery U, Caveliers V, Muyldermans S, Lahoutte T, Fagret D, Ghezzi C, Devoogdt N. 
Nanobodies targeting mouse/human VCAM1 for the nuclear imaging of atherosclerotic 
lesions. Circ Res 2012;110(7):927-37