Pilot Study Evaluating Panitumumab-IRDye800 and 89Zr-Panitumumab for Dual-Modality Imaging for Nodal Staging in Head and Neck Cancer
Phase: PHASE1
Conditions: Squamous Cell Carcinoma of the Head and Neck, Carcinoma of the Head and Neck
Sponsor: Andrei Iagaru

 
IRB-41878 / ENT0066 
Page 1 of 51 
19 August 2021 
 
Pilot Study Evaluating Panitumumab-IRDye800 and 89Zr-Panitumumab for 
Dual-Modality Imaging for Nodal Staging in Head and Neck Cancer 
IRB-41878  
ENT0066 
NCT03733210 
 
Relevant US FDA submissions: 
  
89Zr-panitumumab: 
IND 135573, Andrei Iagaru, MD (IND-holder) 
 
 
(NCI’s IND 116229 is incorporated by cross-reference)  
  
Panitumumab-IRDye800: 
IND 119474, incorporated by cross-reference  
 
 
(Eben L. Rosenthal, MD)  
  
Cetuximab-IRDye800: 
IND 115706, incorporated by cross-reference  
 
 
(Eben L. Rosenthal, MD)  
  
IRDye800 
Master File MF-25167, incorporated by cross-reference  
 
 
(LI-COR Biosciences, Inc)  
 
SRC approval date: 
03 April 2018 
 

 
IRB-41878 / ENT0066 
Page 2 of 51 
19 August 2021 
 
Version date 
Document History 
12 Jun 2017 
Full draft, for initial IRB and pre-IND submission 
20 Dec 2017 
Initial Version – IRB/FDA/SRC 
26 Mar 2018 
Final SRC Comments 
08 Jun 2018 
Initial IND submission 
07 Jul 2018 
Received “Study may proceed” from FDA 
04 Sep 2018 
IRB approval granted for the study 
01 Mar 2019 
Protocol modifications: 
- 
Personnel update: Added Roan Raymundo as CRC, Kristen Cunanan as statistician 
(substituting previous statistician Vandana Sundaram), and Fred Baik as co-investigator 
- 
Clarify language regarding study procedures (section 9) 
- 
Addition Appendix C that includes a device list used for detection/imaging of 
89Zr-panitumumab 
12 Apr 2019 
Protocol modifications: 
- 
Removal of “Received an investigational drug within 30 days prior to first dose of 
panitumumab-IRDye800” as an exclusion criterion (section 3.2 and Appendix A). 
- 
Addition of correlative studies for primary tumor assessment (section 8).  
- 
Addition of collection of vital signs just before infusion of the 89Zr-panitumumab bolus 
infusion (section 9.2.2) 
- 
Updated Appendix C with in-house developed 1mm resolution mobile PET system 
(collaboration with dr. Craig Levin, Radiology).  
17 Sep 2019 
Protocol modifications: 
- 
Extension of window of PET/CT from Day 0 to the Day before Surgery. 
- 
Inclusion of dosimetry sub-study (3-5 subjects) to collect dosimetry data that will 
provide insight on 89Zr-panitumumab toxicity data. 
- 
Clarification on Day 15 and Day 30 study procedures.  
- 
Personnel updates: Removed Andrew Birkeland, MD as co-investigator. 
- 
Administrative changes to the protocol document. 
13 Jan 2020 
- 
Removal Stefania Chirita as CRC, addition of Grace Yi as CRC 
20 Apr 2020 
- 
Dose modification of panitumumab-IRDye800 
Revisions to Appendix B include: 
- 
Addition of investigational device "OnLume Imaging System" 
- 
Removal of investigational device “PDE-NEO II” 
8 May 2020 
- 
Removes investigational device "OnLume Imaging System," erroneously identified as 
the intraoperative near-infrared fluorescence imaging device “Asimov 7685”  
- 
Adds investigational device “PDE-NEO II” back to protocol. 
- 
Add identifiers for IND number and NCT number 
19 Aug 2021 
(also in 6 Aug 2020 
versions) 
Protocol modifications (non-significant change) – Addition of investigational device: 
- 
“IMAGE1 S RUBINA System” for evaluation of excised tissue only, not for treatment 
decisions  
19 Aug 2021 
(also in 23 Apr 2021 / 
5 April 2021 versions) 
Protocol modifications:  
- Clarified expected Adverse Event collected window to only designated study dates 
- Cardiac Monitoring, Adverse Event and Serious Adverse Event reporting clarification 
- Change IND-holder to Andrei Iagaru, MD  
 

 
IRB-41878 / ENT0066 
Page 3 of 51 
19 August 2021 
 
Pilot Study Evaluating Panitumumab-IRDye800 and 89Zr-Panitumumab for 
Dual-Modality Imaging for Nodal Staging in Head and Neck Cancer 
Coordinating Center 
Stanford Cancer Institute;  Stanford Medicine at Stanford University  
875 Blake Wilbur Drive 
Stanford, CA 94305 
-Principal Investigator;  Protocol Director;  and IND-holder 
Andrei Iagaru, MD 
Professor of Radiology 
Dept of Radiology, Division of Nuclear Medicine 
Stanford Medicine at Stanford University M/C 5281 
300 Pasteur Drive, Room H2200 
Stanford, CA 94305 
 
  
Co-Investigator 
Dimitrios Colevas, MD 
Stanford Cancer Institute 
875 Blake Wilbur Dr  
Stanford, CA 94305-5826 
 
  
Co-Investigator 
Frederick T. Chin, PhD  
Assistant Professor-Research, Dept of Radiology 
1201 Welch Road, Room PS049 
Stanford, CA 94305 
 
  
Co-Investigator 
Vasu Divi, MD  
Assistant Professor of Otolaryngology 
Head and Neck Surgery  
875 Blake Wilbur Dr, CC-2223 
Stanford, CA 94305-5826 
 
   
Co-Investigator 
Fred Baik, MD  
Assistant Professor of Otolaryngology 
Head and Neck Surgery  
900 Blake Wilbur Dr 
Stanford, CA 94305-5826 
 
   
Co-Investigator 
Chris Holsinger, MD  
Professor, Chief of Head and Neck Surgery 
Stanford Cancer Center 
875 Blake Wilbur Drive, CC-2227  
Stanford, CA 94305 
 
  
Co-Investigator 
Guido Davidzon, MD  
Clinical Assistant Professor of Radiology 
300 Pasteur Dr, H2200  
Stanford, CA 94305  
  
  

 
IRB-41878 / ENT0066 
Page 4 of 51 
19 August 2021 
Biostatistician 
Kristen Cunanan, PhD 
Senior Biostatistician, Quantitative Sciences Unit 
Stanford University School of Medicine 
1070 Arastradero Road, Room 235 
Palo Alto, CA 94304 
 
  
Postdoctoral Researcher 
Nynke S. van den Berg, PhD 
Department of Otolaryngology 
Center for Clinical Sciences Research 
Stanford University 
 
   
Research Data Analyst 
Valentina Ferri 
Department of Radiology 
Division of Nuclear Medicine and Molecular Imaging 
Stanford University Medical Center 
300 Pasteur Dr, H2200 
Stanford, CA 94305 
  
Study Coordinator 
Roan Courtney Raymundo 
Cancer Clinical Trials Office 
Stanford University Medical Center 
800 Welch Rd, FC2C103 
Palo Alto, CA 94304 
 
  
Study Coordinator 
Alexander A. Valencia 
Cancer Clinical Trials Office 
Stanford University Medical Center 
800 Welch Rd, FC3C62 
Palo Alto, CA 94304 
 
 
Study Coordinator 
Grace Yi 
Cancer Clinical Trials Office 
Stanford Univ, Medical Center 
800 Welch Rd, FC3C62 
Palo Alto, CA 94304 
 
 

 
IRB-41878 / ENT0066 
Page 5 of 51 
19 August 2021 
TABLE OF CONTENTS 
PROTOCOL SYNOPSIS ..................................................................................................................... 7 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS................................................................ 10 
SCHEMA ........................................................................................................................................ 11 
1. OBJECTIVES ............................................................................................................................ 12 
1.1. PRIMARY OBJECTIVE .............................................................................................................. 12 
1.2. SECONDARY OBJECTIVE .......................................................................................................... 12 
1.3. EXPLORATORY OBJECTIVES ..................................................................................................... 12 
2. BACKGROUND ....................................................................................................................... 12 
2.1 
STUDY DISEASE .................................................................................................................... 14 
2.2  STUDY AGENTS .................................................................................................................... 14 
2.2.1 
89Zr-panitumumab............................................................................................................................................... 14 
2.2.2 
Panitumumab-IRDye800 .................................................................................................................................. 14 
2.3 
RATIONALE .......................................................................................................................... 14 
2.4 
STUDY DESIGN ..................................................................................................................... 15 
3. PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES ............................................... 18 
3.1 
INCLUSION CRITERIA .............................................................................................................. 18 
3.2 
EXCLUSION CRITERIA ............................................................................................................. 19 
3.3 
INFORMED CONSENT PROCESS ................................................................................................ 19 
3.4 
ENROLLMENT PROCESS .......................................................................................................... 19 
3.5 
STUDY TIMELINE ................................................................................................................... 19 
4. TREATMENT PLAN ................................................................................................................. 19 
4.1 
TREATMENT SCHEDULE .......................................................................................................... 19 
4.2 
ADMINISTRATION OF STUDY AGENTS ......................................................................................... 20 
4.3  DOSE RATIONALE.................................................................................................................. 20 
4.4  DEFINITION OF DOSE-LIMITING TOXICITY (DLT) AND COHORT EXPANSION ....................................... 23 
4.5  STUDY DRUG DISCONTINUATION ............................................................................................. 23 
4.6  GENERAL CONCOMITANT MEDICATION AND SUPPORTIVE CARE GUIDELINES .................................... 23 
4.7 
 CRITERIA FOR REMOVAL FROM STUDY ...................................................................................... 23 
4.8 
ALTERNATIVES AND RISK PROTECTION / MITIGATION .................................................................. 23 
5 
INVESTIGATIONAL AGENT INFORMATION ........................................................................... 24 
5.1 
DESCRIPTION OF STUDY DRUGS ............................................................................................... 24 
5.1.1 89Zr-panitumumab .................................................................................................................................................... 24 
5.1.2 Panitumumab-IRDye800 ....................................................................................................................................... 26 
5.2 EXPECTED TOXICITIES ................................................................................................................ 27 
5.2.1 Expected Toxicities of 89Zr-panitumumab ..................................................................................................... 27 
5.2.2 Expected Toxicities of Panitumumab-IRDye800......................................................................................... 28 
5.3 AVAILABILITY ........................................................................................................................... 30 
5.4 AGENT ORDERING .................................................................................................................... 30 
5.5 AGENT ACCOUNTABILITY ............................................................................................................ 30 
6. DOSE MODIFICATIONS .......................................................................................................... 30 

 
IRB-41878 / ENT0066 
Page 6 of 51 
19 August 2021 
7. ADVERSE EVENTS AND REPORTING PROCEDURES .............................................................. 30 
7.1 
ADVERSE EVENT ................................................................................................................... 30 
7.2 
SERIOUS ADVERSE EVENT ....................................................................................................... 30 
7.3 
ASSESSMENT OF CAUSALITY .................................................................................................... 31 
7.4 
SEVERITY OF ADVERSE EVENTS ................................................................................................ 31 
7.5 
SAFETY MONITORING AND REPORTING ..................................................................................... 32 
7.5.1 Monitoring of Adverse Events .............................................................................................................................. 32 
7.5.2 Recording and Reporting Adverse Events and Serious Adverse Events ........................................... 32 
8. CORRELATIVE/SPECIAL STUDIES ........................................................................................... 33 
9. STUDY CALENDAR.................................................................................................................. 34 
9.1 STUDY PROCEDURES ................................................................................................................. 34 
9.2 STUDY PROCEDURES ................................................................................................................. 36 
9.2.1 Screening/Pre-Treatment (Within 30 days of treatment start) ......................................................... 36 
9.2.2 Day 0 ................................................................................................................................................................................ 37 
9.2.3. 
Day 1 to Day before Surgery: .......................................................................................................................... 37 
9.2.4.    Day 2 to 5 (Day of Surgery) .............................................................................................................................. 38 
9.2.5.     Day 15 (± 4 days) ................................................................................................................................................. 38 
9.2.6 Day 30 (± 4 days) ....................................................................................................................................................... 38 
9.3 DESCRIPTION OF EVALUATIONS / PROCEDURES .............................................................................. 38 
9.3.1 
Laboratory Evaluations .................................................................................................................................... 38 
9.3.2 
Physical Examinations ....................................................................................................................................... 39 
9.3.3 
Medical History ..................................................................................................................................................... 39 
9.3.4 
Vital Signs ................................................................................................................................................................ 39 
9.3.5 
Tumor and lymph node imaging .................................................................................................................. 39 
9.3.6 
Cardiac Monitoring ............................................................................................................................................. 39 
10. MEASUREMENTS ................................................................................................................... 39 
10.1  PRIMARY OUTCOME MEASURE ............................................................................................... 39 
10.2  SECONDARY OUTCOME MEASURES .......................................................................................... 40 
11. REGULATORY REQUIREMENTS ............................................................................................. 40 
11.1 INSTITUTIONAL REVIEW OF PROTOCOL ...................................................................................... 40 
11.2 DATA AND SAFETY MONITORING PLAN ..................................................................................... 40 
11.3 DATA MANAGEMENT PLAN .................................................................................................... 41 
12. STATISTICAL CONSIDERATIONS ............................................................................................ 41 
13. REFERENCES ........................................................................................................................... 43 
APPENDICES .................................................................................................................................. 46 
APPENDIX A:  PARTICIPANT ELIGIBILITY CHECKLIST ............................................................................. 46 
APPENDIX B:  OPTICAL IMAGING MODALITIES: OVERVIEW .................................................................. 48 
APPENDIX C:  IMAGING MODALITIES FOR THE DETECTION OF 89ZR: OVERVIEW ....................................... 50 
APPENDIX D: IMAGE1 S RUBINA SYSTEM KARL STORZ COMPONENTS OVERVIEW .. ERROR! BOOKMARK 
NOT DEFINED. 

 
IRB-41878 / ENT0066 
Page 7 of 51 
19 August 2021 
PROTOCOL SYNOPSIS  
TITLE 
Pilot Study Evaluating Panitumumab-IRDye800 and 89Zr-Panitumumab for Dual-Modality 
Imaging for Nodal Staging in Head and Neck Cancer 
STUDY PHASE 
Early phase 1 (pilot study) 
INDICATION 
Biopsy confirmed diagnosis of squamous cell carcinoma of the head and neck (HNSCC). 
Subjects diagnosed with any T stage, any subsite within the head and neck that are 
scheduled to undergo surgical resection. Subjects with recurrent disease or a new primary 
will be allowed. 
INVESTIGATIONAL 
PRODUCT  
89Zr-panitumumab and panitumumab-IRDye800. 
This study seeks to determine if the combined use of 
89Zr-panitumumab and 
panitumumab-IRDye800 can be used to identify tumor-loaded lymph nodes in subjects 
with HNSCC who undergo surgery with curative intent. The table below summarizes the 
planned dose level. 
Dosing Schedule 
No of subjects 
14 
Dose of  
panitumumab-IRDye800 
30 mg  
Dose of  
89Zr-panitumumab 
1.0 mCi, allowable range: 
0.8 to 1.2 mCi (29 to 45 Mbq) 
Specific Activity of 89Zr-panitumumab 
> 200 Ci/mmol 
PET imaging post-injection 
Day 0 to Day before Surgery 
Timing of intraoperative imaging and surgical 
procedure post-injection 
Day 2 to 5 post-infusion 
 
 
TREATMENT 
SCHEDULE  
Subjects receive 18F-FDG-PET/CT and/or 18F-FDG-PET/MRI as part of their standard of care 
prior to study enrollment. After infusion of study agents on Day 0, subjects will undergo 
89Zr-panitumumab PET/CT imaging between Day 0 and the Day before Surgery. Subjects 
enrolled in the dosimetry sub-study will undergo imaging on day 0 to the day before 
surgery, for a total of 3 PET/CT scans.  
 
Subjects will undergo surgical resection at 2-5 days after infusion (see figure below) based 
on expected half-life of panitumumab-IRdye800. Imaging will be performed 
intraoperatively using the optical imaging devices listed in Appendix B and the 
89Zr-detecting/imaging devices listed in Appendix C. The oncologic surgery will be 
conducted following the standard of care. Ex vivo imaging of the specimen prior to 
pathological assessment will be performed using non-invasive radioactive and fluorescence 
imaging modalities that do not violate or destroy the tissue. 
 
TREATMENT 
SCHEDULE  
Subjects receive 18F-FDG-PET/CT and/or 18F-FDG-PET/MRI as part of their standard of care 
prior to study enrollment. After infusion of study agents on Day 0, subjects will undergo 
89Zr-panitumumab PET/CT imaging between Day 0 and the Day before Surgery. Subjects 
enrolled in the dosimetry sub-study will undergo imaging on day 0 to the day before 
surgery, for a total of 3 PET/CT scans.                                                                        (continued) 

 
IRB-41878 / ENT0066 
Page 8 of 51 
19 August 2021 
TREATMENT 
SCHEDULE  
Subjects will undergo surgical resection at 2-5 days after infusion (see figure below) based 
on expected half-life of panitumumab-IRdye800. Imaging will be performed 
intraoperatively using the optical imaging devices listed in Appendix B and the 
89Zr-detecting/imaging devices listed in Appendix C. The oncologic surgery will be 
conducted following the standard of care. Ex vivo imaging of the specimen prior to 
pathological assessment will be performed using non-invasive radioactive and fluorescence 
imaging modalities that do not violate or destroy the tissue. 
PRIMARY 
OBJECTIVE(S) 
Determine the sensitivity and specificity of 89Zr-panitumumab for the detection of 
tumor-involved regional lymph nodes. 
As defined by histological and/or pathological evaluation (gold standard), the total number 
of tumor-positive nodes will be determined and correlated to the radiologically-suspicious 
nodes identified by 89Zr-panitumumab and 18F-FDG contrast agents using PET/CT and/or 
PET/MRI imaging. The specificity and sensitivity of 89Zr-panitumumab will be calculated 
and compared to the specificity and sensitivity of 18F-FDG for metastatic lymph node 
identification. 
SECONDARY 
OBJECTIVE(S) 
Determine the number (proportion) of lymph nodes determined to be tumor-positive by 
histological and/or pathological evaluation that were NOT predicted tumor-positive by 
89Zr-panitumumab.  
As defined by histological and/or pathological evaluation (gold standard), the total number 
of tumor-positive nodes will be determined and compared to the 89Zr-panitumumab and 
18F-FDG-PET/CT and/or -PET/MRI imaging findings. We will compare the odds of a false 
negative using 89Zr-panitumumab-PET relative to the odds of a false negative using a 
18F-FDG-PET and compare their respective negative predictive values. 

 
IRB-41878 / ENT0066 
Page 9 of 51 
19 August 2021 
EXPLORATORY 
OBJECTIVE(S) 
 
Determine the sensitivity and specificity of panitumumab-IRDye800 for the detection 
of tumor-involved regional lymph nodes. 
After isolation of lymph nodes from the specimen in the pathology lab, lymph node 
fluorescence will be measured prior to histological and/or pathological evaluation 
(gold standard). Sensitivity and specificity will be calculated by comparison of 
fluorescence intensity to histological and/or pathological evaluation (gold standard). 
Results will be compared to the sensitivity and specificity of 89Zr-panitumumab and 
18F-FDG (primary objective).  
 
Determine the number (proportion) 
of lymph nodes determined to 
be 
tumor-positive by histological and/or pathological evaluation that were NOT 
predicted tumor-positive by panitumumab-Irdye800.  
We will compare the odds of a false negative using fluorescence imaging of 
panitumumab-IRDye800 to the odds of a false negative using 89Zr-panitumumab-PET 
and 18F-FDG-PET and compare the negative predictive values. Additionally, we will test 
the association of the panitumumab-Irdye800 results to 89Zr-panitumumab-PET and 
18F-FDG-PET results with the Phi coefficient. 
SAMPLE SIZE AND 
DURATION 
OF 
STUDY 
It is anticipated that 14 subjects will be enrolled into the study. Safety data and adverse 
events will be reported at 15 days after the last subject receives the infusion, which is in 
excess of 4-fold the half-life of the largest dose of pantimumab-IRDye800 (2.3 days) and of 
the half-life of 89Zr-panitumumab (3.3 days). Each subject will be followed for 30 days 
following the last dose of study medication. 
  
It is anticipated that the study will require 12 to 18 months to be completed.   
STATISTICAL 
CONSIDERA-TIONS 
General analysis tools  
All specimens from both cohorts will be pooled for the primary and secondary analyses. 
We will use the matched pair Durkalski’s test that accounts for the correlation of multiple 
specimens per patent, to compare the specificity and sensitivity of 89Zr-panitumumab-PET 
to 18F-FDG-PET. We will compare the odds of a false negative with 89Zr-panitumumab-PET 
relative to the odds of obtaining a false negative with 18F-FDG-PET.  
 
Approach to drawing statistical inference  
Significance for all tests will be assessed at the 0.05 level and 95% confidence intervals will 
be reported and interpreted. 
 
Descriptive statistics 
We will present means and standard deviations (or medians and interquartile ranges when 
appropriate) for continuous characteristics such as maximum standard uptake values 
(SUVmax) as determined with 89Zr-panitumumab-PET and 18F-FDG-PET and radioactivity 
counts of 89Zr-panitumumab in the node(s) as determined with the PET probe, and 
tumor-to-background ratios (TBRs) and mean florescence intensity (MFI) for 
panitumumab-Irdye800. For categorical variables such as drainage pattern and number of 
lymph nodes visualized, we will present frequency statistics. Graphical tools such as heat 
maps, histograms, and boxplots will be used to assess distributional properties of 
continuous variables. We will illustrate the nature of the relationship between 
SUVmax/radioactivity counts and/or MFI/TBRs and/or drainage pattern across all subjects, 
the relationship will be illustrated with a heat map and spaghetti plot. When appropriate, 
transformations – including a log-based transformation – may be considered to stabilize 
variance. 

 
IRB-41878 / ENT0066 
Page 10 of 51 
19 August 2021 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS  
89Zr 
Zirconium-89 
AE 
Adverse Event 
BID 
Twice Daily 
BSA 
Body Surface Area 
CBC 
Complete Blood Count 
CI 
Confidence Interval 
CMAX 
Maximum Concentration Of Drug 
CNS 
Central Nervous System 
CRF 
Case Report/Record Form 
CTCAE 
Common Terminology Criteria For Adverse Events 
DLT 
Dose-Limiting Toxicity 
DSMC 
Data Safety Monitoring Committee 
ECG 
Electrocardiogram 
ECOG 
The Eastern Cooperative Oncology Group 
EGFR 
Epidermal Growth Factor Receptor 
FDA 
Food and Drug Administration 
GI 
Gastrointestinal 
GMP 
Good Manufacturing Practice 
Hgb 
Hemoglobin 
HNSCC 
Head And Neck Squamous Cell Carcinoma 
HTN 
Hypertensions 
ILD 
Interstitial Lung Disease 
IND 
Investigational New Drug 
IRB 
Institutional Review Board 
IV 
Intravenous 
LLN 
Lower Limit Of Normal  
MTD 
Maximum Tolerated Dose 
NIR 
Near Infra-Red 
NHS 
N-hydroxysuccinimide 
PLT 
Platelet 
RBC 
Red blood cell 
SAE 
Serious Adverse Event 
SCC 
Squamous Cell Carcinoma 
TBR 
Tumor to Background Ratio 
SCCHN 
Squamous cell carcinoma of the head and neck  
TSH 
Thyroid stimulating hormone  
UAB 
University of Alabama at Birmingham 
ULN 
Upper Limit Of Normal 
UNK 
Unknown 
WBC 
White blood cell 
WHO 
World Health Organization 

 
IRB-41878 / ENT0066 
Page 11 of 51 
19 August 2021 
SCHEMA 
Figure 1. Study overview. 
 
Study plan. The study is an open label, single institution, pilot study to determine the distribution 
pattern of 89Zr-panitumumab and panitumumab-IRDye800 in subjects with head and neck squamous cell 
carcinoma (HNSCC) that undergo surgery with lymphadenectomy of curative intent. 30 mg of 
panitumumab-IRDye800 will be administered 1-5 days prior to surgery, intravenous (IV) over 15 min 
followed by an observation period of 30 min. 89Zr-panitumumab will be systemically injected at a dose of 
1.0 mCi +/- 20%, and with a specific activity greater than 200 Ci/mmol at the time of injection. The 
injected mass dose is less than or equal to 1 mg (7 nmol); the subject will be monitored for 1 hour 
post-administration. If at any point two subjects in a cohort experience a DLT, then the study will stop 
and safety data will be reviewed. The medical monitor and safety review will occur independently. 
 
There will be 7 subjects enrolled into each cohort (total of 14 subjects in the study) whereby, based on 
the preoperative work-up, including a physical exam and evaluation of the pre-existing imaging data, 
subjects will be assigned to the node negative or node positive group. 
 
Rationale for the two cohorts. To ensure the inclusion of sufficient subjects with clinically positive 
lymph nodes, we created a cohort structure. Including both node-positive and node-negative subjects 
will ensure that we will have tumor-positive nodes when performing the data analysis. Moreover, by 
analyzing data from node-positive subjects it will become possible to assess if, in case large lymph node 
metastasis are present, the tracer(s) can still reach the node or if rerouting (a phenomenon known to 
happen in sentinel node mapping, i.e., drainage to a “false” sentinel node occurs because the “true” 
sentinel node cannot be reached). As shown in the study schema, all subjects regardless if enrolled in 
cohort 1 or 2, will undergo the same treatment, and upon data collection statistical analysis will be 
performed with the pooled data. 

 
IRB-41878 / ENT0066 
Page 12 of 51 
19 August 2021 
1. 
OBJECTIVES 
1.1. 
Primary Objective 
 
Determine the sensitivity and specificity of 89Zr-panitumumab for the detection of tumor-involved 
regional lymph nodes. 
As defined by histological and/or pathological evaluation (gold standard), the total number of 
tumor-positive nodes will be determined for both 89Zr-panitumumab and 18F-FDG-PET imaging findings. 
The specificity and sensitivity of 89Zr-panitumumab will be calculated and compared to the specificity 
and sensitivity of 18F-FDG for metastatic lymph node identification. Additionally, we will determine the 
level of association between the 89Zr-panitumumab-PET results and 18F-FDG-PET results with the Phi 
coefficient. 
 
1.2. 
Secondary Objective  
Determine the number (proportion) of lymph nodes determined to be tumor-positive by histological 
and/or pathological evaluation that were NOT predicted tumor-positive by 89Zr-panitumumab 
labeling.  
We will calculate the odds of a false negative using 89Zr-panitumumab-PET relative to the odds of a false 
negative using a 18F-FDG-PET and compare the negative predictive values of 89Zr-panitumumab-PET and 
18F-FDG-PET. 
 
1.3. 
Exploratory Objectives  
 
Determine the sensitivity and specificity of panitumumab-IRDye800 for the detection of 
tumor-involved regional lymph nodes. 
After isolation of lymph nodes from the specimen in the pathology lab, lymph node fluorescence will 
be measured prior to histological and/or pathological evaluation (gold standard). Sensitivity and 
specificity will be generated by comparison of fluorescence intensity and histological and/or 
pathological evaluation (gold standard). Findings will furthermore be compared to the sensitivity and 
specificity of 89Zr-panitumumab and 18F-FDG (primary objective). 
 
Determine the number (proportion) of lymph nodes determined to be tumor-positive by 
histological and/or pathological evaluation that were NOT predicted tumor-positive by 
panitumumab-Irdye800 labeling.  
We will measure the level of association between panitumumab-IRDye800 results and 
89Zr-panitumumab-PET and 18F-FDG-PET results with the Phi coefficient.  
 
Dosimetry 
In a subset of 3-5 subjects, dosimetry data will be collected to determine the toxicity of 
89Zr-panitumumab to the organs.  
 
NOTE:  It is planned that exploratory objectives will only be reported in publication(s), if any, but not on 
ClinicalTrials.gov. 
 
 
2. 
BACKGROUND 
The most important determinant of survival for many cancer types is the presence of lymph node 
metastasis (1–3). In head and neck cancer, nodal metastases reduce 5-year survival to half, regardless of 
the primary tumor T stage (2–4). Likewise, regional metastases to axillary nodes in breast cancer 
decreases 5-year survival by approximately one-third (5). Although nodal disease can often be detected 
on routine physical exam or anatomic imaging with or without metabolic imaging, there are many cases 
where clinical and radiographic exams are negative, but microscopic disease is identified within the 

 
IRB-41878 / ENT0066 
Page 13 of 51 
19 August 2021 
primary nodal basin. This finding dramatically changes the diagnosis, and as a result, great effort is taken 
to harvest the first echelon lymph node(s) during removal of the primary tumor. When metastatic 
disease is too small to be detected preoperatively, this leads to down staging and under treatment. 
 
Complete nodal dissection causes significant morbidity. The gold standard for detection of regional 
metastatic disease in HNSCC traditionally has been a regional nodal dissection that is associated with 
shoulder dysfunction and pain due to accessory nerve (cranial nerve XI) injury being common after neck 
dissection (6–9). Moreover, 60% to 80% of subjects undergoing a neck dissection with sectioning of the 
nerve have pain, limited abduction of the shoulder, and anatomic deformities such as scapular flaring, 
droop, and protraction (10). To reduce morbidity, there has been a gradual migration away from 
extensive dissection to more limited dissection offered by sentinel node biopsy where only the primary 
tumor draining lymph node(s) are removed for detailed histologic examination (5,11–14). Where 
sentinel node biopsy has already displaced regional lymphadenectomy in melanoma and breast surgery 
to avoid the associated deficits associated with this more aggressive approach, it is now also advocated 
for HNSCC (NCCN guidelines, version 1, 2017/2018).  
 
Sentinel lymph node biopsy is performed as a surgical staging method to detect occult nodal disease in 
those tumor types with a high metastatic rate and where lymph node disease predicts outcome and 
informs adjuvant treatment decisions. The premise of sentinel node surgery is that regional metastasis 
from the primary tumor occurs through drainage of lymphatics to a single (or several) lymph nodes that 
can only be defined by mapping at the time of surgery. Sentinel node mapping occurs by local 
radiotracer or blue dye injection surrounding the primary tumor, thereby identifying the natural 
lymphatic drainage pattern from the primary tumor directly to the sentinel node(s). Sentinel nodes 
undergo aggressive histopathologic exam to assess for micro- or macro-metastatic disease. 
 
Meta-analysis of sentinel node dissection in breast cancer, head and neck cancer, and melanoma have 
validated the accuracy of sentinel node biopsy in predicting occult lymph node metastasis (5,14–16), 
with a sensitivity of 91% (9) and a 3 to 10% false-negative rate. The false-negative rate can be due to 
poor injection technique or not anticipating the full extent of disease during injection, but the rerouting 
and skip metastasis phenomenon’s have been postulated here as well (17–19). Moreover, although 
sentinel node mapping is superior to radiographic and clinical exam, it is still limited by the need for 
direct injection of the dye or radiolabeled compound. Upstaging with sentinel node assessment can 
thus only be assessed in tumor types that are accessible for local injection. This is significant because it 
influences standard of care (sentinel node surgery or complete lymphadenectomy) in these subject 
populations only. Identification of regional disease will inform prognostic information and/or determine 
the need and extent of adjuvant therapies for additional tumor types. Most importantly however, 
remains the fact that both lymphadenectomy and sentinel node biopsy do not allow for intraoperative 
lymph node staging. In both cases, post-operative (histo-) pathological evaluation is required to 
determine whether or not lymph node metastasis were present in the regional lymph node basin(s). 
Thus, HNSCC patients would benefit from an alternative technique that, ideally, allows for both 
preoperative as well as intraoperative lymph node staging. 
 
Fluorescently labeled antibodies are currently used to target and visualize tumor cells 
intra-operatively. The safety and efficacy of cetuximab-IRDye800 were evaluated in the phase 1 clinical 
trial entitled “Open-label Study Evaluating the Safety and Pharmacokinetics of Escalating Doses of 
cetuximab-IRDye800 as an Optical Imaging Agent to Detect Cancer During Surgical Procedures,” 
(incorporated to IND by cross-reference). A second phase 1 clinical trial is currently in progress, and is 
entitled “Open-label Study Evaluating the Safety and Pharmacokinetics of Escalating Doses of 

 
IRB-41878 / ENT0066 
Page 14 of 51 
19 August 2021 
Panitumumab-IRDye800 as an Optical Imaging Agent to Detect Head and Neck Cancer During Surgical 
Procedures” (IRB-35064, incorporated to IND by cross-reference).  
 
This clinical trial is proposed to determine if a systemic injection of tracer labeled antibody will 
specifically accumulate in tumor containing lymph nodes to enhance identification. If successful, we 
will leverage existing technologies, PET and fluorescently labeled antibodies, in order to expand regional 
lymph node assessment to cancer types where direct injection is not possible. 
 
2.1 
Study Disease 
This study is being performed in head and neck squamous cell carcinoma (HNSCC). Because the standard 
of care in this setting is currently complete lymphadenectomy, our proposed method will allow direct 
comparison with conventional lymphadenectomy and thus calculation of false positive and negative 
rates, sensitivity and specificity. Potential expansion to other cancer types not readily accessible for 
tracer injection, e.g., ovarian, uterine, and pancreatic cancer, are possible after showing the feasibility 
and validity of the approach in this study. 
 
2.2  
Study Agents 
The study agents for this trial are 89Zr-panitumumab and panitumumab-IRDye800.  
 
2.2.1 
89Zr-panitumumab  
89Zr-panitumumab is a conjugate of 89Zr, the radioactive isotope of zirconium (Zr), and panitumumab, 
the fully-humanized anti-epidermal growth factor receptor (anti-EGFR) IgG2 monoclonal antibody 
approved by FDA as Vectibix. The approved single agent indication for Vectibix is treatment of 
metastatic colorectal carcinoma with disease progression. See Section 5.1.1 for more information. 
 
2.2.2 
Panitumumab-IRDye800  
Panitumumab-IRDye800 is a conjugate of panitumumab and IRDye® 800CW N-hydroxysuccinimide 
(NHS) ester infrared dye (LI-COR Biosciences, Inc., Lincoln, NE). See Section 5.1.2 for more information 
regarding panitumumab-IRDye800. 
 
2.3 
Rationale 
Overall Impact of proposed studies on surgical oncology 
Upstaging with sentinel node assessment has only been assessed in tumor where the tumors are 
accessible for local injection. We plan to determine if additional tumor types are amenable to regional 
lymph node staging after systemic injection of tracer labeled antibody. Identification of a novel lymph 
node detection methodology has the potential to 1) increase the sensitivity and decrease the false 
negative rate by avoiding the variability of direct injection; and 2) allow study of lymph nodes within 
non-superficial cancer types that are known to metastasize such as prostate, ovarian, uterine, lung and 
pancreatic cancers.  
 
Although this study assesses an EGFR-directed antibody, this work, if successful, would have implications 
for any large protein-based imaging strategy. Currently, at least 12 such trials exist on ClinicalTrials.gov.  

 
IRB-41878 / ENT0066 
Page 15 of 51 
19 August 2021 
 
The methodology of this study and future studies could dramatically improve the standard of care in 
the following ways: 
1)  Non-invasive detection of subclinical disease may allow improved subject selection for surgery as 
well as provide the surgeon with a roadmap for planning the surgical procedure.  
2)  Detect subclinical disease in the operating room at the time of resection:  Accurate identification 
of nodes may identify metastasis not detected by PET, and early identification of metastasis will 
improve survival. 
3)  Real time feedback provided the radioactive and fluorescence signatures of the tracers:  Combined 
use could ultimately improve both the sensitivity and specificity of metastatic cancer detection and 
the ability to accurately resect it. 
4)  Reduction of surgery time:  Although outside the scope of this study, successful identification of 
nodes in the clinic may reduce surgery time by reducing the need for complete nodal resection, 
reducing surgery time by up to 40 minutes. This might reduce the time subject is in surgery, and the 
cost of the surgery. 
5)  Increased survival rate:  Replacing complete nodal resection as the standard of care with 
tumor-directed node resection might decrease the negative effects that accompany complete 
resection, and might also improve survival rate.  
6)  This 
is 
the 
first-in-human 
dual 
modality 
study 
involving 
89Zr-panitumumab 
and 
panitumumab-IRDye800 for regional lymph node staging specifically focusing on the identification of 
tumor-loaded lymph nodes. However, promising results might lead to expansion of this 
methodology to use in other cancer types. Intravenous injection of antibody-labeled radiotracers 
would allow regional lymph node staging in other cancer types where local injection is not possible. 
This would tremendously broaden the application to those indications for which lymph node staging 
is considered of great prognostic value (eg, gynecological, urological).  
 
2.4 
Study Design 
For clinicaltrials.gov and Stanford Clinical Trials Directory compliance: 
 
The primary purpose for the protocol is to develop a universal lymph node detection strategy. 
This study evaluates if systemic injections of 
89Zr-panitumumab in conjunction with 
pantitumumab-IRDye800 can be used to identify tumor-loaded lymph nodes to expand the 
capabilities of non-invasive and intraoperative cancer imaging. 
 
The interventional model is Sequential. 
 
There are 2 cohorts. Both cohorts will receive the same treatment  
 
The study is open-label. No masking is used. 
 
The study is non-randomized. 
 
The primary outcome is the number (proportion) of lymph nodes determined to be 
tumor-positive by histological and/or pathological evaluation that were predicted to be 
tumor-positive by 89Zr-panitumumab PET/CT imaging. 
 
The secondary outcome is the number (proportion) of lymph nodes determined to be 
tumor-positive by histological and/or pathological evaluation that were NOT predicted 
tumor-positive by 89Zr-panitumumab PET/CT imaging.  
 
The study is an open-label pilot study to determine the efficacy of 89Zr-panitumumab in tumor-loaded 
node detection in subjects with HNSCC that undergo surgery with curative intent.  It is anticipated that 
14 subjects will be enrolled into the study. Subjects will be enrolled to the node negative (no suspicion 
of tumor-positive lymph nodes in the neck; cN0) or node positive (suspicion of tumor-positive lymph 

 
IRB-41878 / ENT0066 
Page 16 of 51 
19 August 2021 
nodes in the neck; cN+) group based on the preoperative work-up, which includes a physical exam and 
evaluation of the pre-existing imaging data. 
 
All subjects will receive a dose of 30 mg panitumumab-IRDye800. Subjects will subsequently receive 
1 mCi +/- 20% of 89Zr-panitumumab. If at any point after infusion, 2 subjects experience a DLT (Grade 2 
or greater toxicity), then the study will stop, and safety data will be reviewed.  
 
The known rate of infusion reactions of panitumumab is 1% (package insert); therefore, we expect a DLT 
rate of approximately 1% or higher with panitumumab-IRDye800 or 89Zr-panitumumab. The probability 
of observing two or more DLTs within a 10-subject cohort (requiring stopping the study) is 0.4%; if the 
DLT rate is as high as 5%, the probability of 2 or more DLT is 8.6%.  
 
For an overview of the proposed study, see Study Schema (page 9), and the dosing schedule below. 
Briefly, subjects will undergo 18F-FDG-PET prior to study enrollment, as is standard of care. 
Administration of panitumumab-IRDye800 will occur by IV over 15 minutes, followed by a 30-minute 
observation period. Administration of 89Zr-panitumumab will occur by IV, per radioactive drugs 
administration policies. The subjects will be observed for 1 hour following the 89Zr-panitumumab 
injection.  
 
After infusion of study agents on Day 0, subjects will undergo 89Zr-panitumumab PET/CT imaging. One 
scan will be performed at any time starting on Day 0 (after end of observation period post 
89Zr-panitumumab administration) and until the day before surgery (inclusive). Subjects enrolled in the 
dosimetry sub-study will undergo three scans, performed at any time starting on Day 0 (after end of 
observation period post 89Zr-panitumumab administration) and until the day before surgery. If available, 
the scans will be performed on Day 0, Day 1 and on the day before surgery.  
 
Subjects will undergo surgical resection 2-5 days after infusion of study drugs.  Imaging will be 
performed intraoperatively using a novel beta probe and/or high-energy gamma probe (see Appendix C 
for a list of devices) and the optical imaging devices (see Appendix B for a list of devices), to assess the 
tumor and lymph node(s) prior to resection, and the wound bed after surgical removal. The surgery will 
be conducted in the standard of care, and the surgeon will not use the imaging data to make decisions.  
 
Ex vivo, imaging of the specimens prior to pathological assessment will be performed using non-invasive 
imaging modalities that do not violate or destroy the tissue. These may include beta probe and/or 
high-energy gamma probe, an open-field imaging system, a closed-field imaging system and a 
fluorescence flatbed scanning device (see Appendix B and C for a list of devices). Additionally, a closed 
Cherenkov imaging system may be used to image the specimen after removal (see Appendix C). 
Methods have been described in detail in the literature (20–25). 
 
Table 1:  Dosing Schedule 
No. of subjects 
14 
Dose of panitumumab-IRDye800 
30 mg  
Dose of 89Zr-panitumumab 
1.0 mCi, allowable range 0.8 to 1.2 (29 to 44 Mbq) 
Specific Activity of 89Zr-panitumumab 
>200 Ci/mmol 
PET imaging post-infusion* 
Day 0 to the Day before Surgery 
Timing of surgical procedure post-infusion 
Day 2 to 5 post-infusion 
 

 
IRB-41878 / ENT0066 
Page 17 of 51 
19 August 2021 
Each subject will be followed for 30 days following the last dose of study medication. 
 
Outcome measures to answer the primary and secondary objectives set: 
Preoperative data: 
1. Collect safety data on tracer-infusion. 
2. The number and location of 18F-FDG-PET positive nodes. 
3. The number and location of 89Zr-panitumumab-PET positive nodes. 
 
Intraoperative data: 
4. The number and location of 89Zr-panitumumab-PET positive nodes.  
5. The number and location of panitumumab-IRDye800 positive nodes.  
 
Post-operative data: 
6. Collect safety data in follow-up (up to 30 days post-infusion). 
a. This includes tests and observations to identify both acute and late-treatment specific 
toxicity: vital signs; physical exam; toxicity grading; assignment of performance status; 
hematology; and blood chemistries (basic metabolic profile to include magnesium and 
phosphorus).  NCI Common Toxicity Criteria v5.0 will be used for grading of toxicity. 
7. Determine ex vivo fluorescence imaging information on panitumumab-IRDye800 (method 
described previously in (21)).  
8. Determine the histo-pathological status of the primary tumor. 
9. Determine the histo-pathological status of the lymph nodes: tumor-positive (isolated tumor 
cells, micro- or macro-metastasis) or tumor-negative.  
10. Determine, using immunohistochemistry, on the surgically excised tissue specimens:  
a. Tumor tissue viability 
b. EGFR expression 
c. Vessel density 
We have previously described the methods for analysis in (26).  
 
For qualification and quantification of the fluorescence signal and the radioactive signal, we follow the 
following rules: 
- 
Intraoperative fluorescence assessment of panitumumab-IRDye800:  
There will be no set level of fluorescence whereby we consider tissue positive or negative; it is based 
on operator’s impression.  
- 
Ex vivo fluorescence assessment of panitumumab-IRDye800: 
From the fluorescence images taken in the operation room, we will calculate tumor-to-background 
ratios (TBRs) as such to define a more quantitative read-out (similar to as described in the IRB-35064 
study). Based on the current data available from our IRB-35064, in our 50 mg cohort, we found an 
average TBR of 6.53±1.2, a sensitivity of 89±5.1%, a specificity of 92±3.5% (AUC: 0.93±0.05). The 
NPV and PPV were 94±2.8% and 92±9.5%, respectively. We will extrapolate these findings to the 
current study to further validate the findings from our phase I study (IRB-35064).   
- 
Radioactive assessment of 89Zr-panitumumab: 
Following the standard of care evaluation of PET/CT scans, maximum standard uptake values 
(SUVmax) will be calculated for the accumulation of 89Zr-panitumumab in tumor tissue and/or lymph 
nodes. As background reading, the SUVmax of the mediastinum will be determined.  
Tentative cutoff for ‘imaging positive’: an SUVmax value of the lymph nodes of minimally 1.4x the 
background (mediastinum). In all cases, (histo-) pathology serves as the gold standard for “true” 
positive / negative lymph nodes. Subsequently a ROC curve will be generated whereby we will select 

 
IRB-41878 / ENT0066 
Page 18 of 51 
19 August 2021 
the point of highest specificity and sensitivity and from there we will determine if our tentative 
cutoff was valid or if we need to adjust.  
- 
Comparison fluorescence and radioactivity-based findings: 
All tissues that will be excised during surgery will be evaluated for the presence of radioactivity and 
fluorescence and scored as such being positive / negative. Evaluated tissues are either 1) fluorescent 
only; 2) radioactive only; 3) both radioactive and fluorescent; or 4) neither radioactive nor 
fluorescent. This will be done quantitatively (Y/N approach) and qualitatively (see above). 
o Because the antibody is the same, only the label (IRDye800 or 89-Zr) differs, we expect that 
tissue samples that are radioactive are also fluorescent and vice versa. However, this is 
something that will be investigated in this study.    
 
Statistical considerations are described in detail in Section 11.  
 
Dosimetry 
Previously, for the antibody trastuzumab, it has been shown that when giving a pre-dose of cold (i.e. not 
radiolabeled) trastuzumab, prior to giving the radiopharmaceutical, the toxicity to the liver (and other 
organs) was found to be significantly lower resulting in the ability to go up on the dose of the 
radiopharmaceutical given, improving the preoperative image quality. For 89Zr-panitumumab, there is 
little data on dosimetry. At the moment one publication reporting on data in 3 patients (28) whereby it 
was shown that upon giving a ~1 mCi dose, there’s relative high toxicity to the organs, in particular the 
liver (28).  
 
In our current study, in a subset of 3-5 subjects we will collect dosimetry data by assessing the 
biodistribution of 89Zr-panitumumab over time as such to determine the toxicity of 89Zr-panitumumab to 
the organs. To obtain dosimetry data, at various time points after injection of 89Zr-panitumumab, PET/CT 
scans are to be acquired. The minimum number of PET/CT scans needed is three.  
 
For the current study, these three PET/CT scans will be obtained between the end of observation period 
after the 89Zr-panitumumab infusion on Day 0 and the day before surgery (inclusive). If available, the 
scans will be performed on Day 0, Day 1 and on the day before surgery.  
 
For each patient, on the acquired PET/CT scans, volumes of interest (VOIs) will be drawn around the 
organs, tumor and lymph nodes. Subsequently, the total activity in each VOI will be recorded in units 
of Becquerel (Bq). Time activity curves (TACs) will be generated and then integrated to obtain the 
number of disintegrations (NDs) in each region. Hereafter the data will be loaded into dedicated 
software (e.g., OLINDA/EXM code (version 1.1.) after which the absorbed dose (in mGy/MBq) to each 
VOI can be determined. The internal dosimetry calculation model will be implemented following the 
Committee on Medical Internal Radiation Dose (MIRD) guidelines.  
 
 
3. 
PARTICIPANT SELECTION AND ENROLLMENT PROCEDURES 
3.1 
Inclusion Criteria 
1. Biopsy-confirmed diagnosis of squamous cell carcinoma of the head and neck. 
2. Subjects diagnosed with any T stage, any subsite within the head and neck that are scheduled to 
undergo surgical resection.  Subjects with recurrent disease or a new primary will be allowed.  
3. Planned standard of care surgery with curative intent for squamous cell carcinoma.  
4. Age ≥ 19 years. 

 
IRB-41878 / ENT0066 
Page 19 of 51 
19 August 2021 
5. Have acceptable hematologic status, coagulation status, kidney function, and liver function 
including the following clinical results: 
Hemoglobin ≥ 9 gm/dL 
White blood cell count > 3000/mm3  
Platelet count ≥ 100,000/mm3  
Serum creatinine ≤ 1.5 times upper reference range 
 
3.2 
Exclusion Criteria 
1. Myocardial infarction (MI); cerebrovascular accident (CVA); uncontrolled congestive heart 
failure (CHF); significant liver disease; or unstable angina within 6 months prior to enrollment. 
2. Previous bilateral neck dissection. 
3. History of infusion reactions to monoclonal antibody therapies. 
4. Pregnant or breastfeeding. 
5. Magnesium or potassium lower than the normal institutional values. 
6. Subjects receiving Class IA (quinidine, procainamide) or Class III (dofetilide, amiodarone, sotalol) 
antiarrhythmic agents. 
7. Subjects with a history or evidence of interstitial pneumonitis or pulmonary fibrosis. 
8. Severe renal disease or anuria. 
9. Known hypersensitivity to deferoxamine or any of its components. 
 
3.3 
Informed Consent Process 
All participants must be provided a consent form describing the study with sufficient information for 
participants to make an informed decision regarding their participation. Participants must sign the IRB 
approved informed consent prior to participation in any study specific procedure.  The participant must 
receive a copy of the signed and dated consent document. The original signed copy of the consent 
document must be retained in the medical record or research file.  
 
3.4 
Enrollment Process 
After signing an informed consent, subjects will be assigned a unique subject identification number 
based on the OnCore number and sequential numeric code (i.e. ENT0066-001, -002, etc.). The subject 
identification number will be used on all subject specific Case Report Forms (CRFs) and serious adverse 
event (SAE) forms.  Participant information should be entered into OnCore within 5 business days. 
 
3.5 
Study Timeline 
Primary Completion: 
The study will reach primary completion 24 months from the time the study opens to accrual. 
 
Study Completion: 
The study will reach study completion 36 months from the time the study opens to accrual.  
The anticipated study start date:  July 2018 
The anticipated study completion date:  October 2020 
 
 
4. 
TREATMENT PLAN 
4.1 
Treatment Schedule 
This study will assess a microdose of 89Zr-panitumumab and an imaging dose of panitumumab-IRDye800 
in 14 subjects. The study drugs will be administered on Day 0, and subjects will undergo one 
89Zr-panitumumab PET/CT imaging anytime starting on Day 0 and the Day before Surgery (inclusive). 

 
IRB-41878 / ENT0066 
Page 20 of 51 
19 August 2021 
Subjects enrolled in the dosimetry sub-study will undergo imaging  anytime starting on Day 0 and until 
the day before surgery (inclusive), for a total of three scans; if available, the scans will be performed on 
Day 0, Day 1 and on the day before surgery.  
 
Subjects will undergo surgical resection at 2 to 5 days after infusion of study drug (see Table 1). 
Intraoperative and post-operative imaging data will be collected to answer the study objectives. The 
study will be stopped if any 2 subjects experience a DLT of grade 2 or higher that is likely to be related to 
the study drugs administered.    
 
4.2 
Administration of study agents 
Panitumumab-IRDye800 
Administration of panitumumab-IRDye800 will be performed consistent with institutional policy. The 
solution will be diluted to a total volume of 100 mL with 0.9% sodium chloride injection, USP. Dosage 
level will be 30 mg panitumumab-IRDye800 (< 1/12 of a therapeutic dose of panitumumab). 
Administration of panitumumab-IRDye800 will occur by IV over 15 minutes followed by a 30-minute 
observation period. Additional treatment for infusion reactions and electrolyte imbalances will be given 
as per institutional policy, if needed. 
 
89Zr-panitumumab 
After infusion of the panitumumab-IRDye800 the subject will receive the prescribed injection of 
89Zr-panitumumab. Approximately 75 MBq (2 mCi) of 89Zr will be conjugated with panitumumab 
antibody. The dosage will be <1 mg 89Zr-panitumumab (< 1% of a therapeutic dose of panitumumab). 
The 89Zr-panitumumab will be systemically injected via IV with a dose of 1 mCi (+/- 20%).  Subjects will 
be observed for 1 hour after administration. Additional treatment for infusion reactions and electrolyte 
imbalances will be given as per institutional policy, if needed. Staff will be trained to handle the amounts 
of radioactive material represented by 89Zr-panitumumab. The appropriate equipment will be used to 
administer and transport the 89Zr-panitumumab. 
 
A low-dose CT will be obtained from vertex to toes; this will use 120 kV and dose modulation based on 
body habitus, ranging 10-105 mA. This will be followed by a static PET emission scan over the same area. 
 
All infusions/injections will be done according to Stanford facilities guidelines. Consistent with the 
panitumumab package insert, the study drugs 89Zr-panitumumab and/or panitumumab-IRDye800 will 
not be mixed with, or administered as an infusion with other medicinal products, nor infused through a 
peripheral intravenous line or indwelling intravenous catheter.  
 
4.3  
Dose Rationale 
Rationale for dose of 1.0 mCi (37 Mbq) of 89Zr-panitumumab and PET imaging at Day 1 to 2 
post-infusion. The absorbed dose to the liver is relatively high, which limits the dose that can be 
administered to humans to approximately 1.0 mCi. The human studies reported in the literature have 
used 1 or 2 mCi and achieved good image quality (27,28).  
 
It is hypothesized that the systemic circulation of the antibody-drug will accumulate specifically within 
the tumor during the first 24 to 36 hours after infusion based on our preliminary data previously 
presented. However, we do expect that longer periods of accumulation in the primary tumor 
(2 to 5 days) will result in non-specific drainage of dye into the regional lymph nodes from non-specific 
lymphatic drainage form the tumor.  
 

 
IRB-41878 / ENT0066 
Page 21 of 51 
19 August 2021 
Rationale for dose of 30 mg panitumumab-IRDye800 without loading dose.  Previously we identified a 
flat dose of 50 mg of panitumumab-IRDye800 as the optimal dose for intraoperative imaging in HNSCC, 
but we have recently reviewed data for almost 54 patients who received panitumumab-IRDye800 and 
have evidence to support lowering the dose to 30 mg:  
1) We have shown that the tumor-to-background (TBR) ratio is the same for doses in the range 
25-50 mg. As can be seen in Figure 2 and Table 2, irrespective of the dose given, a fixed dose or 
a dose in mg/kg, the varies between 2-3. A dose of 30 mg would translate to a dose of 
approximately 0.41 mg/kg (assuming a patient weighing 73 kg). At this dose, we also do not 
expect that the timing is going to be of an issue, something which we did see when giving a 
lower dose of around 0.3 mg/kg  (Figure 3).   
2) There has been progressive improvement in our understanding of the benefit of the surgical 
imaging over the past 2 years, and we are now looking at margins in the primary specimen, 
rather than microscopic disease (29–31);  
3) In the lymph node data that we recently analyzed, we found a high sensitivity and specificity 
(84.6% and 94.0%, respectively) for identifying metastatic nodes. Furthermore, we 
demonstrated that a lower dose reduced the number of false-positives lymph nodes identified. 
Combined, this data leads us to believe that a lower dose (<0.5 mg/kg) may thus allow for 
improved metastatic lymph node detection compared to a >0.5 mg/kg dose of 
panitumumab-IRDye800 (32)   (Figure 4);  
4) The imaging software that we have been using continues to improve, and with this increased 
sensitivity, allows us to detect lower amounts of drug (both LICOR Biosciences Inc., and 
Novadaq/Stryker are continuously working on improved imaging devices – we have 
long-standing collaboration agreements in place);  
5) As of June 2019 we received our second lot of panitumumab-IRDye800 and we have seen an 
improved fluorescence signal coming from this lot compared to the previous batch.  
 
With that in mind, we would like to change the dose to 30 mg.   
  
Figure 2. a) Correlation between primary tumor mean fluorescence 
intensity (MFI) and the fixed-dose of panitumumab-IRDye800 
administered 
to 
the 
patient; 
b) 
Correlation 
between 
tumor-to-background 
ratio 
(TBR) 
and 
the 
fixed-dose 
of 
panitumumab-IRDye800 administered to the patient; c) Correlation 
between primary tumor MFI and the average dose of 
panitumumab-IRDye800 administered to the patient; d) Correlation 
Table 2. Comparison of clinical variables for primary 
tumor MFI and TBRs. 
*p<0.05; **p<0.01; N.S. = not significant 
MFI = mean fluorescence 
intensity; TBR = 
tumor-to-background ratio. Adapted from Nishio et 
al., MIB 2018. 
 

 
IRB-41878 / ENT0066 
Page 22 of 51 
19 August 2021 
between TBR and the average dose of panitumumab-IRDye800 
administered to the patient. Adapted from Nishio et al., MIB 2018. 
 
Figure 3. a) Within the weight-based dosing group, no significant 
difference between primary tumor MFI and TBR was found when 
looking at the time between infusion and surgery (1-2 days vs. >3 
days); b) In the fixed-dosing group, significantly higher primary 
tumor MFIs were found when the infusion to surgery window was 
1-2 days vs. 3 days (p<0.05). Adapted from Nishio et al., MIB 2018. 
 
Figure 4. Effect of the panitumumab-IRDye800 on the find 
rate of false-positive lymph nodes. a) Rates of true positive, 
false positive, false negative and true negative lymph nodes 
(LNs) over three groups by weight adjusted dose. b) 
Representative fluorescence images of metastatic and 
benign lymph nodes for the three dose groups.  
TP = true positive (fluorescence positive, histopathologically 
confirmed metastatic LN); TN = true negative(fluorescence 
negative, histopathologically benign LN);FP= false positive 
(fluorescence positive, histopathologically benign LN);FN = 
false negative(fluorescence negative, histopathologically 
confirmed metastatic LN). 
 
 
Surgical timing 2-5 days post-infusion. Calculating the TBR over time can be used to identify the optimal 
day of surgery that will provide the greatest tumor contrast. The proposed time course for imaging and 
surgery is based on data obtained from our cetuximab-IRDye800 and panitumumab-IRDye800 study, 
which has demonstrated increasing fluorescence intensity up to 3 days post injection of the 
antibody-dye conjugate (36). We found that most of our subjects had accessible tumors that could be 
imaged non-invasively in the clinic over time since oral cavity lesions can be well-visualized as well as 
cutaneous manifestations. The optimal imaging time point for 89Zr-panitumumab is nearly identical to 
that of panitumumab-IRDye800.  Thus, we plan to perform the surgery or image for up to 5 days to 
identify the optimal TBR as shown in our previous study.  
 
Rationale for observation period. We will follow up with subjects on Day 15, which is greater than 4 
half-lives of panitumumab. The half-life of panitumumab when given in multiple doses is known to be 
approximately 7 days (per package insert). However, when administered at smaller doses the half-life is 
less since the pharmacokinetics are non-linear. We know that at 2 mg/kg, the half-life is 2.3 days (FDA 
Drug Approval Package, Clinical Pharmacology Biopharmaceutics Review, application 125147), which is 
less than the 1 mg we are administering as our highest dose. Because the highest proposed dose in the 
current study is 50 mg of panitumumab-IRDye800, it is not expected to be detectable beyond 12 days 
after administration in our subject population. Fifteen days is also greater than 4-fold the half-life of 89Zr, 
which is 78.4 hours (3.3 days). The duration of 15 days after infusion is therefore chosen as the time 
point to assess for safety. The study will also follow up with subjects on Day 30. 
 
Pharmacokinetic intervals. Because the pharmacokinetics of single dose of panitumumab are well 
known, only limited pharmacokinetics will be performed. Blood levels will be monitored on Day 0 before 
infusion; 1 to 2 hours after infusion; and on the day of surgery, and on Day 15 for 
panitumumab-IRDye800 and free IRDye800. Clearance of panitumumab occurs through the binding in 
the liver and through the reticuloendothelial system as occurs with endogenous immunoglobulin.  

 
IRB-41878 / ENT0066 
Page 23 of 51 
19 August 2021 
 
4.4  
Definition of Dose-limiting toxicity (DLT) and Cohort Expansion 
Adverse events will be graded according to the CTCAE v5.0  
(https://ctep.cancer.gov/protocolDevelopment/electronic applications/ctc.htm).  
 
Dose-limiting toxicity will be defined as any Grade 2 or greater toxicity that is determined by the 
principal investigator to be possibly, probably or definitely-related to study drugs and clinically 
significant for subjects who received panitumumab-IRDye800 and 89Zr-panitumumab for this study. 
Clinically significant is defined based on NCI definition – a result that is large enough to affect a subject’s 
disease state in a manner that is noticeable to the subject and/or caregiver or requires intervention. 
 
4.5  
Study Drug Discontinuation  
Study drug will be discontinued for any of the following: 
 
Subject withdraws consent for the study 
 
Death attributed to study drug 
 
Serious systemic anaphylactic reaction (Grade 3 or higher)  
 
Any serious rare reactions attributed to study drug 
 
If one of these events occurs, and is a serious adverse event (see Section 7.2), the FDA, IRB and Stanford 
DSMC will be notified immediately and there will be a comprehensive review of the safety data prior to 
resuming and further study drug administration. 
 
4.6  
General Concomitant Medication and Supportive Care Guidelines 
Other than chemotherapy (including any EGFR-targeting agent), subjects may continue any medication 
they are receiving at study entry for underlying medical conditions. All medications taken at time of 
study entry will be recorded. Any changes in concomitant medication, including additions, 
discontinuations, and dose changes occurring during the study will be recorded. 
 
Medications administered on the Day 0 until Day 30 will not be collected unless given for a reportable 
adverse event or reportable serious adverse event (see Section 7 for definitions). 
 
4.7 
 Criteria for Removal from Study 
Treatment will be stopped and subjects will be removed from study due to unacceptable adverse 
events, withdrawal of consent or non-compliance. 
 
4.8 
Alternatives and Risk Protection / Mitigation  
Alternatives 
 
This study is in the setting of tumor excision of biopsy-confirmed diagnosis of HNSCC, and the 
experimental component is infusion of 89Zr-panitumumab and panitumumab-IRDye800, which 
may help visualize the tumor and tumor margins as well as identify tumor-loaded lymph nodes 
for the surgeon. The surgery itself is considered regular medical care. Therefore, the alternative 
to participating in this study is to have the tumor excision surgery without the 
89Zr-panitumumab and panitumumab-IRDye800 infusion.  
 
Procedures to protect against and minimize potential risks:  
 
This study is designed enroll appropriate subjects populations (see Section 3.1 Inclusion Criteria, 
and Section 3.2 Exclusion Criteria).  

 
IRB-41878 / ENT0066 
Page 24 of 51 
19 August 2021 
 
Subjects will be monitored regularly by the investigators and the study team after 
investigational 89Zr-panitumumab and panitumumab-IRDye800 and surgery, through 30 days 
(± 1 week) post-89Zr-panitumumab and panitumumab-IRDye800 treatment, for adverse events 
by means of physical exams, blood tests, and ECGs.  
 
Subjects will be given a 24-hour emergency number in case problems arise between clinic visits. 
 
Subject records will be kept in a secure location at Stanford University Medical Center accessible 
only to authorized personnel. 
 
 
5 INVESTIGATIONAL AGENT INFORMATION 
5.1 
Description of Study Drugs   
This IND proposes a study of the sequential use of 2 investigational imaging agents, 89Zr-panitumumab 
and panitumumab-IRDye800.   
 
9.2.3. 
5.1.1 89Zr-panitumumab  
Zirconium is a Group IVB transition metal, and its isotope, 89Zr, is an excellent candidate for ImmunoPET.  
89Zr decays through positron emission and electron capture with a half-life of 78.4 hours (3.3 days), 
which is similar to the optimal TBR time for most monoclonal antibodies. An advantage of 89Zr is that it 
requires less energy to produce. One limitation of this isotope is that its high gamma emission of 
908.97 keV restricts the administered dose in subjects.   
 
Over the years, many preclinical studies have been performed in vivo with various 89Zr-labeled 
antibodies.  At present, there are 48 studies listed on ClinicalTrials.gov: 9 with 89Zr-labeled bevacizumab, 
8 with 89Zr-labeled trastuzumab, 4 with 89Zr-labeled cetuximab, and 2 with 89Zr-labeled panitumumab. 
The latter two studies are completed and were performed by NCI.  
 
Of the clinicaltrials.gov published studies, 3 report on the use of DFO (deferoxamine) that is proposed to 
be used to link 89Zr to panitumumab for this study.  
 
89Zr-panitumumab is an established investigational PET agent by the FDA.  Peer-reviewed published 
dosimetry data and first human experience with 89Zr-panitumumab does not report any major adverse 
events related to 89Zr-panitumumab (27-28).  In Lindenberg et al (28), three subjects with metastatic 
colon cancer were administered approximately 1 mCi (37 MBq) of 89Zr-panitumumab by IV, with whole 
body (base of skull to mid-thigh) static images obtained at 2-6 hours, 1-3 days, and 5-7 days 
post-injection.  One participant only completed two post-injection scans due to scheduling constraints; 
the other two participants completed three post-injection scans.  Based on whole organ image contours 
of the liver, kidneys, spleen, stomach, lungs, bone, gut, heart bladder and psoas muscle, the whole-body 
effective dose was estimated between 0.264 mSv/MBq (0.97 rem/mCi) and 0.330 mSv/MBq 
(1.22 rem/mCi). 
 
The following dosimetry tables are reproduced from Lindenberg et al. (28). 

 
IRB-41878 / ENT0066 
Page 25 of 51 
19 August 2021 
Table 3:  Results from OLINDA 1.1 estimating the dose using the residence times for the two subjects 
who were scanned three times 
 
 

 
IRB-41878 / ENT0066 
Page 26 of 51 
19 August 2021 
Table 4:  Results from OLINDA 1.1 estimating the dose using all three subjects but only the first two 
scans to generate the time activity curve from which average residence times were calculated 
 
 
89Zr-panitumumab will be manufactured at the MIPS Cyclotron and Radiochemistry Facility per the 
manufacturing information in 
 (IND-holder Andrei Iagaru, MD).  
 
Following the 89Zr-panitumumab bolus injection, a PET/CT the scan will be performed anytime starting 
on Day 0 until the day before surgery (inclusive). The whole body effective dose for this procedure is the 
3-5 mSv. In the subjects that will participate in the dosimetry sub-study whereby they will receive a total 
of three PET/CT scans, the whole body effective dose of the PET/CT scans will be 9-15 mSv.  
 
9.2.4. 
5.1.2 Panitumumab-IRDye800  
Panitumumab-IRDye800 was manufactured from commercially-sourced panitumumab and cGMP 
IRDye® 800CW N-hydroxysuccinimide (NHS) ester infrared dye (LI-COR Biosciences, Inc.) at the GMP 
biologics facility at LI-COR Biosciences.   
 
Panitumumab is as described above. IRDye800CW has a molecular weight of 1166 Da and is supplied as 
a lyophilized powder. It can be dissolved in water or DMSO at concentrations up to 20 mg/mL. The dye 

 
IRB-41878 / ENT0066 
Page 27 of 51 
19 August 2021 
in 1:1 solution of phosphate buffered saline (PBS):methanol has an absorbance maximum of 777 nm and 
an emission maximum of 791 nm. IRDye800CW is a near-infrared fluorescent imaging dye that can be 
easily bound to proteins through its NHS Ester group.  IRDye800CW is not FDA-approved, and much of 
the information regarding IRDye800 remains proprietary.  However, LI-COR Biosciences manufactures 
IRDye800 under cGMP conditions, and has submitted a drug master file (MF) to the FDA (MF-25167) 
that is cross-referenced for the IND under which this study is conducted.  
 
Panitumumab-IRDye800 is produced by mixing the panitumumab and IRDye800 components in 
phosphate buffer at pH 8.5 and allowing the conjugation reaction to proceed at 20 to 25ºC. The 
conjugation reaction is followed by a buffer exchange into pH 7.4 PBS. The desired stoichiometry for the 
product is approximately 1.5 dye molecules per antibody molecule.  
 
Panitumumab-IRDye800 has been previously evaluated as an imaging agent in several Stanford studies, 
in patients with head and neck cancer (IRB-35064), brain tumors (IRB-43179), lung cancer (IRB-43102), 
and pancreatic cancer (IRB-42237) for a total of 77 patients studied to date.  A related agent, 
cetuximab-IRDye800, has been used in Stanford study IRB-35068, IRB-35789 and IRB-37595.  
 
5.2 Expected Toxicities  
9.2.5. 
5.2.1 Expected Toxicities of 89Zr-panitumumab 
The toxicities of 89Zr-panitumumab are analogous to the known toxicities of panitumumab (see 
package insert); panitumumab-IRDye800; and 18F-FDG-PET with the additional toxicities of the IRDye800 
chelator, deferoxamine. The toxicities of deferoxamine as elaborated in the prescribing information are 
reviewed below. 
 
5.2.1.1 Deferoxamine Toxicities 
Deferoxamine:  Deferoxamine (Desferal) is approved throughout much of the world for the treatment of 
acute iron intoxication and of chronic iron overload due to transfusion-dependent anemias. 
Deferoxamine chelates iron by forming a stable complex that prevents the iron from entering into 
further chemical reactions. It readily chelates iron from ferritin and hemosiderin but not readily from 
transferrin; it does not combine with the iron from cytochromes and hemoglobin. Deferoxamine does 
not cause any demonstrable increase in the excretion of electrolytes or trace metals. In this use as an 
imaging drug, the chelate site is occupied by 89Zr and is not displaced by serum iron. 
5.2.1.1.1.  At the Injection Site 
Localized irritation; pain; burning; swelling; induration; infiltration; pruritus; erythema; wheal formation; 
eschar; crust; vesicles; local edema. Injection site reactions may be associated with systemic allergic 
reactions.  
5.2.1.1.2.  Hypersensitivity Reactions and Systemic Allergic Reactions 
Generalized rash; urticaria; anaphylactic reaction with or without shock; angioedema.  
5.2.1.1.3.  Body as a Whole 
Local injection site reactions may be accompanied by systemic reactions like arthralgia; fever; headache; 
myalgia; nausea; vomiting; abdominal pain; or asthma. Infections with Yersinia and Mucormycosis have 
been reported in association with Desferal use.  
5.2.1.1.4.  Cardiovascular 
Tachycardia; hypotension; shock. 
5.2.1.1.5.  Digestive 
Abdominal discomfort; diarrhea; nausea; vomiting.  
5.2.1.1.6.  Hematologic 
Blood dyscrasia (thrombocytopenia; leucopenia). 

 
IRB-41878 / ENT0066 
Page 28 of 51 
19 August 2021 
5.2.1.1.7.  Hepatic 
Increased transaminases; hepatic dysfunction.  
5.2.1.1.8.  Musculoskeletal 
Muscle spasms. Growth retardation and bone changes (e.g., metaphyseal dysplasia) are common in 
chelated subjects given doses above 60 mg/kg, especially those who begin iron chelation in the first 
three years of life.  If doses are kept to 40 mg/kg or below, the risk may be reduced.  
5.2.1.1.9.  Nervous System 
Neurological disturbances including dizziness; peripheral sensory, motor, or mixed neuropathy; 
paresthesias; seizures; exacerbation or precipitation of aluminum-related dialysis encephalopathy.  
5.2.1.1.10.  Special Senses 
High-frequency sensorineural hearing loss and/or tinnitus are uncommon if dosage guidelines are not 
exceeded and if dose is reduced when ferritin levels decline. Visual disturbances are rare if dosage 
guidelines are not exceeded. These may include decreased acuity; blurred vision; loss of vision; 
dyschromatopsia; night blindness; visual field defects; scotoma; retinopathy (pigmentary degeneration); 
optic neuritis; and cataracts.  
5.2.1.1.11.  Respiratory 
Acute respiratory distress syndrome (with dyspnea, cyanosis, and/or interstitial infiltrates).  
5.2.1.1.12.  Skin 
Very rare generalized rash.  
5.2.1.1.13.  Urogenital 
Dysuria; acute renal failure; increased serum creatinine and renal tubular disorders.  
5.2.1.1.14.  Postmarketing Reports 
There are postmarketing reports of deferoxamine-associated renal dysfunction, including renal failure. 
Monitor subjects for changes in renal function (e.g., increased serum creatinine).  
Combined, the previous experience in humans with antibodies labeled with 89Zr supports the conclusion 
that a trial of labeled panitumumab at a mass dose of 1 mg, less than 7 nmole, approximately 1/420 of 
the usual clinical dose, will not pose a significant risk to the subjects in the proposed early clinical 
development. 
 
9.2.6. 
5.2.2 Expected Toxicities of Panitumumab-IRDye800 
With the exception of infusion reactions and allergic responses, toxicities associated with 
panitumumab-based therapy are usually dose-dependent and associated with prolonged therapy.  
Because panitumumab will be delivered at sub-therapeutic doses and will only be administered once, it 
is anticipated that the primary adverse events will be dose-independent reactions such as infusion 
reaction or allergic reaction.   
5.2.2.1 Dermatologic and Soft Tissue Toxicity (Black Box Warning)  
Studies reporting dermatologic toxicities have given therapeutic doses of panitumumab repeatedly 
during treatment cycles since this is required to achieve a tumor response.  In the proposed study we 
give one, sub-therapeutic dose.  
 
In one study, dermatologic toxicities occurred in 90% of subjects and were severe (NCI CTC Grade 3 and 
higher) in 16% of subjects (package insert).  The clinical manifestations included, but were not limited to, 
dermatitis acneiform;  pruritus;  erythema;  rash;  skin exfoliation;  paronychia;  dry skin;  and skin 
fissures.  Subjects who develop dermatologic or soft tissue toxicities should be monitored for the 
development of inflammatory or infectious sequelae.  Life threatening and fatal infectious complications 
including necrotizing fasciitis;  abscesses;  and sepsis have been observed in subjects treated with 
panitumumab.  Panitumumab should be withheld or discontinued for toxicities associated with severe 
or life-threatening inflammatory or infectious complications.  

 
IRB-41878 / ENT0066 
Page 29 of 51 
19 August 2021 
5.2.2.2 Infusion reaction (Black Box Warning) 
Because the study proposes to administer a single sub-therapeutic dose, the most likely adverse event 
we anticipate is an infusion reaction. Minor (Grade 1) infusion reactions from panitumumab occur at a 
frequency of approximately 1%, with severe reactions (anaphylaxis) rarely reported (package insert). 
Serious infusion reactions can occur; requiring medical intervention and immediate, permanent 
discontinuation of panitumumab include rapid onset of airway obstruction (bronchospasm; stridor; and 
hoarseness); hypotension; shock; loss of consciousness; myocardial infarction; and/or cardiac arrest.  
5.2.2.3 Cardiac Toxicity 
Prolonged QT interval. Toxicology and other preclinical studies performed at UAB in 2013 with 
cetuximag-IRDye800 identified a small, but statistically significant increase in QT-intervals.  These 
studies in non-human primates after administration of cetuximab-IRDye800 identified an increase in the 
QTc interval for cetuximab alone compared to cetuximab-IRDye800. There was also a 
statistically-significant 
difference 
between 
the 
QTc interval 
between 
the 
cetuximab 
and 
cetuximab-IRDye800 that will require assessment of interval ECG and exclusion criteria of subjects at risk 
for arrhythmias (see Exclusion Criteria). Screening ECG and intermittent ECG data will be obtained as 
part of the current study. Thus far, in our ongoing panitumumab-IRDye800 trials in HNSCC, such effects 
have not been seen (Stanford protocol IRB-35064).  
5.2.2.4 Pulmonary Fibrosis / Interstitial Lung Disease (ILD) 
Pulmonary fibrosis occurred in less than 1% of subjects in clinical studies using panitumumab.  Subjects 
with a history or evidence of interstitial pneumonitis, pulmonary fibrosis, were excluded from most 
clinical trials (package insert). The estimated risk in a general population is therefore unknown.  Cases of 
ILD, including fatalities, have been reported in subjects treated with panitumumab. Interrupt therapy for 
the acute onset or worsening of pulmonary symptoms. 
5.2.2.5 Hypomagnesemia and Electrolyte Abnormalities  
In one study, hypomagnesemia (NCI-CTC Grade 3 or 4) requiring oral or intravenous electrolyte repletion 
occurred in 2% of subjects. Hypomagnesemia occurred 6 weeks or longer after the initiation of 
panitumumab (package insert). Both hypomagnesemia and hypocalcemia occurred in some subjects. 
Electrolytes should be monitored periodically during treatment and for 8 weeks after the completion of 
therapy. Replete electrolytes as necessary using standard infusion guidelines. 
5.2.2.6 Photosensitivity  
Exposure to sunlight can exacerbate dermatologic toxicity (package insert). Advise subjects to wear 
sunscreen and hats and limit sun exposure while receiving panitumumab. 
5.2.2.7 Ocular Toxicities 
Keratitis and ulcerative keratitis, known risk factors for corneal perforation, have been reported with the 
use of panitumumab (package insert). Monitor for evidence of keratitis or ulcerative keratitis. Interrupt 
or discontinue therapy for acute or worsening keratitis.  
5.2.2.8 Other Toxicities   
It is also possible that other panitumumab related toxicities will appear (fatigue or diarrhea), but 
because the proposed dose is a fraction of the therapeutic dose and is administered only once, these are 
likely not to be the dose limiting toxicities in this clinical trial. We do not expect significant toxicities 
from IRDye800 because rodent toxicology studies have not demonstrated toxicity, and it has similar 
chemical structure as indocyanine green (which has been delivered to humans in gram quantities for 
decades without significant toxicity). 
 
In one study, dermatologic toxicities occurred in 90% of subjects and were severe (NCI CTC Grade 3 and 
higher) in 16% of subjects (package insert). The clinical manifestations included, but were not limited to, 
dermatitis acneiform; pruritus; erythema; rash; skin exfoliation; paronychia; dry skin; and skin fissures. 
Subjects who develop dermatologic or soft tissue toxicities should be monitored for the development of 

 
IRB-41878 / ENT0066 
Page 30 of 51 
19 August 2021 
inflammatory or infectious sequelae. Life threatening and fatal infectious complications including 
necrotizing fasciitis; abscesses; and sepsis have been observed in subjects treated with panitumumab. 
Panitumumab should be withheld or discontinued for toxicities associated with severe or 
life-threatening inflammatory or infectious complications. 
 
5.3 Availability  
Panitumumab-IRDye800 will be provided by Stanford’s investigational pharmacy. It has been 
manufactured at the GMP biologics facility at LI-COR Biosciences Inc. using cGMP IRDye800CW and 
commercially-available panitumumab. Formal testing of the panitumumab-IRDye800 for stability, 
sterility and antigen specificity is contained within the CMC section according to an FDA-approved 
process. The manufacturing and quality processes are documented elsewhere. 
 
89Zr-panitumumab will be manufactured at the MIPS Cyclotron and Radiochemistry Facility, at Stanford. 
 
5.4 Agent Ordering  
89Zr-panitumumab  
89Zr-panitumumab will be manufactured on demand at the MIPS Cyclotron and Radiochemistry Facility.  
As necessary, 89Zr-panitumumab will be held in appropriate storage until delivery to the clinical site.  
 
Panitumumab-IRDye800 
Per Stanford standard operating procedures, the Stanford investigational pharmacy will be responsible 
for storage of panitumumab-IRDye800 and dispensing of the drug after subjects are screened and 
enrolled to the study.  
 
5.5 Agent Accountability  
The Principal Investigator will be responsible for the accounting of 
89Zr-panitumumab and 
panitumumab-IRDye800, including proper labeling; documentation of lot numbers; dose and 
administration records; and storage of drug. The investigator will also be responsible for ensuring study 
drugs are correctly labeled and the appropriate dose is administered per the study protocol.  
 
 
6. 
DOSE MODIFICATIONS 
Apart from the dosing discussed in Section 4.3, there are no other dose modifications allowed in this 
study. If there is a limited range of tumor-to-background ratio identified in this study, we will consider 
amending the protocol to add higher doses of panitumumab-IRDye800 or 89Zr-panitumumab.  
 
 
7. 
ADVERSE EVENTS AND REPORTING PROCEDURES 
7.1 
Adverse Event 
An adverse event is any event that is presents during the trial that was not observed at baseline or has 
worsened from baseline.  
 
7.2 
Serious Adverse Event 
A serious adverse event is defined (21CFR§312.32) as any adverse experience that suggests a significant 
hazard, contraindication, side effect, or untoward medical occurrence that: 
 
Results in death, 

 
IRB-41878 / ENT0066 
Page 31 of 51 
19 August 2021 
 
Is life-threatening (Note: the term “life-threatening” refers to an event in which the subject was 
at risk of death at the time of the event rather than to an event which hypothetically might have 
caused death if it were more severe), 
 
Requires (or prolongs) hospitalization, 
 
Causes persistent or significant disability/incapacity, 
 
Results in congenital anomalies or birth defects, or 
 
Other conditions which in the judgment of the Investigator represent significant hazards 
 
Medical and scientific judgment should be exercised in deciding whether expedited reporting is 
appropriate in other situations, such as important medical events that may not be immediately 
life-threatening or result in death or hospitalization, but may jeopardize the subject, or may require 
intervention to prevent one of the other outcomes listed in the above definition. These should be 
considered serious. 
 
Any pregnancy which occurs during this clinical trial must be reported to the Sponsor and treated as a 
serious adverse event with regard to the reporting time line. Any pregnancy must be followed through 
conclusion of the pregnancy (delivery or termination). Administration of study drug will be discontinued 
in a subject who becomes pregnant. If a male subject reports a pregnancy of his spouse or significant 
other while participating in the trial, data regarding the outcome of this pregnancy must be collected. 
 
7.3 
Assessment of Causality 
For any adverse event that occurs during this study, it will be the responsibility of the Investigator to 
assess the relationship of the event to study treatment.  
For this clinical trial, the following criteria will be used: 
 
Unrelated: There is no temporal relationship between the event and the administration of the 
study drug, and/or the event is clearly due to the subject’s medical condition, other therapies, 
or accident. 
 
Possibly-related: There is some temporal relationship between the event and the administration 
of the study drug and the event is unlikely to be explained by the participant’s medical condition 
or other therapies. 
 
Probably-related: The temporal relationship between the event and the administration of the 
study drug is compelling, and the participant’s medical condition or other therapies cannot 
explain the event. 
 
Definitely-related: The temporal relationship between the event and the administration of the 
study drug is compelling, the participant’s medical condition or other therapies cannot explain 
the event and the event follows a known or suspected response pattern to the medication. 
 
Note that for this clinical trial, adverse reactions defined by the panitumumab package insert are 
considered “Expected” as cited by 21CFR§312.32(a).  
 
7.4 
Severity of Adverse Events 
Adverse events will be graded per NCI Common Terminology Criteria for Adverse Events (CTCAE v5.0). 
 
Mild (Grade 1) 
 
Moderate (Grade 2) 
 
Severe (Grade 3) 
 
Immediately life-threatening/Fatal (Grade 4 and 5) 
 

 
IRB-41878 / ENT0066 
Page 32 of 51 
19 August 2021 
Adverse events that are solely laboratory test results without clinical consequence or sequelae or 
hospitalization will be graded by investigator judgement.  
 
7.5 
Safety Monitoring and Reporting 
7.5.1 Monitoring of Adverse Events 
Both serious and non-serious adverse events (AEs) will be clearly noted in source documentation and 
listed on study specific Case Report Forms (CRFs). The Protocol Director (PD) or designee will assess each 
AE to determine whether it is unexpected according to the Informed Consent, Protocol Document, 
package insert, or cross-referenced Investigator’s Brochure, and related to the investigation.  
 
All adverse events (AEs), regardless of seriousness or relationship to study drug, are to be collected only 
on designated study dates from signing of informed consent through 30 days after administration of 
study drug, and recorded in the study specific worksheets, with the following exceptions: 
 
• 
AEs that are solely laboratory values; are not related to the study drug; AND are clinically 
non-significant may not be collected.  
• 
Non serious AEs that are not related to the study drug; are not clinically significant; AND are 
expected in the post-surgery clinical setting may not be collected. 
• 
SAEs that occur from signing of informed consent to prior to administration of study agent may 
not be collected unless assessed as possibly, probably or definitely-related to a study procedure. 
 
All patients enrolled in this study receive surgical intervention in the course of their standard of care. As 
a consequence of this surgery, patients may experience certain expected and normal adverse events. 
The following post-operative adverse events will be captured only in the patient’s Electronic Health 
Record (EHR) source documentation and not in the adverse event log. If the adverse event exceeds the 
grading listed below or occurs outside the post-operative time window, the adverse event will be 
recorded in the Adverse Event Logs.  
 
Surgical wound site and associated, expected secondary signs and symptoms, including:  
o CTCAE v5.0 Grade 1 erythema, edema, and pruritis.  
o CTCAE v5.0 Grade 1 pain associated with surgical wound, including headaches – mild 
pain, little to no limit on adult daily life.  
o CTCAE v5.0 Grade 1 nausea, vomiting, and dysphagia.  
o CTCAE v5.0 Grade 1 weight loss, anemia, and electrolyte abnormalities.  
o CTCAE v5.0 Grade 2 trismus.  
 
Whenever possible, symptoms should be grouped as single syndrome or diagnosis.  The Investigator 
should specify the date of onset, maximal intensity, corrective therapy given, outcome, and his/her 
assessment of causality. 
 
Any AE that is not resolved by the end of the study and considered to be potentially related to study 
drug or was the cause for the subject’s withdrawal will be followed as clinically indicated until its 
resolution, or if non resolving, until considered stable.  All SAEs will be tracked until resolution, or until 
30 after the last dose of the study treatment. 
 
7.5.2 Recording and Reporting Adverse Events and Serious Adverse Events 
Non-serious adverse events will be reported annually to the FDA via an Annual Report and to the IRB via 
Continuing Review. 
 

 
IRB-41878 / ENT0066 
Page 33 of 51 
19 August 2021 
The PD (aka Principle Investigator) must immediately report within 24 hours of knowledge of event to 
the Sponsor-Investigator (i.e. IND Holder, Andrei Iagaru, MD), any serious adverse event, whether or not 
considered related to study drug.  SAEs of all grades will be reported to the Sponsor-Investigator using 
the Stanford Cancer Institute SAE CRF.  The investigator must provide a detailed description of the 
event, the treatment regimen, relevant laboratory and evaluations and assessment of the relationship of 
the AE to the study drug.  All relevant information should be reported as it becomes available. 
 
SAEs CTCAE Grade 3 and above, and all subsequent follow up reports will be reported to the Stanford 
Cancer Institute Data and Safety Monitoring Committee (DSMC) using the study specific CRF regardless 
of the event’s relatedness to the investigation.  Following review by the DSMC, events meeting the IRB 
definition of ‘Unanticipated Problem’ will be reported to the IRB using eProtocol within 10 working days 
of DSMC review, or within 5 working days for deaths or life threatening experiences. 
 
Adverse events deemed serious, unexpected (i.e. not described in the protocol, package insert, 
cross-referenced Investigator’s Brochure or informed consent documents) and related to study drug 
must be reported to Sponsor-Investigator using the FDA MedWatch form 3500a within 24 hours of 
knowledge of event.  The Sponsor Investigator is responsible for deciding whether the event meets IND 
Safety Reporting criteria. 
 
Events will be submitted to Sponsor Investigator Andrei Iagaru, MD, at: 
 
-----Andrei Iagaru, MD, Professor of Radiology 
Dept of Radiology, Division of Nuclear Medicine 
Stanford Medicine at Stanford University M/C 5281 
300 Pasteur Drive, Room H2200 
Stanford, CA 94305 
 
  
 
It will be the responsibility of the Sponsor-Investigator to provide to the FDA all information concerning 
significant hazards, contraindications, side effects or precautions felt significant to the safety of the drug 
being studied.  The PD is responsible for accurate and timely communication to the Sponsor-Investigator 
of any events reportable to FDA.  Subjects will be instructed prior to participation on the importance of 
reporting any symptoms (new or worsening), and/or any physical changes throughout their participation 
in the study. These events will be recorded accordingly in the CRF. Abnormal laboratory and/or clinical 
assessments will also be captured in the appropriate CRF. 
 
8. 
CORRELATIVE/SPECIAL STUDIES  
Conform our phase I study (IRB-35064), we will continue collecting pharmacokinetics data, hence the 
blood draws. We will also continue collecting imaging data on the primary tumor. This data will be used 
for: 1) drug delivery studies to gain better insight in the panitumumab-Irdye800 distribution in the 
tumor; and 2) to further study if the drug can be used to define (intraoperative) margins. Furthermore 
preoperative standard of care imaging obtained during routine evaluation will be used to correlate with 
pathological findings.   
 

 
IRB-41878 / ENT0066 
Page 34 of 51 
19 August 2021 
9. 
STUDY CALENDAR 
9.1 Study Procedures  
Enrolled subjects will follow the schedule of evaluations provided below. 
 

 
IRB-41878 / ENT0066 
Page 35 of 51 
19 August 2021 
 
Table 5: Study Procedures 
 
SCREENING/ 
PRE-TREATMENT 
(WITHIN 30 DAYS OF 
START OF 
TREATMENT) 
DAY 0  DAY 1-4 
DAY OF SURGERY 
(DAY 2 TO 5) 
DAY 15 
(± 4 days) 
DAY 30 
(± 4 days) 
INFORMED CONSENT 
X 
 
 
 
 
 
MEDICAL HISTORY 
X 
 
 
 
 
 
PHYSICAL EXAMINATION 1 
X 
X 
 
 
X 
 
VITAL SIGNS 
X 
X 
 
X 
X 
 
HEIGHT AND WEIGHT 
X 
 
 
 
 
 
PERFORMANCE STATUS 1 
X 
 
 
 
X 
 
ECG 
X 2 
X 3 
 
 
X 
 
CHEMISTRIES4 
X 
X 
 
X 
X 
 
HEMATOLOGY5 
X 
 
 
 
X 
 
TSH 
X 
 
 
 
 
 
PTT/PT/INR 
X 
 
 
 
 
 
SERUM PREGNANCY 6 
X 
X 
 
 
 
 
PK–FLUORESCENT-LABELED 
ANTIBODY 7 
 
X 
X 
X 
X 
 
PK-IMMUNOGENICITY 8 
 
X8 
 
 
X 
 
IV 
INFUSION 
OF 
PANITUMUMAB-IRDYE800 9 
 
X 
 
 
 
 
BOLUS 
INJECTION 
OF 
89ZR-PANITUMUMAB 10 
 
X 
 
 
 
 
SURGICAL RESECTION 11 
 
 
 
X 
 
 
TUMOR IMAGING 
X 13 
X 12 
X 12 
X 14 
 
 
PATHOLOGICAL EVALUATIONS 14 
 
 
 
X 
 
 
ADVERSE EVENTS 15 
 
X 
 
X 
X 
X 
CONCURRENT MEDICATIONS 16 
X 
X 
X 
X 
X 
X 
1. A physical examination will be done at baseline; standard head and neck examination and system-oriented physical 
examination will be conducted on Day 0 and Day 15. Examinations do not have to be repeated on Day 0 if 
completed within 21 days prior to infusion. Performance status assessment will be done at baseline and Day 15.  
Examinations collected for surgical procedure are acceptable for screening purposes.  
2. An ECG will be obtained at screening to evaluate baseline. A previous ECG that was obtained as part of standard of 
care may be used as the baseline ECG if obtained within 21 days prior to of infusion. 
3.  On day of infusion, ECG will be collected 30 (±10) min after the end of panitumumab-IRDye800 infusion. Also an 
ECG will be obtained at the end of the 1 hour (±10 mins) observation period after completion of injection of 
89Zr-panitumumab.  

 
IRB-41878 / ENT0066 
Page 36 of 51 
19 August 2021 
4. Chemistries to include a standard basic metabolic profile with magnesium and phosphorus. Chemistries and other 
blood work collected for surgical procedure are acceptable for screening purposes. Chemistries do not have to be 
repeated on Day 0 if completed within 21 days prior to infusion. 
5. Hematology (i.e., CBC) values include WBC; RBC; Hgb; hematocrit and platelet counts. Blood work collected for 
surgical procedure are acceptable for screening purposes. 
6. A serum pregnancy test will be obtained on all women of childbearing age at baseline; a urine pregnancy test will 
be performed on Day 0 if the result of a serum pregnancy test within 72 hours before administration of 
panitumumab-IRDye800 is not available.  
7. Blood samples for serum level of panitumumab-IRDye800 antibody and unconjugated dye, and 89Zr-panitumumab 
antibody will be drawn as follows: on Day 0 prior to panitumumab-IRDye800 infusion and at the end of the 1-hour 
(± 10 mins) observation period after completion of injection of 89Zr-panitumumab; on Day 1-4 (only one sample will 
be collected on the same day when the PETC/CT will be performed); on Day of surgery and on Day 15. The Day 15 
time point will be 15 days ± 4 days, but is abbreviated as Day 15 throughout the protocol. 
8. Blood will be collected on Day 0 prior to panitumumab-IRDye800 dose and on Day 15 and banked for future 
immunogenicity testing. Immunogenicity testing time points will not vary with dose. 
9. Panitumumab-IRDye800 infusion to be given over 15 (±5 mins) minutes followed by 30 minutes (±10 mins) 
observation period.  
10. 89Zr-panitumumab administered as a bolus injection to be done after the end of the observation period after 
panitumumab-IRDye800 infusion; will be followed by 1 hour (± 10 mins) of observation period. 
11. Surgical excision will be performed 2-5 days after the infusion of the study drugs.  
12. A 89Zr-PET/CT scan will be acquired after injection of 89Zr-panitumumab. One scan will performed at any time 
starting on Day 0 (after end of observation period post 89Zr-panitumumab administration) and until the day before 
surgery (inclusive). Subjects enrolled in the dosimetry sub-study will undergo three scans, performed at any time 
starting on Day 0 (after end of observation period post 89Zr-panitumumab administration) and until the day before 
surgery (inclusive); if available, the scans will be performed on Day 0, Day 1 and on the day before surgery. 
13. A standard of care 18F-FDG-PET scan acquired within year from the day of study drug infusion is acceptable, even if 
this scan was/is acquired outside of Stanford. 
14. Radiotracing and fluorescence imaging: Lymph node (and primary tumor) imaging will be done using the optical 
imaging devices (see Appendix B), in the clinic on Day 0 and at any other clinic visits between infusion and surgery if 
tumor is amenable to imaging and depending on subject availability. Radiotracer detection using the devices listed 
in Appendix C will be performed during surgery. Lymph nodes (and primary tumors) will be imaged intraoperatively 
to determine threshold of detection. Following surgery, pathological assessment of the specimens will take place.  
15. See Section 7.5.1 for adverse events monitoring and reporting. 
16. Concurrent medications will be recorded at screening. Medications administered on the Day 0 until Day 30 will not 
be collected unless given for a reportable adverse event or reportable serious adverse event. 
 
9.2 Study Procedures  
Subjects screened and enrolled will follow schedule of evaluations provided at the beginning of this 
protocol. The following evaluations will be performed: 
 
9.2.1  Screening/Pre-Treatment (Within 30 days of treatment start) 
 
Obtain written informed consent 
 
Medical history including current medications 
 
Assessment of performance status 
 
Physical examination 
 
Vital signs to include blood pressure, heart rate, respiratory rate, temperature 
 
Height and weight 

 
IRB-41878 / ENT0066 
Page 37 of 51 
19 August 2021 
 
Basic metabolic panel, serum magnesium and phosphorus 
 
CBC (WBC, RBC, Hgb, hematocrit and platelet counts) 
 
TSH 
 
PT/PTT/INR 
 
Serum pregnancy test for women of childbearing potential 
 
ECG  
 
Assessment of concomitant medications. 
 
A standard of care 18F-FDG-PET scan acquired within a year from the day of study drug 
infusion is acceptable, even if this scan was/is acquired outside of Stanford.  
 
NOTE: Labs and studies obtained for perioperative assessment can be used for   
screening evaluations. 
 
9.2.2  Day 0 
 
Prior to Infusion 
 
Vital signs (blood pressure, heart rate, respiratory rate, temperature)  
 
Assessment of performance status (within 21 days) 
 
Physical examination (within 21 days) 
 
Chemistries (electrolytes, creatinine, BUN, magnesium, phosphorus) (within 21 
days) 
 
Pregnancy test for women of childbearing potential. If the result of a serum 
pregnancy test within 72 hours before administration of panitumumab-IRDye800 is 
not available, a urine pregnancy test will be performed on Day 0 
 
Blood sample for panitumumab-IRDye800 antibody and 89Zr-panitumumab antibody 
 
Blood sample for future assessment of immunogenicity  
 
IV infusion of panitumumab-IRDye800 over 15 minutes (± 5 mins) 
 
Vital signs immediately following panitumumab-IRDye800 infusion (+ 5 mins) 
 
Observation for 30 min (± 10 mins) 
 
ECG 30 min (± 10 mins) after the end of panitumumab-IRDye800 infusion 
 
Vital signs just before 89Zr-panitumumab administration  
 
IV injection of 89Zr-panitumumab bolus followed by: 
 
Vital signs immediately following 89Zr-panitumumab administration (+ 5mins) 
 
Observation for 1 hour (± 10 mins)  
 
Blood sample for panitumumab-IRDye800 antibody and 89Zr-panitumumab antibody 
collected at 1 hour (± 15 mins) after administration of 89Zr-panitumumab 
 
ECG will be obtained at 1 hour (± 15 mins) after administration of 89Zr-panitumumab 
 
Assessment for adverse events at the end of the 1 hour observation period  
 
DOSIMETRY STUDY ONLY:  
 
89Zr-panitumumab whole body PET/CT imaging after completion of observation 
 
9.2.3   Day 1 to Day before Surgery: 
 
The following assessments will performed once, at any time between Day 1 and the day 
before surgery (including on Day 1 and on the day before surgery):  
 
Blood sample for panitumumab-IRDye800 antibody and 
89Zr-panitumumab 
antibody. 
 
89Zr-panitumumab whole body PET/CT imaging. 

 
IRB-41878 / ENT0066 
Page 38 of 51 
19 August 2021 
 
Assessment for adverse events. 
 
Assessment for concomitant medications. 
 
Imaging using the optical and radiotracer imaging/detection devices in the clinic to 
assess fluorescence and radiotracer intensity if tumor amenable to imaging and 
depending on subject availability.  
 
DOSIMETRY STUDY ONLY:  
 
A total of two 89Zr-panitumumab whole body PET/CT scans will performed at any 
time between Day 1 and the day before surgery (including on Day 1 and on the day 
before surgery if possible); if available, the scans will preferably be performed on 
Day 1 and on the day before surgery. 
 
Blood sample for panitumumab-IRDye800 antibody and 89Zr-panitumumab antibody 
will be collected on the same days when PET/CT imaging is performed. 
 
9.2.4.    Day 2 to 5 (Day of Surgery) 
 
Prior to surgery: Vital signs (blood pressure, heart rate, respiratory rate, temperature)  
 
Chemistries (electrolytes, creatinine, BUN, magnesium, phosphorus)  
 
Blood sample for panitumumab-IRDye800 antibody and 89Zr-panitumumab antibody  
 
Scheduled routine surgical resection, per standard of care 
 
Intraoperative imaging using the optical and radiotracer imaging/detection devices (if 
accessible for imaging; Appendix B and C) 
 
Pathological evaluations – tissue assessments of the pathological tissues by optical scanning 
after clinical assessment by pathologist but prior to permanent fixation of the tissue  
 
Assessment for adverse events 
 
Assessment for concomitant medications 
 
9.2.5.     Day 15 (± 4 days) 
 
Physical examination  
 
Performance Status  
 
Vital signs (blood pressure, heart rate, respiratory rate, temperature)  
 
Chemistries (electrolytes, creatinine, BUN, magnesium, phosphorus)  
 
CBC 
 
Assessment for adverse events 
 
Assessment for concomitant medications 
 
Blood sample for panitumumab-IRDye800 antibody and 89Zr-panitumumab antibody and 
immunogenicity 
 
ECG 
 
9.2.6 Day 30 (± 4 days) 
 
Investigator or study staff will contact the subject by telephone or review of electronic 
medical record data to collect any additional adverse events that are attributable to the 
study and/or concomitant medications. 
 
9.3 Description of Evaluations / Procedures  
9.3.1 
Laboratory Evaluations 
Blood specimens will be collected for hematology (WBC, RBC; hemoglobin, hematocrit, and platelet 
counts), basic metabolic profile electrolytes, creatinine, BUN, magnesium and phosphorus, and serum 
pregnancy if necessary. If laboratory evaluations are obtained within 21 days of Day 0, they do not have 

 
IRB-41878 / ENT0066 
Page 39 of 51 
19 August 2021 
to be repeated. Blood will be collected for fluorescent-labeled antibody pharmacokinetics and 
furthermore, blood will be obtained and banked for future analysis of immunogenicity against the study 
drug as requested by the FDA in pre-IND conversations. 
9.3.2 
Physical Examinations 
A physical examination will be conducted to include review of all major systems prior to enrollment to 
study. If the initial physical examination is obtained within 21 days of Day 0, the exam does not have to 
be repeated. Standard head and neck examination and system-oriented physical examination will be 
conducted on other visits. 
9.3.3 
Medical History 
A complete medical history including age, sex, race, current medications, any current or previous 
medical conditions, any previous surgeries, smoking history, and alcohol use will be done at screening. 
9.3.4 
Vital Signs 
Vital signs including blood pressure, heart rate, respiratory rate, and temperature will be collected at 
each clinic visit. Height and weight will be collected at screening. 
9.3.5 
Tumor and lymph node imaging 
Imaging will be done utilizing the optical imaging devices (see Appendix B for details). The camera head 
will be placed over the tumor and/or lymph nodes and images will be obtained and recorded.  
9.3.6 
Cardiac Monitoring 
Preclinical studies performed at UAB (2013) identified a small, but statistically significant increase in 
QT-intervals using cetuximab. These studies in non-human primates after administration of 
cetuximab-IRDye800 identified an increase in the QTc interval for cetuximab alone compared to 
cetuximab-IRDye800. There was also a statistically significant difference between the QTc interval 
between the cetuximab and cetuximab-IRDye800 that will require assessment of interval ECG and 
exclusion criteria of patients at risk for arrhythmias, see exclusion criteria. Screening ECG and 
intermittent ECG data will be obtained as part of the study. We reference the full toxicology report for 
Cetuximab-IRDye800 (IND 115706) recently submitted to the FDA. However, more recent investigation 
(40) has failed to substantiate this QTc risk in panitumumab-IRDye800 and has further shown no 
significant evidence of cardiac toxicity.  
 
An ECG will be obtained during the screening period, on day of infusion (at 30 min (±10) after the end of 
panitumumab-IRDye800 infusion and at the end of the 1 hour observation period after completion of 
injection of 89Zr-panitumumab) and on Day 15.  A previous ECG that was obtained as part of standard of 
care may be used as the baseline ECG if obtained within 21 days prior to injection and will be reviewed 
any time prior to eligibility. QT/QTc interval will be assessed for each time point.  A supervising physician 
will review the ECG results the same day they are recorded, the final review can be delayed (pending on 
availability of final reading) but initial review for safety is done the same day. 
 
10. 
MEASUREMENTS 
10.1  
Primary Outcome Measure 
The number (proportion) of lymph nodes determined to be tumor-positive by histological and/or 
pathological evaluation that were predicted to be tumor-positive by 89Zr-panitumumab labeling. 
We will compare the number and location of 18F-FDG-avid nodes within the regional lymphatics to the 
number and location of 89Zr-panitumumab-avid nodes in relation to the postoperative neck dissection 
histopathology (gold standard).  
Outcome Measure:  Preoperatively, the location and number of 18F-FDG-avid nodes as well as 
the number and location of 
89Zr-panitumumab-avid nodes will be determined by 2 
board-certified Nuclear Medicine physicians (Dr. Guido Davidzon and Dr. Andrei Iagaru).  Once 
all radioactive and fluorescent nodes are removed intraoperatively, standard of care will be 

 
IRB-41878 / ENT0066 
Page 40 of 51 
19 August 2021 
performed via completion neck dissection. The excised tissue specimens will be sent to 
pathology where the tumor status of the lymph nodes will be determined (histology serves as 
our gold standard). This will allow us to determine true and false positive and negative tumor 
values for 89Zr-panitumumab and 18F-FDG in identifying the tumor-loaded lymph nodes. 
Time Frame:  Final false positive and negative rate, sensitivity and specificity of sentinel node 
detection using 89Zr-panitumumab can be determined towards the completion of the trials 
(once all subjects have been included and all the data has been collected).  
Safety Issue:  No 
 
10.2  
Secondary Outcome Measures 
The number (proportion) of lymph nodes determined to be tumor-positive by histological and/or 
pathological evaluation that were NOT predicted tumor-positive by 89Zr-panitumumab labeling.  
We will compare the number and location of 18F-FDG-avid nodes within the regional lymphatics to the 
number and location of 89Zr-panitumumab-avid nodes in relation to the postoperative neck dissection 
histopathology (gold standard).  
Outcome Measure:  Preoperatively, the location and number of 18F-FDG-avid nodes as well as 
the number and location of 89Zr-panitumumab-avid nodes will be determined.  Once all 
radioactive and fluorescent nodes are removed intraoperatively, standard of care will be 
performed via completion neck dissection. The excised tissue specimens will be sent to 
pathology where the tumor status of the lymph nodes will be determined (histology serves as 
our gold standard). This will allow us to determine true and false positive and negative tumor 
values for 89Zr-panitumumab and 18F-FDG in identifying the tumor-loaded lymph nodes. 
Specifically we will look for lymph nodes that were 18F-FDG positive on preoperative imaging 
and/or fluorescently labeled by panitumumab-IRDye800, but do now show uptake of 
89Zr-panitumumab.  
Time Frame:  Final false positive and negative rate, sensitivity and specificity of sentinel node 
detection using panitumumab-IRDye800 can be determined towards the completion of the trial 
(once all subjects have been included and all the data have been collected). 
Safety Issue:  No 
 
 
11. 
REGULATORY REQUIREMENTS 
11.1 
Institutional Review of Protocol 
The protocol, the proposed informed consent and all forms of participant information related to the 
study (e.g. advertisements used to recruit participants) will be reviewed and approved by the Stanford 
IRB and Stanford Cancer Institute Scientific Review Committee (SRC).  Any changes made to the protocol 
will be submitted as a modification and will be approved by the IRB prior to implementation.  The 
Protocol Director will disseminate the protocol amendment information to all participating 
investigators.  The protocol and any significant amendments will be submitted to FDA.   
 
11.2 
Data and Safety Monitoring Plan 
The Stanford Cancer Institute Data and Safety Monitoring Committee (DSMC) will be the monitoring 
entity for this study. The DSMC will audit study-related activities to determine whether the study has 
been conducted in accordance with the protocol, local standard operating procedures, FDA regulations, 
and Good Clinical Practice (GCP).  This may include annual review of the following types of documents 
participating in the study: regulatory binders, case report forms, eligibility checklists, and source 
documents.  In addition, the DSMC will regularly (monthly) review any DLTs, serious adverse events, and 
protocol deviations associated with the research to ensure the protection of human subjects.  Results of 

 
IRB-41878 / ENT0066 
Page 41 of 51 
19 August 2021 
the DSMC audit will be communicated to the IRB and the appropriate regulatory authorities at the time 
of continuing review, or in an expedited fashion, as needed. 
 
11.3 
Data Management Plan 
The Protocol Director, or designees noted in the Delegation of Authority Log, will maintain adequate and 
accurate participant case histories with observations and other data pertinent to the study.  Original 
source documents will be transcribed to Case Report Forms (CRFs).  Source documents include hospital 
records, clinical charts, laboratory and pharmacy records, and recorded electronic data.  Case report 
forms will be developed using the OnCore database system and maintained by the study team.  CRFs will 
be kept in a locked office, only accessible to the research team.   
 
 
12. STATISTICAL CONSIDERATIONS 
Data from both cohorts (14 subjects) will be combined for all primary and secondary analyses. 
 
Primary objective 
Determine the sensitivity and specificity of 89Zr-panitumumab for the detection of tumor-involved 
regional lymph nodes. 
Using the histological and/or pathological evaluation of the lymph node as the gold standard, we will 
calculate and compare the sensitivity and specificity of 89Zr-panitumumab and 18F-FDG PET/CT imaging 
findings. We will test the level of association of the 89Zr-panitumumab-PET results and the 18F-FDG-PET 
results with the Phi coefficient. 
 
We will use the matched pair Durkalski’s test (36), accounting for the cluster-correlation within subjects, 
for the sensitivity and specificity comparisons (primary and exploratory) using the clust.bin.pair package 
(37) in the R-statistical software (39). Significance for both primary and exploratory analyses will be 
assessed at the 0.05 level and to assess uncertainty, 95% confidence intervals will be provided for all 
estimates. 
 
Secondary Objective  
Determine the number (proportion) of lymph nodes determined to be tumor-positive by histological 
and/or pathological evaluation that were NOT predicted tumor-positive by 89Zr-panitumumab 
labeling.  
We will calculate the odds of a false negative using 89Zr-panitumumab-PET relative to the odds of a false 
negative using a 18F-FDG-PET and compare the negative predictive value (NPV) of 89Zr-panitumumab and 
18F-FDG. 
 
Exploratory Objectives  
 
Determine the sensitivity and specificity of panitumumab-IRDye800 for the detection of 
tumor-involved regional lymph nodes. 
 
After isolation of lymph nodes from the specimen in the pathology lab, lymph node fluorescence will 
be measured prior to histological and/or pathological evaluation (gold standard). Sensitivity and 
specificity will be generated by comparison of fluorescence intensity and histological and/or 
pathological evaluation (gold standard). Findings will furthermore be compared to the sensitivity 
and specificity of 89Zr-panitumumab and 18F-FDG (primary objective) using Durkalski’s test, as 
outlined above. 

 
IRB-41878 / ENT0066 
Page 42 of 51 
19 August 2021 
 
Determine the number (proportion) of lymph nodes determined to be tumor-positive by 
histological and/or pathological evaluation that were NOT predicted tumor-positive by 
panitumumab-Irdye800 labeling.  
 
We will determine the level of association between panitumumab-Irdye800 results and 
89Zr-panitumumab-PET and 18F-FDG-PET results with the Phi coefficient. 
 
Descriptive statistics 
For qualification and quantification of the fluorescence signal and the radioactive signal, we follow the 
following rules: 
- 
Intraoperative fluorescence assessment of panitumumab-IRDye800:  
There will be no set level of fluorescence whereby we consider tissue positive or negative; it is based 
on operator’s impression.  
- 
Ex vivo fluorescence assessment of panitumumab-IRDye800: 
From the fluorescence images taken in the operation room, we will calculate tumor-to-background 
ratios (TBRs) as such to define a more quantitative read-out (similar to as described in the IRB-35064 
study). Based on the current data available from our IRB-35064, in our 50 mg cohort, we found an 
average TBR of 6.53±1.2, a sensitivity of 89±5.1%, a specificity of 92±3.5% (AUC: 0.93±0.05). The 
NPV and PPV were 94±2.8% and 92±9.5%, respectively. We will extrapolate these findings to the 
current study to further validate the findings from our phase I study (IRB-35064).   
- 
Radioactive assessment of 89Zr-panitumumab: 
Following the standard of care evaluation of PET/CT scans, maximum standard uptake values 
(SUVmax) will be calculated for the accumulation of 89Zr-panitumumab in tumor tissue and/or lymph 
nodes. As background reading, the SUVmax of the mediastinum will be determined.  
Tentative cutoff for ‘imaging positive’: an SUVmax value of the lymph nodes of minimally 1.4x the 
background (mediastinum). In all cases, (histo-) pathology serves as the gold standard for “true” 
positive / negative lymph nodes. Subsequently an ROC curve will be generated whereby we will 
select the point of highest specificity and sensitivity and from there we will determine if our 
tentative cutoff was valid or if we need to adjust.  
- 
Comparison fluorescence and radioactivity-based findings: 
All tissues that will be excised during surgery will be evaluated for the presence of radioactivity and 
fluorescence and scored as such being positive / negative. Evaluated tissues are either 1) fluorescent 
only; 2) radioactive only; 3) both radioactive and fluorescent; or 4) neither radioactive nor 
fluorescent. This will be done quantitatively (Y/N approach) and qualitatively (see above). 
o Because the antibody is the same, only the label (IRDye800 or 89-Zr) differs, we expect that 
tissue samples that are radioactive are also fluorescent and vice versa. However, this is 
something that will be investigated in this study.    
 
We will present means and standard deviations (or medians and interquartile ranges when appropriate) 
for continuous characteristics such as maximum standard uptake values (SUVmax) as determined with 
89Zr-panitumumab-PET and 18F-FDG-PET and radioactivity counts of 89Zr-panitumumab in the node(s) as 
determined with the beta probe and/or high-energy gamma probe, and tumor-to-background ratios 
(TBRs) and mean florescence intensity (MFI) for panitumumab-Irdye800. For categorical variables such 
as drainage pattern and number of lymph nodes visualized, we will present frequency statistics. 
Graphical tools such as heat maps, histograms, and boxplots will be used to assess distributional 
properties of continuous variables. We will illustrate the nature of the relationship between 
SUVmax/radioactivity counts and/or MFI/TBRs and/or drainage pattern across all subjects, the 
relationship will be illustrated with a heat map and spaghetti plot. When appropriate, transformations – 
including a log-based transformation – may be considered to stabilize variance 

 
IRB-41878 / ENT0066 
Page 43 of 51 
19 August 2021 
 
Sample Size Justification and Power Considerations   
Since this is an early Phase I study, power considerations are limited but even so, we have excellent 
power to detect differences in specificity. With 14 subjects and an average of 30 nodes per subject, we 
expect 420 specimens on which to calculate and compare sensitivity and specificity. However, in 
calculating power, we must account for the clustering or correlation of lymph nodes within subject. 
Although we will use Durkalski’s test to compare sensitivities and specificities, we estimated power by 
first determining the effective sample size (ESS), adjusting for the correlation of LNs within person, and 
then estimated power using McNemar’s test on this ESS. We assumed an intra-class correlation of 0.005, 
yielding an effective sample size of 367 LNs. With an effective sample size of 367, a prevalence of 7.5%, 
a significance level of 0.05, and a 0.3 proportion of discordant pairs, we have greater than 95% power to 
detect a 0.1 difference in specificities, assuming the lower specificity is 0.7. Similarly, we have greater 
than 71% power to detect a 0.25 difference in sensitivity with the one-sided McNemar test. This 
assumes the proportion of discordant pairs is 0.3 and the lower sensitivity is 0.7. 
 
 
13. 
REFERENCES 
1.  
Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and 
mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer. 2015 
Mar 1;136(5):E359-386.  
2.  
Amit M, Yen TC, Liao CT, Chaturvedi P, Agarwal JP, Kowalski LP, et al. The origin of regional failure 
in oral cavity squamous cell carcinoma with pathologically negative neck metastases. JAMA 
Otolaryngol-- Head Neck Surg. 2014 Dec;140(12):1130–7.  
3.  
d’Alessandro AF, Pinto FR, Lin CS, Kulcsar MAV, Cernea CR, Brandão LG, et al. Oral cavity squamous 
cell carcinoma: factors related to occult lymph node metastasis. Braz J Otorhinolaryngol. 2015 
Jun;81(3):248–54.  
4.  
Civantos FJ, Zitsch RP, Schuller DE, Agrawal A, Smith RB, Nason R, et al. Sentinel lymph node biopsy 
accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a 
prospective multi-institutional trial. J Clin Oncol Off J Am Soc Clin Oncol. 2010 Mar 10;28(8):1395–
400.  
5.  
Kim T, Giuliano AE, Lyman GH. Lymphatic mapping and sentinel lymph node biopsy in early-stage 
breast carcinoma: a metaanalysis. Cancer. 2006 Jan 1;106(1):4–16.  
6.  
Bradley PJ, Ferlito A, Silver CE, Takes RP, Woolgar JA, Strojan P, et al. Neck treatment and shoulder 
morbidity: still a challenge. Head Neck. 2011 Jul;33(7):1060–7.  
7.  
de Bree R, Nieweg OE. The history of sentinel node biopsy in head and neck cancer: From 
visualization of lymphatic vessels to sentinel nodes. Oral Oncol. 2015 Sep;51(9):819–23.  
8.  
Ebrahimi A, Zhang WJ, Gao K, Clark JR. Nodal yield and survival in oral squamous cancer: Defining 
the standard of care. Cancer. 2011 Jul 1;117(13):2917–25.  
9.  
Hernando J, Villarreal P, Alvarez-Marcos F, Gallego L, García-Consuegra L, Junquera L. Comparison 
of related complications: sentinel node biopsy versus elective neck dissection. Int J Oral Maxillofac 
Surg. 2014 Nov;43(11):1307–12.  
10.  Shah S, Har-El G, Rosenfeld RM. Short-term and long-term quality of life after neck dissection. 
Head Neck. 2001 Nov;23(11):954–61.  
11.  Milenović A, Virag M, Knezević P, Boras VV, Ostović KT, Pandurić DG, et al. Evaluation of sentinel 
node biopsy in oral carcinomas. Coll Antropol. 2014 Mar;38(1):279–82.  
12.  Pedersen NJ, Jensen DH, Hedbäck N, Frendø M, Kiss K, Lelkaitis G, et al. Staging of early lymph 
node metastases with the sentinel lymph node technique and predictive factors in T1/T2 oral 
cavity cancer: A retrospective single-center study. Head Neck. 2016 Apr;38 Suppl 1:E1033-1040.  

 
IRB-41878 / ENT0066 
Page 44 of 51 
19 August 2021 
13.  Robbins KT, Ferlito A, Shah JP, Hamoir M, Takes RP, Strojan P, et al. The evolving role of selective 
neck dissection for head and neck squamous cell carcinoma. Eur Arch Oto-Rhino-Laryngol Off J Eur 
Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol - Head Neck Surg. 2013 
Mar;270(4):1195–202.  
14.  Thompson CF, St John MA, Lawson G, Grogan T, Elashoff D, Mendelsohn AH. Diagnostic value of 
sentinel lymph node biopsy in head and neck cancer: a meta-analysis. Eur Arch Oto-Rhino-Laryngol 
Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol - Head Neck Surg. 
2013 Jul;270(7):2115–22.  
15.  Alvarez Amézaga J, Barbier Herrero L, Pijoan del Barrio JI, Martín Rodríguez JC, Romo Simón L, 
Genolla Subirats J, et al. Diagnostic efficacy of sentinel node biopsy in oral squamous cell 
carcinoma. Cohort study and meta-analysis. Med Oral Patol Oral Cirugia Bucal. 2007 May 
1;12(3):E235-243.  
16.  Valsecchi ME, Silbermins D, de Rosa N, Wong SL, Lyman GH. Lymphatic mapping and sentinel 
lymph node biopsy in patients with melanoma: a meta-analysis. J Clin Oncol Off J Am Soc Clin 
Oncol. 2011 Apr 10;29(11):1479–87.  
17.  Byers RM, Weber RS, Andrews T, McGill D, Kare R, Wolf P. Frequency and therapeutic implications 
of “skip metastases” in the neck from squamous carcinoma of the oral tongue. Head Neck. 1997 
Jan;19(1):14–9.  
18.  Civantos FJ, Moffat FL, Goodwin WJ. Lymphatic mapping and sentinel lymphadenectomy for 106 
head and neck lesions: contrasts between oral cavity and cutaneous malignancy. The 
Laryngoscope. 2006 Mar;112(3 Pt 2 Suppl 109):1–15.  
19.  Stoeckli SJ. Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma of the head 
and neck. The Laryngoscope. 2007 Sep;117(9):1539–51.  
20.  Day KE, Beck LN, Deep NL, Kovar J, Zinn KR, Rosenthal EL. Fluorescently labeled therapeutic 
antibodies for detection of microscopic melanoma. The Laryngoscope. 2013 Nov;123(11):2681–9.  
21.  Heath CH, Deep NL, Beck LN, Day KE, Sweeny L, Zinn KR, et al. Use of panitumumab-IRDye800 to 
image cutaneous head and neck cancer in mice. Otolaryngol--Head Neck Surg Off J Am Acad 
Otolaryngol-Head Neck Surg. 2013 Jun;148(6):982–90.  
22.  Kulbersh BD, Duncan RD, Magnuson JS, Skipper JB, Zinn K, Rosenthal EL. Sensitivity and specificity 
of fluorescent immunoguided neoplasm detection in head and neck cancer xenografts. Arch 
Otolaryngol Head Neck Surg. 2007 May;133(5):511–5.  
23.  Withrow KP, Gleysteen JP, Safavy A, Skipper J, Desmond RA, Zinn K, et al. Assessment of 
indocyanine green-labeled cetuximab to detect xenografted head and neck cancer cell lines. 
Otolaryngol--Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2007 Nov;137(5):729–34.  
24.  Withrow KP, Newman JR, Skipper JB, Gleysteen JP, Magnuson JS, Zinn K, et al. Assessment of 
bevacizumab conjugated to Cy5.5 for detection of head and neck cancer xenografts. Technol 
Cancer Res Treat. 2008 Feb;7(1):61–6.  
25.  Grootendorst MR, Cariati M, Pinder SE, Kothari A, Douek M, Kovacs T, et al. Intraoperative 
Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using (18)F-FDG Cerenkov 
Luminescence Imaging: A First-in-Human Feasibility Study. J Nucl Med Off Publ Soc Nucl Med. 2017 
Jun;58(6):891–8.  
26.  de Boer E, Warram JM, Tucker MD, Hartman YE, Moore LS, de Jong JS, et al. In Vivo Fluorescence 
Immunohistochemistry: Localization of Fluorescently Labeled Cetuximab in Squamous Cell 
Carcinomas. Sci Rep. 2015 Jun 29;5:10169.  
27.  Do K, Cao L, Kang Z, Turkbey B, Lindenberg ML, Larkins E, et al. A Phase II Study of Sorafenib 
Combined With Cetuximab in EGFR-Expressing, KRAS-Mutated Metastatic Colorectal Cancer. Clin 
Colorectal Cancer. 2015 Sep;14(3):154–61.  
28.  Lindenberg L, Adler S, Turkbey IB, Mertan F, Ton A, Do K, et al. Dosimetry and first human 

 
IRB-41878 / ENT0066 
Page 45 of 51 
19 August 2021 
experience with (89)Zr-panitumumab. Am J Nucl Med Mol Imaging. 2017;7(4):195–203.  
29.  van Keulen S, Nishio N, Fakurnejad S, Birkeland A, Martin BA, Lu G, et al. The Clinical Application of 
Fluorescence-Guided Surgery in Head and Neck Cancer. J Nucl Med Off Publ Soc Nucl Med. 
2019;60(6):758–63.  
30.  van Keulen S, Nishio N, Birkeland A, Fakurnejad S, Martin B, Forouzanfar T, et al. The Sentinel 
Margin: Intraoperative Ex Vivo Specimen Mapping Using Relative Fluorescence Intensity. Clin 
Cancer Res Off J Am Assoc Cancer Res. 2019 Aug 1;25(15):4656–62.  
31.  van Keulen S, Nishio N, Fakurnejad S, van den Berg NS, Lu G, Birkeland A, et al. Intraoperative 
Tumor Assessment Using Real-Time Molecular Imaging in Head and Neck Cancer Patients. J Am 
Coll Surg. 2019 Dec;229(6):560-567.e1.  
32.  Nishio N, van den Berg NS, van Keulen S, Martin BA, Fakurnejad S, Teraphongphom N, et al. Optical 
molecular imaging can differentiate metastatic from benign lymph nodes in head and neck cancer. 
Nat Commun. 2019 Nov 6;10(1):5044.  
33.  Cohen R, Stammes MA, de Roos IH, Stigter-van Walsum M, Visser GW, van Dongen GA. Inert 
coupling of IRDye800CW to monoclonal antibodies for clinical optical imaging of tumor targets. 
EJNMMI Res. 2011 Dec 1;1(1):31.  
34.  Dean NR, Newman JR, Helman EE, Zhang W, Safavy S, Weeks DM, et al. Anti-EMMPRIN monoclonal 
antibody as a novel agent for therapy of head and neck cancer. Clin Cancer Res Off J Am Assoc 
Cancer Res. 2009 Jun 15;15(12):4058–65.  
35.  Day KE, Sweeny L, Kulbersh B, Zinn KR, Rosenthal EL. Preclinical comparison of 
near-infrared-labeled cetuximab and panitumumab for optical imaging of head and neck 
squamous cell carcinoma. Mol Imaging Biol MIB Off Publ Acad Mol Imaging. 2013 Dec;15(6):722–9.  
36.  Rosenthal EL, Warram JM, de Boer E, Chung TK, Korb ML, Brandwein-Gensler M, et al. Safety and 
Tumor Specificity of Cetuximab-IRDye800 for Surgical Navigation in Head and Neck Cancer. Clin 
Cancer Res Off J Am Assoc Cancer Res. 2015 Aug 15;21(16):3658–66.  
37.  McNEMAR Q. Note on the sampling error of the difference between correlated proportions or 
percentages. Psychometrika. 1947 Jun;12(2):153–7.  
38.  Stock C., Hielscher T (2014). DTComPair: comparison of binary diagnostic tests in a paired study   
design. R package version 1.0.3. URL:   http://CRAN.R-project.org/package=DTComPair.  
39.  R Core Team (2017). R: A language and environment for statistical computing. R Foundation for 
Statistical Computing, Vienna, Austria. URL https://www.R-project.org/. 
40.  Pei, J., Juniper, G., van den Berg, N.S. et al. Safety and Stability of Antibody-Dye Conjugate in 
Optical Molecular Imaging. Mol Imaging Biol. 2020. https://doi.org/10.1007/s11307-020-01536-2. 
 
 

 
IRB-41878 / ENT0066 
Page 46 of 51 
19 August 2021 
APPENDICES 
 
APPENDIX A:  Participant Eligibility Checklist  
 
A Participant Eligibility Checklist will be completed in its entirety for each subject prior to registration.  
The completed, signed, and dated checklist will be retained in the subject’s study file and the study’s 
Regulatory Binder.  
 
The study coordinator, treating physician and an independent reviewer will verify that the participant’s 
eligibility is accurate, complete, and legible in source records.  A description of the eligibility verification 
process should be included in the EPIC or other Electronic Medical Record progress note.  
 
Protocol Title: 
Pilot study evaluating Panitumumab-Irdye800 and 89Zr-Panitumumab 
for dual-modality imaging for nodal staging in head and neck cancer  
Protocol Number: 
IRB-41878 / OnCore# ENT0066 
Principal 
Investigator: 
Andrei Iagaru, MD 
 
II.  Subject Information: 
Subject Name/ID: 
 
Gender:    
 Male     
 Female 
 
III.  Study Information: 
SRC Approved 
 IRB Approved 
 Contract signed 
 
 
III.  Inclusion/Exclusion Criteria 
Inclusion Criteria 
(From IRB approved protocol) 
Yes 
No 
Supporting Documentation* 
1. Biopsy-confirmed 
diagnosis 
of 
squamous 
cell 
carcinoma of the head and neck 
 
 
      
2. Subjects diagnosed with any T stage, any subsite 
within the head and neck that are scheduled to 
undergo surgical resection.  Subjects with recurrent 
disease or a new primary will be allowed 
 
 
      
3. Planned standard of care surgery with curative intent 
for squamous cell carcinoma 
 
 
      
4. Age ≥ 19 years 
 
 
      
5. Have acceptable hematological status, coagulation 
status, kidney function, and liver function including 
the following clinical results: 
-Hemoglobin ≥ 9gm/dL 
-White blood cell count > 3000/mm3 
-Platelet count ≥ 100,000/mm3 
-Serum creatinine ≤ 1.5 times upper reference 
range 
 
 
      

 
IRB-41878 / ENT0066 
Page 48 of 51 
19 August 2021 
APPENDIX B:  Optical Imaging Modalities: Overview 
All of the non-significant risk (NSR) devices listed below, in the determination of the Investigator, meet the following criteria when used as 
proposed in this study: 
 
Are not implanted 
 
Do not support or sustain human life 
 
Are not of substantial importance for diagnosis, curing, mitigating or treating disease; or otherwise preventing impairment of human 
health 
 
Do not present any other potential for serious risk to the health, safety or welfare of subjects 
 
Device name 
Manufacturer 
Commercially available? 
510(k) NSR? 
Serial No. of submission 
to 
 
Intraoperative near-infrared fluorescence imaging, in vivo 
Spy-Phi– and/or PINPOINT – R9000 (Handheld/Endoscopic)  
Novadaq Inc. 
Yes (modified light source) 
No 
Yes 
SN0000 
Explorer Air 
SurgVision 
Yes (modified light source) 
No 
Yes 
SN0000 
PDE-NEO II and/or FIGS 
Hamamatsu 
Photonics KK. 
Yes 
Yes 
N/A 
SN0000 
IMAGE1 S RUBINA System* 
Karl Storz 
Yes 
N/A 
Yes 
SN0017 
Intraoperative near-infrared fluorescence imaging, ex vivo (back table) 
Spy-Phi– and/or PINPOINT – R9000 (Handheld/Endoscopic)  
Novadaq Inc. 
Yes (modified light source) 
No 
Yes 
SN0000 
Explorer Air 
SurgVision 
Yes (modified light source) 
No 
Yes 
SN0000 
IGP ELVIS v4 
LI-COR Biosciences 
No 
No 
Yes 
SN0000 
PDE-NEO II and/or FIGS 
Hamamatsu 
Photonics KK. 
Yes 
Yes 
N/A 
SN0000 
IMAGE1 S RUBINA System* 
Karl Storz 
Yes 
N/A 
Yes 
SN0017 

 
IRB-41878 / ENT0066 
Page 49 of 51 
19 August 2021 
Device name 
Manufacturer 
Commercially available? 
510(k) NSR? 
Serial No. of submission 
to 
 
Laboratory near-infrared fluorescence imaging, ex vivo 
Pearl Triology 
LI-COR Biosciences 
Yes 
 
Odyssey CLx 
LI-COR Biosciences 
Yes 
IGP ELVIS v4 
LI-COR Biosciences 
No 
Leica fluorescence microscope 
Leica 
Yes 
Vevo LAZR-X 
Visualsonics 
Yes 
Firefly stand-alone device 
Intuitive Surgical Inc. 
Yes 
* Please refer to Appendix D for IMAGE1 S RUBINA System Karl Storz Components Overview 

 
IRB-41878 / ENT0066 
Page 50 of 51 
19 August 2021 
APPENDIX C:  Imaging Modalities for the Detection of 89Zr: Overview 
All of the non-significant risk (NSR) devices listed below, in the determination of the Investigator, meet the following criteria when used as 
proposed in this study: 
 
Are not implanted 
 
Do not support or sustain human life 
 
Are not of substantial importance for diagnosis, curing, mitigating or treating disease; or otherwise preventing impairment of human 
health 
 
Do not present any other potential for serious risk to the health, safety or welfare of subjects 
 
Device name 
Manufacturer 
Commercially 
available? 
510(k) 
NSR? 
Serial No. of submission 
to 
 
Intraoperative imaging, in vivo 
Beta probe + Node Seeker  
IntraMedical Imaging 
Yes 
Exempt, class I device 
No 
N/A 
Neoprobe 
Leica Biosystems 
Yes 
Yes, K971167 
No 
N/A 
Crystal probe 
Crystal Photonics 
Yes 
Exempt, class I device 
No 
N/A 
Ex vivo imaging (back table) 
Beta probe + Node Seeker  
IntraMedical Imaging 
Yes 
Exempt, class I device 
No 
N/A 
Neoprobe 
Leica Biosystems 
Yes 
Yes, K971167 
No 
N/A 
Crystal probe 
Crystal Photonics 
Yes 
Exempt, class I device 
No 
N/A 
Beta camera 
IntraMedical Imaging 
No 
Not yet applied for 
N/A 
N/A 
Laboratory imaging  
Beta camera 
IntraMedical Imaging 
No 
 
Cherenkov imager (LightPath) 
LightPoint Medical 
Yes 
1 mm resolution mobile PET scanner  
Dr Craig Levin (in-house design) 
No 
 

 
IRB-41878 / ENT0066 
Page 51 of 51 
19 August 2021 
APPENDIX D: IMAGE1 S RUBINA System Karl Storz Components Overview 
Material 
Description  
Quantity 
CE-certified 
FDA-approved 
TM340 
32" 4K Monitor 
1 
X 
X 
TC201 
IMAGE1 S CONNECT II, connect module 
1 
X 
X 
TC304 
IMAGE1 S 4U-LINK, link module 
1 
X 
X 
TL400 
Cold Light Fountain Power LED Rubina 
1 
X 
X 
TH121 
IMAGE1 S 4U RUBINA, OPAL1 NIR/ICG, two-chip 4K UHD camera head 
1 
X 
X 
495NCSC 
Fiber Optic Light Cable 
2 
X 
X 
26003ACA 
HOPKINS Straight Forward Telescope 0°, enlarged view, diameter 10 mm, length 31 cm 
1 
X 
X 
8711AGA 
HOPKINS Straight Forward Telescope 0°, NIR/ICG, ø 10mm, 20cm 
1 
X 
X 
8710AGA 
HOPKINS Straight Forward Telescope 0°, NIR/ICG, diameter 5.8 mm, length 20 cm 
1 
X 
X 
28272 CN/UGK/HC 
Components for mechanical holding arm  
1 
X 
X 
28172 HM/HR 
Components for mechanical holding arm  
1 
X 
X 
28164AC 
HOPKINS Forward Telescope 0°, enlarged view, diameter 4 mm, length 18 cm 
1 
X 
X 
28614BC 
HOPKINS Forward Telescope 30°, enlarged view, diameter 4 mm, length 18 cm 
1 
X 
X 
28614FC 
HOPKINS Forward Telescope 45°, enlarged view, diameter 4 mm, length 18 cm 
1 
X 
X 
20916025 AGA 
VITOM II NIR/ICG Telescope 0° 
1 
X 
X 
20100032 
Fluorescein Blue Filter System, for fluorescence diagnosis 
1 
X 
X 
20100033 
Fluorescein Barrier Filter 
1 
X 
X