[18F]Fluorofuranylnorprogesterone (FFNP) PET/MR Imaging of Progesterone Receptor Expression in Invasive Breast Cancer
Phase: PHASE2
Conditions: Invasive Breast Cancer
Sponsor: University of Wisconsin, Madison

 
 
 
 
 
 
 
 
 
 
 
 
[18F]Fluorofuranylnorprogesterone (FFNP) PET/MR 
Imaging of Progesterone Receptor Expression in 
Invasive Breast Cancer 
 
October 18, 2023 
 
NCT03212170 
 
 
 

1 
 
[18F]Fluorofuranylnorprogesterone (FFNP) PET/MR Imaging of 
Progesterone Receptor Expression in Invasive Breast Cancer 
 
UW Study # 2017-0533 
 
UWCCC PRMC # UW23007 
 
 
 
Lead Clinical Investigator: 
Amy Fowler, M.D., Ph.D. 
 
University of Wisconsin-Madison 
 
Clinical Co-Investigator: 
Roberta Strigel, M.D., M.S. 
 
University of Wisconsin-Madison 
 
 
Kari B. Wisinski, MD 
 
University of Wisconsin-Madison 
 
 
Lee G. Wilke, MD 
 
University of Wisconsin-Madison 
 
Study Pathologists: 
Aparna Mahajan, M.D. 
 
University of Wisconsin-Madison 
 
 
Stephanie M. McGregor, MD, PhD 
 
University of Wisconsin-Madison 
 
Study Statistician: 
Emmanuel Sampene, Ph.D. 
 
University of Wisconsin-Madison 
 
Funding Sponsors: 
Institute of Clinical and Translational Research 
 
Carbone Comprehensive Cancer Center 
 
Department of Radiology 
 
University of Wisconsin-Madison 
 
 
National Institutes of Health (KL2TR000428) 
 
 
UW-Madison Department of Radiology 
 
 
Protocol Version Date: 
October 18, 2023 
 
 

2 
 
 
 
Lead Clinical Investigator 
Clinical Co-Investigator 
Amy Fowler MD, PhD 
Roberta Strigel MD, MS 
Assistant Professor 
Assistant Professor 
Department of Radiology 
Department of Radiology 
University of Wisconsin-Madison 
University of Wisconsin-Madison 
600 Highland Avenue 
600 Highland Avenue 
Madison, WI 53792-3252 
Madison, WI 53792-3252 
(T) 608-262-9186 
(T) 608-265-0805 
(P) 608-262-2122 ID:6682 
(P) 608-262-2122 ID:9236 
afowler@uwhealth.org 
rstrigel@uwhealth.org 
 
 
Study Pathologist 
Aparna Mahajan, MD 
Assistant Professor 
Department of Pathology and Laboratory Medicine 
University of Wisconsin-Madison 
D4/207B Clinical Science Center 
600 Highland Avenue 
Madison, WI  53792-2472 
(T) 608-263-4445 
(P) 608-265-7000 ID:9526 
amahajan@uwhealth.org  
 
 
 
 
 

3 
 
TABLE OF CONTENTS 
 
1. 
PROTOCOL SUMMARY ...................................................................................................... 7 
2. 
INTRODUCTION ................................................................................................................ 11 
3. 
STUDY AIMS/STUDY OBJECTIVES ............................................................................... 12 
4. 
SELECTION OF PATIENTS ............................................................................................... 13 
5. 
RESEARCH DESIGN AND METHODS ............................................................................ 14 
6. 
REGISTRATION PROCEDURES ...................................................................................... 21 
6.1 
Patient Recruitment ........................................................................................................ 21 
6.2 
Patient Enrollment .......................................................................................................... 22 
6.3 
Eligibility Verification ................................................................................................... 22 
6.4 
Registration Content Requirements ............................................................................... 22 
6.4.1 
Protocol Number ..................................................................................................... 22 
6.4.2 
Investigator Identification ....................................................................................... 22 
6.4.3 
Patient Identification ............................................................................................... 22 
6.5 
Criteria for Removal from Study ................................................................................... 23 
7. 
TREATMENT/INTERVENTION PLAN ............................................................................ 23 
7.1 
Administration Schedule ................................................................................................ 23 
7.2 
Dose Modifications ........................................................................................................ 23 
7.3 
Prohibited Concurrent Medications ................................ Error! Bookmark not defined. 
7.4 
Supportive Care Guidelines ........................................................................................... 23 
7.5 
Duration of Follow-up .................................................................................................... 24 
8. 
ADVERSE EVENTS ............................................................................................................ 24 
8.1 
Purpose ........................................................................................................................... 24 
8.2 
Terminology ................................................................................................................... 24 
8.3 
Reporting Procedure ....................................................................................................... 25 
8.4 
Additional Adverse Event Information .......................................................................... 26 
9. 
MEASURMENT OF TREATMENT OR INTERVENTION EFFECT ............................... 27 
10. 
STUDY PARAMETERS ................................................................................................... 27 
11. 
DRUG FORMULATION AND PROCUREMENT .......................................................... 27 
11.1 
Gadolinium based intravenous contrast agent ............................................................ 27 
11.2 
21-[18F]Fluoro-16α,17α–[(R)-1’-α-furylmethylidene) dioxyl]-19-norpregn-4-ene-
3,20-dione (FFNP) .................................................................................................................... 27 

4 
 
11.2.1 Other Names ........................................................................................................... 27 
11.2.2 Classification........................................................................................................... 27 
11.2.3 Mode of Action ....................................................................................................... 28 
11.2.4 Storage and Stability ............................................................................................... 28 
11.2.5 Dose Specifics ......................................................................................................... 28 
11.2.6 Preparation .............................................................................................................. 28 
11.2.7 Route of Administration ......................................................................................... 28 
11.2.8 Incompatibilities ..................................................................................................... 28 
11.2.9 Availability ............................................................................................................. 29 
11.2.10 
Side Effects ......................................................................................................... 29 
11.2.11 
Nursing/Patient Implications ............................................................................... 29 
11.3 
Anastrozole .................................................................. Error! Bookmark not defined. 
12. 
STATISTICAL CONSIDERATIONS............................................................................... 29 
12.1 
Primary Objective ....................................................................................................... 29 
12.1.1 To compare FFNP uptake of biopsy-proven primary PR+ breast malignancies 
measured using PET/MRI with the reference standard of PR immunohistochemistry (IHC).
 
29 
12.2 
Secondary Objectives ................................................................................................. 30 
12.2.1 To determine the test-retest reproducibility of quantitative assessment of tumor 
FFNP uptake. ........................................................................................................................ 30 
12.2.2 To determine the intra- and inter-observer variability of quantitative assessment of 
FFNP. 30 
12.2.3 To evaluate the optimal cut-point of FFNP uptake for distinguishing between PR 
negative and PR positive invasive breast cancer. ................................................................. 30 
12.2.4 To estimate the association of tumor FFNP uptake (continuous SUVmax) with 
research-based Oncotype DX scores (0-100). ...................................................................... 31 
12.3 
Exploratory Objectives ............................................................................................... 31 
12.3.1 To evaluate heterogeneity of tumor FFNP uptake. ................................................. 31 
12.3.2 To correlate tumor FFNP uptake with serum progesterone and estradiol levels. ... 31 
12.3.3 To correlate tumor FFNP uptake with disease recurrence. ..................................... 31 
12.3.4 To evaluate changes in FFNP uptake, PR immunostaining, and Ki67 
immunostaining in response to anastrozole. .......................... Error! Bookmark not defined. 
12.4 
Evaluation of Toxicity ................................................................................................ 32 
13. 
PATHOLOGY REVIEW................................................................................................... 32 
13.1 
Justification ................................................................................................................. 32 
13.2 
Required Pathology Materials .................................................................................... 32 

5 
 
13.3 
Routing ....................................................................................................................... 33 
14. 
RECORDS TO BE KEPT .................................................................................................. 33 
14.1 
Images ......................................................................................................................... 33 
14.2 
Regulatory and Consent.............................................................................................. 33 
14.3 
Confidentiality ............................................................................................................ 33 
15. 
PATIENT CONSENT AND PEER JUDGMENT ............................................................ 34 
16. 
DATA AND SAFETY MONITORING ............................................................................ 34 
16.1 
Risks ........................................................................................................................... 35 
16.1.1 MRI ......................................................................................................................... 35 
16.1.2 PET ......................................................................................................................... 35 
16.1.3 CT (performed only in rare instances when the subject is unable to be imaged using 
the simultaneous PET/MRI scanner). ................................................................................... 36 
16.1.4 Unexpected findings ............................................................................................... 36 
16.1.5 Drug side effects ..................................................................................................... 37 
17. 
REFERENCES .................................................................................................................. 38 
 
 
 

6 
 
ABBREVIATIONS 
CT 
 
Computed tomography 
DCE-MRI 
Dynamic contrast enhanced magnetic resonance imaging 
ER 
 
Estrogen receptor 
FDA  
U.S. Food and Drug Administration  
FDG  
18F-fluorodeoxyglucose 
FFNP  
18F-fluorofuranylnorprogesterone 
HER2  
Human epidermal growth factor receptor 2 
IHC 
 
Immunohistochemistry 
IRB 
 
Institutional review board 
mCi 
 
MilliCurie 
MIRS  
Medical Imaging Research Support 
MRI 
 
Magnetic resonance imaging 
PACS  
Picture archiving and communication system 
PET  
Positron emission tomography 
PR 
 
Progesterone receptor 
ROC  
Receiver operating characteristic 
ROI 
 
Region of interest 
SUV  
Standard uptake value 
UW 
 
University of Wisconsin 
 

7 
 
1. 
PROTOCOL SUMMARY 
TITLE OF STUDY 
[18F]Fluorofuranylnorprogesterone (FFNP) PET/MR Imaging of Progesterone Receptor 
Expression in Invasive Breast Cancer 
 
CLINICAL PHASE 
Phase 2 
 
INVESTIGATORS 
Lead clinical investigator:  Amy Fowler, MD, PhD, University of Wisconsin-Madison 
Clinical co-investigators:  Roberta Strigel, MD, MS; Kari Wisinski, MD; Lee Wilke, MD, 
Aparna Mahajan, MD; Stephanie McGregor, MD, PhD, University of Wisconsin-Madison  
 
This is an investigator-initiated clinical trial performed at a single site. 
 
PERIOD OF TRIAL 
Planned study conduct duration of approximately 36 months. 
 
STUDY OBJECTIVES 
Integrated whole-body magnetic resonance imaging (MRI)-positron emission tomography 
(PET) scanners have recently been introduced for clinical use.  This technology combines 
the anatomic and perfusion data obtained with dynamic contrast enhanced (DCE) MRI 
with functional imaging data obtained from PET.  For breast imaging, the combination of 
MRI and PET has important potential to improve diagnostic accuracy and provide 
molecular characterization of breast cancer.  The overall purpose of this research is to 
test the accuracy of PET/MRI imaging with 18F-fluorofuranylnorprogesterone (FFNP) for 
measuring progesterone receptor (PR) expression in patients with invasive breast cancer.   
 
Primary Objective 
To compare FFNP uptake of biopsy-proven primary PR+ breast malignancies 
measured 
using 
PET/MRI 
with 
the 
reference 
standard 
of 
PR 
immunohistochemistry (IHC). 
 
Secondary Objectives 
1) To determine the test-retest reproducibility of quantitative assessment of tumor 
FFNP uptake; 2) to determine the intra- and inter-observer variability of quantitative 
assessment of tumor FFNP;  3) to evaluate the optimal cut-point of FFNP uptake 
for distinguishing between PR-negative and PR-positive invasive breast cancer; 
and 4) estimate the association of tumor FFNP uptake (continuous SUVmax) with 
research-based Oncotype DX scores (0-100). 
 
Exploratory Objectives 
1) To evaluate heterogeneity of tumor FFNP uptake; 2) to correlate tumor FFNP 
uptake with serum progesterone and estradiol levels; and 3) to correlate tumor 
FFNP uptake with disease recurrence.  
 

8 
 
INCLUSION CRITERIA 
• Women 18 years of age or older 
• Diagnosis of biopsy-proven invasive breast cancer measuring at least 1.0 cm 
in diameter by any imaging modality 
• Biopsy-proven PR-positive) or PR-negative invasive breast cancer 
• Undergoing diagnostic breast MRI ordered by the referring clinician for staging 
and extent of disease* 
 
EXCLUSION CRITERIA 
• Inability or unwillingness to provide informed consent to the study 
• Patients who have had neoadjuvant chemotherapy/endocrine therapy, surgical 
intervention, or radiation for the current biopsy-proven malignancy 
• Patients with breast expanders 
• Patients who are or might be pregnant or lactating 
• Patient girth exceeds the bore of the PET/MRI scanner 
• Patients with a contraindication to gadolinium based contrast agents, including 
allergy or impaired renal function (per UW Health Guidelines) 
• Patients with a history of allergic reaction attributable to compounds of similar 
chemical or biologic composition to FFNP 
• Patients in liver failure as judged by the patient’s physician 
• Patients with standard contraindications to MRI, including claustrophobia and 
metallic implants incompatible with MRI 
• Patients requiring intravenous (IV) conscious sedation for imaging are not 
eligible; patients requiring mild, oral anxiolytics for the clinical MRI will be 
allowed to participate as long as the following criteria are met: 
o The subject has their own prescription for the medication 
o The informed consent process is conducted prior to the self-
administration of this medication 
o They come to the research visit with a driver 
• Patients unable to lie prone for 30 minutes for imaging 
 
 
STUDY DESIGN 
This is a prospective, one-arm, study which will enroll patients with newly diagnosed 
breast cancer scheduled for diagnostic breast MRI for preoperative staging/extent of 
disease evaluation as part of standard of care.  Eligible patients will be consented for 
participation in the research study which includes a directed breast PET/MRI with the 
investigational radiopharmaceutical, FFNP.  FFNP uptake of the known, biopsy-proven 
malignancy will be measured using standardized uptake values (SUV) and tumor-to-
normal tissue ratios.  The proposed work-flow is described in the schema below.  
 
NUMBER OF SUBJECTS 
 
* Patients with newly diagnosed invasive breast cancer from a screening breast MRI are eligible to 
participate in this research. For these subjects, the research breast PET/MRI should be performed prior to 
any treatment or surgery for the invasive breast cancer. 

9 
 
The primary objective is to compare FFNP SUVmax from PET/MRI with the PR 
immunohistochemistry semi-quantitative score obtained by using the Allred score (0-8) 
(1). The correlation of the two measures will be evaluated with Pearson’s correlation 
coefficient. The null hypothesis is H0: p0=0.20 and the alternative hypothesis is H1: p1 
=0.70. 
 
A sample size of 21 patients achieves 80% power to detect this difference, using a one-
sided hypothesis test with a Type I error of 5%, accounting for 1 dropout. Up to 5 subjects 
with PR-negative breast cancer will be enrolled.  
 
To measure test-retest reproducibility, a subset of up to 5 PR+ participants will have test-
retest FFNP scans.   
 
 
 
 
 

10 
 
SCHEMA 
 
Clinical 
Breast MRI 
Directed Research 18F-
FFNP Breast PET/MRI 
exam  
 
NOTE: If no previous 
breast MRI, the MRI 
component of the 
PET/MRI study is used as 
the clinical breast MRI 
 
Also, PET/CT plus MRI 
scan may be done if 
subjects are unable to 
undergo a PET/MRI scan 
 
Sub-study (N=5 PR+):  
Repeat 18F-FFNP 
PET/MRI 
 
Eligible patient presenting for 
diagnostic breast MRI for 
staging/extent of disease  
Clinical breast MRI 
interpretation and 
management 
RESEARCH 
STANDARD OF 
CARE 
Breast Surgery and 
Pathologic Analysis 

11 
 
2. 
INTRODUCTION 
The majority of deaths due to breast cancer occur in women with estrogen receptor alpha 
positive (ER+) disease (2).  Endocrine therapy targets the estrogen signaling pathway 
controlling tumor growth and is standard treatment for women with ER+ primary and 
metastatic breast cancer.  However, endocrine therapy is effective in some but not all 
women with ER+ tumors.  Due to the well-recognized diversity and complexity of ER 
signaling mechanisms, it is inevitable that some patients will have or develop disease that 
has circumvented standard methods for blocking ER function and have become 
endocrine insensitive.  This important shift in receptor functionality cannot be directly 
measured by current clinical diagnostic approaches. Thus, a reliable test that measures 
functional endocrine sensitivity in a single patient is imperative and has potential for 
significant clinical impact.   
 
Progesterone receptor (PR) is a classic estrogen-regulated target gene (3).  Measuring 
changes in PR expression may be a useful pharmacodynamic biomarker for ER function 
and endocrine sensitivity.  Howell et al. showed using tissue biopsy that changes in PR 
protein levels within a few weeks after initiating anti-estrogen therapy with tamoxifen in 
patients with locally advanced or recurrent ER+ breast cancer correlated with prolonged 
time to progression and improved survival (4).  When analyzing the PR status using only 
the pretreatment biopsy, no significant differences in survival or time to progression were 
identified.  Thus, PR can serve as a pharmacodynamic biomarker of endocrine sensitivity 
and ERα functional activity. 
 
Tumoral expression of PR can be visualized and quantified through the use of an 
investigational radiolabeled progestin, 18F-fluorofuranylnorprogesterone (FFNP), and 
positron emission tomography (PET) imaging (5-10).  A “first-in-human” study involving 
20 patients with invasive breast cancer has been published using FFNP-PET/CT imaging 
(11).  There were no adverse events, changes in vital signs, laboratory values or 
electrocardiograms, or clinically detectable pharmacologic effects.  Dosimetry evaluation 
determined that the effective dose equivalent of FFNP is comparable to other clinically 
utilized PET imaging agents.  FFNP uptake as measured by tumor-to-normal breast 
tissue ratios was greater in PR+ cancers compared to PR- cancers.  Thus, FFNP-PET 
appears to be a feasible method of imaging PR in breast cancer patients.  
 
A drawback of PET for imaging primary breast cancer is its limited spatial resolution.  
Magnetic resonance imaging (MRI), however, produces exquisitely detailed images of the 
breast due to its high spatial resolution.  MRI evaluation of breast cancer is dependent on 
anatomic detail to characterize tumor morphologic characteristics and functional 
assessment of lesion perfusion, characterized by the time-dependent uptake and lesion 
enhancement with gadolinium contrast (dynamic contrast enhanced MRI). These features 
make breast MRI the most sensitive method for the detection of breast cancer (13).  In 
contrast, CT does not offer the soft tissue differentiation necessary for evaluation of the 
breast.  Thus, MRI has become the standard of care when an additional modality is 
necessary to evaluate for breast cancer.  CT is not used in clinical practice to evaluate 
the breasts. 
 

12 
 
Combining PET with MRI leverages the benefits of both modalities for the evaluation of 
breast cancer.  Simultaneously acquired MRI images assists with PET radiotracer dose 
reduction, which is a necessary, critical advancement for the translation of PET/MRI 
imaging of the breast to clinical practice.  Our research team has developed and validated 
the imaging acquisition protocol and workflow for breast PET/MRI (14).  The protocol 
accounts for MR attenuation correction, quantitative standardized uptake value (SUV) 
calculation using PET, motion correction, co-registration of the two imaging modalities, 
radiopharmaceutical dose reduction, and patient workflow considerations.  Although this 
protocol was validated using 18F-fluorodeoxyglucose (FDG), it will be applicable for any 
novel molecular radiotracer to be imaged in combination with MRI, including FFNP.   
 
It is important to validate the accuracy and reproducibility of quantitative tumor FFNP 
uptake measured using PET/MRI breast imaging.  Further studies will be performed to 
test whether FFNP-PET/MRI can be used to distinguish patients with endocrine-sensitive 
from endocrine-resistant ER+ primary breast cancer.  To the best of our knowledge, this 
study will be the first to investigate simultaneous breast PET/MRI imaging with FFNP for 
measuring PR expression in primary breast cancer.  
 
3. 
STUDY AIMS/STUDY OBJECTIVES 
The goal of this research is to test the accuracy of PET/MRI imaging with 18F-
fluorofuranylnorprogesterone (FFNP) for measuring progesterone receptor (PR) 
expression in patients with invasive breast cancer.  We hypothesize that FFNP SUVmax 
from PET/MRI will correlate well against the semi-quantitative PR immunohistochemistry 
score.   
 
3.1  Primary objective:  
To compare FFNP uptake of biopsy-proven primary PR+ breast malignancies measured 
using PET/MRI with the reference standard of PR immunohistochemistry (IHC). 
 
3.2  Secondary objectives: 
• To determine the test-retest reproducibility of quantitative assessment of tumor 
FFNP uptake. 
• To determine the intra- and inter-observer variability of quantitative assessment of 
tumor FFNP. 
• To evaluate the optimal cut-point of FFNP uptake for distinguishing between PR-
negative and PR-positive invasive breast cancer. 
• Estimate the association of tumor FFNP uptake (continuous SUVmax) with 
research-based Oncotype DX scores (0-100) 
 
3.3  Exploratory objectives: 
• To evaluate heterogeneity of tumor FFNP uptake. 
• To correlate tumor FFNP uptake with serum progesterone and estradiol levels. 
• To correlate tumor FFNP uptake with disease recurrence. 
 
Study duration:  36 months.  Our estimated rate of accrual is 1 participant per month.   

13 
 
 
4. 
SELECTION OF PATIENTS 
Study Population: 
Female patients of all races and ethnic backgrounds at least 18 years of age with a current 
diagnosis of invasive breast cancer who are undergoing breast MRI for staging and extent 
of disease ordered by their provider as part of routine clinical care. 
 
4.1  Eligibility Criteria 
Inclusion Criteria: 
4.1.1 Women 18 years of age or older 
4.1.2 Diagnosis of biopsy-proven invasive breast cancer measuring at 
least 1.0 cm in diameter by any imaging modality 
4.1.3 Biopsy-proven PR-positive or PR-negative invasive breast cancer 
4.1.4 Undergoing diagnostic breast MRI ordered by the referring clinician 
for staging and extent of disease† 
 
Exclusion Criteria: 
4.1.5 
Inability or unwillingness to provide informed consent to the study 
4.1.6 
Patients who have had neoadjuvant chemotherapy/endocrine 
therapy, surgical intervention, or radiation for the current biopsy-
proven malignancy 
4.1.7 
Patients with breast expanders 
4.1.8 
Patients who are or might be pregnant or lactating 
4.1.9 
Patients with a contraindication to gadolinium based contrast 
agents, including allergy or impaired renal function (per UW Health 
Guidelines) 
4.1.10 Patients with a history of allergic reaction attributable to compounds 
of similar chemical or biologic composition to FFNP 
4.1.11 Patients in liver failure as judged by the patient’s physician 
4.1.12 Patients with standard contraindications to MRI, including 
claustrophobia and metallic implants incompatible with MRI 
4.1.13 Patients requiring conscious sedation for imaging are not eligible; 
patients requiring mild, oral anxiolytics for the clinical MRI scan will 
be allowed to participate as long as the following criteria are met: 
4.1.13.1 The patient has their own prescription for the medication 
 
† Patients with newly diagnosed invasive breast cancer from a screening breast MRI are eligible to 
participate in this research. For these subjects, the research breast PET/MRI should be performed prior to 
any treatment or surgery for the invasive breast cancer. 

14 
 
4.1.13.2 The informed consent process is conducted prior to the 
self-administration of the medication. 
4.1.13.3 The patient comes to the research visit with a driver. 
4.1.14 Patients unable to lie prone for 30 minutes for imaging 
 
5. 
RESEARCH DESIGN AND METHODS 
5.1 
Study Design 
This prospective, one-arm, single-institutional research study will enroll patients 
with invasive breast cancer scheduled for diagnostic breast MRI for preoperative 
staging/extent of disease evaluation.  Eligible patients will be consented for 
participation in the research study which will be performed on a separate day from 
the clinical breast MRI, if already performed, but prior to surgery.  Ideally, the 
research breast PET/MRI study should be performed prior to any interventions (i.e. 
biopsies) prompted by the clinical breast MRI if performed prior to the research 
study, but this is not required.  The results of the FFNP-PET/MRI will not be used 
to guide patient management.  However, the clinical breast MRI component of the 
examination will be interpreted and reported with management recommendation 
as per routine clinical care.  Surgical management, radiation therapy, and adjuvant 
therapy will follow standard of care.  A research-based Oncotype DX score will be 
obtained from the surgical specimen for research purposes only. The proposed 
work-flow is described in the schema above. 
 
5.2 
Reference Standard 
The primary objective is to measure FFNP uptake of biopsy-proven primary PR+ 
invasive breast cancer using PET/MRI.  The reference standard will be PR 
expression measured with immunohistochemistry performed as per the current 
standard of care.   
 
At UW Health, PR status is routinely reported as positive or negative and includes 
a visual estimation of the percentage of cells staining positive as well as intensity 
of staining.  This information will be obtained from the pathology report in the 
subject’s electronic medical record and will be used to calculate a semi-quantitative 
Allred score (1).  If the information needed to calculate the Allred score is not 
included in the clinical pathology report, a pathologist on the research study team 
will review the existing PR IHC slides.  Comparison of FFNP uptake with PR IHC 
expression will be performed as previously described for 18F-fluoroestradiol and 
ER IHC (15). 
 
The Allred score is the sum of the proportion score and the intensity score (Table 
1) (1).  PR-negative cancers can have either an Allred score of 0 or 2 (1+1).  PR-
positive cancers can have an Allred score of 3, 4, 5, 6, 7, or 8.  An Allred score of 
1 does not exist. 
 
 

15 
 
 
Table 1:  Allred Scoring System 
 
Percentage of Positive-
Staining Tumor Cells 
Proportion 
Score (PS) 
Average Intensity of 
Positive Tumor Cells  
Intensity 
Score (IS) 
None 
0 
None 
0 
<1% 
1 
Weak 
1 
1-10% 
2 
Intermediate 
2 
10-33% 
3 
Strong 
3 
33-66% 
4 
 
 
66-100% 
5 
 
 
 
5.3 
Study Calendar/Schedule 
 
The study calendar/schedule is detailed in Table 2. 
 
Table 2:  Study Calendar/Schedule 
 
Study Activity 
Baselinea 
Imaging 
Dayb 
Clinical 
Follow-Upc 
Informed Consenth 
X 
 
 
Demographicsd 
X 
 
 
Medical Historyd 
X 
 
X 
Radiology Reportsd 
X 
 
X 
Pathology Reports (Breast biopsy 
and final surgical excision)d 
X 
 
X 
Concomitant Medication Review 
 
X 
 
Pre-Scan Pregnancy Test (if needed) 
 
X 
 
Day of last menstrual period (if 
premenopausal) 
 
X 
 
Height and Weight 
 
X 
 
Vital Signse 
 
X 
 
Blood for Hormone Levels 
 
X 
 
FFNP-PET/MRIi 
 
Xj 
 
Adverse Event Evaluationf 
 
X 
X 
Research-based Oncotype DX 
Scoreg 
 
 
X 
(a) Baseline is defined as the time period from initial subject contact until injection of FFNP. 
(b) Imaging Day is defined as the day of the research FFNP-PET/MRI session. 
(c) Any standard of care clinical visits, labs, or imaging exams obtained during this time period will be 
reviewed from the electronic medical record to correlate with scan results.   
(d) Clinical data, including age, primary breast cancer data (standard clinical histopathology including 
ER/PR/HER2/Ki-67, location, size, and date of biopsy/diagnosis), Oncotype Dx recurrence score 
(if obtained clinically), mammographic breast density, and menopausal status will be recorded.  If 
premenopausal, menstrual cycle data will be recorded. 
(e) Vitals signs (blood pressure, heart and respiratory rate, and temperature) will be measured before 
FFNP injection, after FFNP injection, and after the PET/MRI scan. 

16 
 
(f) Adverse events occurring within a 24-hour period post-FFNP infusion will be recorded by the study 
coordinator who will contact the subject within 1 to 3 days. 
(g) A research-based Oncotype DX assay will be performed using the resection specimen, if remaining 
tissue is available. 
(h) During the COVID-19 pandemic, consent procedures will be conducted by phone, when possible, 
to minimize face-to-face contact subjects have with the research team.  An encrypted copy of the 
consent form will be mailed or emailed to subjects prior to the scheduled consent phone call. 
(i) Subjects who are unable to undergo a PET/MRI scan will be invited to undergo a PET/CT scan in 
addition to separate MRI scan. 
(j) For subjects participating in the test-retest cohort, the second scanning session will be done 24 
hours apart or within a maximum 14-day time frame. 
 
5.4 
Clinical Breast MRI (Standard of Care) 
The clinical breast MRI will be performed and interpreted according to standard 
clinical practice. If additional management recommendations are generated based 
on the clinical breast MRI (i.e. identification of suspicious findings requiring biopsy), 
the research examinations will ideally be scheduled prior to the date of scheduled 
intervention(s) but can also be performed after a biopsy procedure. The patient will 
be informed of this possibility at the time of initial consent. 
 
5.5 
Research Breast Imaging (FFNP- PET/MRI) 
 
5.5.1 Timing of Research Breast Imaging Session  
Patients must complete the research imaging session prior to 
surgical/oncologic intervention for their biopsy-proven breast cancer as part 
of their routine clinical care.  Ideally, the research breast PET/MRI study 
should be performed prior to any interventions (i.e. biopsies) prompted by 
the clinical breast MRI if performed prior to the research study, but this is 
not required.   
 
If patients are also scheduled for PET/CT imaging with FDG for standard of 
care clinical staging evaluation, the research imaging session cannot be 
performed on the same day as FDG-PET/CT due to the half-life of 18F.   
 
If patients are also scheduled for lymphoscintigraphy using 99mTc-based 
radiopharmaceuticals, the research study should be scheduled on a 
separate day prior to the lymphoscintigraphy study.  
 
5.5.2 Patient Preparation  
The patient does not need to be fasting for FFNP-PET/MRI.  Prior to arrival, 
the patient should be well-hydrated (encourage drinking two-three 8-12 oz 
glasses of water) unless a fluid-restriction diet is prescribed by the patient’s 
treating physician (e.g., congestive heart failure).  The patient should 
continue to take any of their prescribed medications as scheduled by their 
treating physician. 
 
Upon arrival, subject compliance with pre-procedure instructions will be 
confirmed.   Subject completion of the informed consent documentation will 
also be confirmed. The patient’s height and weight and vital signs (blood 

17 
 
pressure, heart and respiratory rate, and temperature) will be measured and 
recorded. 
 
5.5.3 FFNP Administration  
The patient will have an intravenous line placed, typically in the hand or arm 
opposite to the known primary breast cancer, FFNP will be given by a slow 
infusion (approximately 2 minutes), and the dose administered will be 
approximately 7 mCi.  The injection site will be inspected by the technologist 
to assess for any possible infiltration.  Vital signs (blood pressure, heart and 
respiratory rate, and temperature) will be taken after injection.  The patient 
will wait approximately 60 minutes to allow for biodistribution and tumor 
uptake of the radiopharmaceutical prior to imaging.  The patient should void 
immediately prior (5-10 minutes) to image acquisition.  Vital signs (blood 
pressure, heart and respiratory rate, and temperature) will be taken after 
the PET/MRI acquisition is complete.   
 
All adverse events occurring within a 24-hour period post-FFNP infusion will 
be recorded (a phone call to the participant is acceptable means of 
collecting this information). The adverse events to be specifically monitored 
during the infusion include localized discomfort at the IV injection site, pain, 
respiratory difficulties, flushing, dizziness, pruritus/rash, and any other 
symptoms that could be secondary to an anaphylactic reaction. The subject 
will be instructed to report any subjective symptoms or sensory changes 
noted. 
 
In the rare instance that the subject is unable to be imaged using the 
simultaneous PET/MRI scanner (e.g. excessive girth, technical issue with 
scanner performance), the subject will have the option to undergo two 
separate scans.  A breast MRI (approximately 30 to 40 minutes) will be 
performed using a 3T breast MRI scanner (e.g. GE Signa Premier) using 
MRI sequences as described above, and a breast specific PET/CT scan will 
be performed using a PET/CT scanner (e.g. Discovery IQ or GE Discovery 
710) located in the Department of Radiology in the Wisconsin Institutes for 
Medical Research (WIMR) Tower 1.  The subject will be positioned prone 
with arms overhead.  Following a CT scout (topogram), a directed low-dose, 
non-contrast, non-breathhold, non-diagnostic CT scan through the 
chest/breasts will be performed for attenuation correction calculations.  
Next, a static PET emission scan of the thoracic region to specifically cover 
the breasts will be acquired in 3D acquisition mode.  The entire examination 
is expected to take approximately 15-20 minutes.  Post-processing includes 
PET image reconstruction, correction for attenuation and co-registration 
with the CT images and also with the separately obtained breast MRI. 
 
5.5.4 Imaging 
Quality 
Assurance 
(QA)/Quality 
Control 
(QC) 
Procedure 
QA/QC procedures will include review of DICOM files against study 
protocols. The PET/MRI scanners must be kept calibrated in accordance 

18 
 
with the manufacturer’s recommendations. The scanners should routinely 
be assessed for quantitative integrity and stability by being tested using 
current imaging protocols on a standard phantom. For SUV measurements, 
this assessment should include a comparison against a dose calibrator to 
ensure accuracy; that is, a comparison of the absolute activity measured 
versus the measured activity injected, should be performed. 
 
A daily QC check must be performed at the beginning of the day, including 
the PET/MRI scanner and dose calibrator, in accordance with the 
manufacturer recommendations. If any of the QC results are outside of the 
manufacturer’s guidelines, the study must be rescheduled and the problem 
rectified before scanning any patients. 
 
5.5.5 Research Imaging Acquisition 
Image acquisition and reconstruction protocols specific to this research 
study will be available in a separate “Imaging Manual”.  The protocol is 
briefly described here. 
 
The breast PET/MRI will be acquired using the GE Discovery 750W 3T MR 
scanner containing the PET insert and an 8-channel breast coil qualified for 
PET/MRI located in the basement level of WIMR Tower 1.  Directed breast 
PET/MRI data will be acquired with the patient in the prone position.  
Imaging will be performed by research technologists under guidance of the 
principal and/or collaborating investigators.  MRI-sequences utilized in a 
standard clinical breast MRI will be obtained, including T1-weighted imaging 
without fat suppression and T2-weighted fat suppressed and diffusion 
weighted imaging (DWI) prior to gadolinium contrast administration followed 
by T1-weighted fat suppressed DCE imaging.  The MRI sequences will 
include standard clinical sequences and may include research MRI 
sequences under development and evaluation at the University of 
Wisconsin.  The standard MR-based attenuation correction algorithm 
provided by GE will be used for this study.  The MRI sequence(s) will be co-
registered to the PET data for motion correction.  Breast specific PET 
emission data will be acquired simultaneous with the MR images (Figure 1). 
The entire examination is expected to take 30 – 40 minutes. 
 

19 
 
Figure 1: Simultaneous acquisition of PET events during the acquisition of the MRI sequences.  PET data 
will be segmented and motion corrected corresponding to the anatomic position as determined by the MRI 
sequence coinciding with the PET data acquisition. 
 
5.5.6 Research Imaging Analysis 
Two independent readers blinded to the clinical outcome will undergo two 
sessions of image interpretation of FFNP-PET/MRI scans separated in time 
by a washout period of at least 4 weeks.  Images will be reviewed for general 
quality.  The known biopsy-proven breast cancer(s) will be identified on the 
PET/MRI examinations based on its known location from the prior clinical 
breast MRI, if performed, or the patient’s previous imaging, as is typically 
done in routine clinical practice.  MRI will be used to localize the lesion(s), 
measure the lesion size (in three dimensions), and assign the region of 
interest (ROI) for PET imaging analysis.  Each lesion will be analyzed for 
(1) qualitative appearance (visible above background or not) and (2) semi-
quantitative FFNP uptake.   
 
Qualitative Analysis of FFNP uptake (lesion-level):  FFNP uptake will be 
evaluated qualitatively with the following grading scale: no uptake (tumor < 
background), minimal uptake (tumor = background), mild (tumor slightly > 
background), moderate uptake (tumor >> background), and intense uptake 
(tumor >>> background). Tumor uptake will also be dichotomized as 
increased (moderate or intense uptake) or absent (no uptake, minimal or 
mild uptake).   
 
Quantitative Analysis of FFNP uptake (lesion-level):  Standardized 
uptake values (SUV) will be measured by manually drawing a region of 
interest (ROI) to encompass the entire lesion guided by the lesion extent 
visualized on anatomic imaging.  SUV analyses will include, but not be 
limited to, SUVmax (maximum value), SUVpeak (small fixed-size ROI centered 
on most intense part of tumor), SUVmean (average value), and SUVsd 
(standard deviation).  Tumor-to-normal tissue uptake ratios will also be 
measured.  Other PET imaging parameters will include FTV (functional 
tumor volume; i.e. the volume of tumor tissue with increased FFNP uptake) 
and TLU (total lesion uptake; i.e. the product of FTV × SUVmean).    Within 
lesion heterogeneity will be explored using the method described by 
Kurland et al (16). 
 
5.6 
Clinical Laboratory Testing 
A blood sample is to be obtained at the time of imaging (drawn prior to FFNP 
injection) and submitted for hormonal analysis (progesterone and 17β-estradiol) 
by the UW Health clinical laboratory.  Results from UW Health clinical laboratory 
automatically post to the subjects’ medical records.  
 
5.7 
Research-Based Oncotype DX Assay 
A genomics-based recurrence risk score will be calculated using a research 
version of the Oncotype DX test (17).  The risk score (0-100) is generated from 

20 
 
expression levels of sixteen cancer related genes and five reference genes (Table 
3) (18,19).  Scores are further categorized as low-risk (0-17), intermediate-risk (18-
30), and high-risk (31-100).  Tissue blocks from the surgical specimen will be 
identified and used for RNA isolation performed by the UW Translational Research 
Initiatives in Pathology (TRIP) Lab, if sufficient remaining tissue is available.  The 
Fowler lab will then perform quantitative polymerase chain reactions published by 
Cronin et al (20) and will follow the algorithm of Habel et al (21) to calculate the 
genomics-based risk score.  Results of this research assay will not be used to 
guide clinical management.  A batched analysis will be performed after all subjects 
are enrolled for those with sufficient remaining tissue. 
 
Table 3:  21 gene panel included in the Oncotype DX Score 
 
HER2 
Group 
ER 
Group 
Proliferation 
Group 
Invasion 
Group 
Other 
Reference 
GRB7 
ER 
Ki67 
Stromelysin 3 
GSTM1 
ACTB 
HER2 
PGR 
STK15 
Cathepsin L2 
CD68 
GAPDH 
 
Bcl2 
Survivin 
 
BAG1 
RPLP0 
 
SCUBE2 Cyclin B1 
 
 
GUS 
 
 
MYBL2 
 
 
TFRC 
 
5.8 
Reproducibility Research Imaging Session (Optional) 
Up to 5 PR+ patients who agree to participate in this optional sub-study of the trial 
will undergo a second (test-rest) study.  The test re-test exam cannot be performed 
the same day but should be completed prior to any therapy or surgical excision.  
This will not delay any scheduled routine standard of care therapy or procedures 
for the patient.  This optional sub-study will be offered to all patients at the time of 
consent until we have accrued 5 PR+ patients onto the sub-study. 
 
 
5.9 
Follow-Up 
Adverse events occurring within 24 hours after FFNP infusion will be recorded by 
the study coordinator who will contact the subject within 1 to 3 days after FFNP 
administration. 
 
Diagnosis of breast cancer recurrence, established per routine clinical care, will be 
recorded at the conclusion of the study for those patients with follow-up information 
available through the electronic medical record system (minimum 1 year after 
primary breast surgery). 
 
Definition of disease recurrence during follow-up will be as follows: 
• Local recurrence:  histologic evidence of ductal carcinoma in situ or invasive 
breast cancer in the ipsilateral breast or chest wall. 
• Regional recurrence:  cytologic or histologic evidence of disease in the 
ipsilateral 
internal 
mammary, 
ipsilateral 
supraclavicular, 
ipsilateral 

21 
 
infraclavicular and/or ipsilateral axillary nodes or soft tissue of the ipsilateral 
axilla.  
• Distant recurrence: cytologic, histologic, and/or radiographic evidence of 
disease in the skin, subcutaneous tissue, lymph nodes (other than local or 
regional metastasis), lung, bone narrow, central nervous system or histologic 
and/or radiographic evidence of skeletal or liver metastasis.  
 
6. 
REGISTRATION PROCEDURES 
Patients must not start protocol procedures prior to registration.  Patients must complete 
the research breast imaging session prior to any interventions prompted by the clinical 
breast MRI, if performed prior to the research study, and prior to surgical/oncologic 
intervention for their biopsy-proven breast cancer as part of their routine clinical care. 
6.1 
Patient Recruitment 
Potential subjects will be identified by the breast imaging radiologist(s) or study 
team members by reviewing Department of Radiology schedules or electronic 
medical records of patients with orders for, scheduled for, or having recently 
completed a clinical breast MRI scan.  The study coordinator will contact these 
patients by phone prior to or after their scheduled MRI and outline the research 
protocol to the patient.   
 
We also plan to use MyChart, UW Health’s patient portal, to recruit patients that 
appear to meet eligibility criteria.  We will obtain all needed approvals from the UW 
Health and the Clinical Research Data Service and follow the required workflows. 
We have an OnCore study record that is interfaced with HealthLink and will track 
individual level recruitment efforts. Once approvals are in place, the IRB approved 
invitation will be posted to invited participants’ research studies page in MyChart. 
Patients will be provided with instructions on how to either contact the research 
team or opt out of participation. 
 
For patients interested in the study, the study coordinator will describe the study in 
more detail and/or record the subject’s preferred contact information and make 
plans to follow-up with the patient by phone to describe the research protocol in 
more detail. If they choose, an encrypted version of the consent form will be 
emailed to them to allow additional time to review the form.  If the patient indicates 
they are interested in proceeding with the study, the research visit will be 
scheduled. 
 
The consent process will occur prior to the administration of research procedures.  
To better accommodate patient schedules, consent procedures will be conducted 
by phone, when possible.  A copy of the consent form will be mailed or emailed to 
subjects prior to the scheduled consent phone call. If emailed, the consent form 
will be encrypted.  A study team member will call potential subjects at the 
scheduled time to review the information in the consent form including study 
procedures, risks associated with participation, alternatives to participation and 
whom to contact for additional information.  Any questions will be addressed during 

22 
 
the course of the phone call and subjects will be encouraged to contact the study 
team with any questions or concerns they might have at any time.  Upon 
completion of the consent process, a copy of the signed consent form will be 
provided in one of the following ways depending on each subject preferences and 
capabilities: 
• 
Electronic signature will be provided using DocuSign 
• 
Subject will be asked to scan a copy of the entire consent document and 
email it back to the study team.  
• 
If subjects are unable to provide an electronic copy of the signed consent 
form, they will be asked to bring a copy of the form to the research visit.    
 
Once institutional requirements are met, remote consenting may continue by 
obtaining electronic signature using the DocuSign software platform. 
6.2 
Patient Enrollment 
Study enrollment will occur when the patient arrives for and consents to the 
research study.  A study team member will meet with the patient, review the 
research protocol, and answer the potential subject’s questions.  The information 
in the consent form, including study procedures, risks associated with participation, 
alternatives to participation and whom to contact for additional information, will be 
reviewed.  Any questions will be addressed prior to the start of any research 
procedures and all subjects will be reminded that participation is optional and they 
can change their mind at any time and still get clinically required testing completed.  
Those interested in participating will be asked to sign informed consent and Health 
Insurance Portability and Accountability Act (HIPAA) authorization and the subject 
will be enrolled in the research study.  Subjects will be assigned a unique ID 
number.  Both the MRI screening questionnaire as well as the PET screening 
questionnaire will be reviewed to confirm eligibility criteria.   
 
6.3 
Eligibility Verification 
The patient must meet all of the eligibility requirements listed in Section 4.0.   
 
6.4 
Registration Content Requirements 
6.4.1 
Protocol Number  
6.4.2 
Investigator Identification  
• Investigator’s name 
6.4.3 
Patient Identification  
• Patient’s name 
• Patient’s address 
• Patient’s Medical Record Number (MRN) 
• Patient demographics 
• Gender 
• Birth date  
• Race 
• Ethnicity 

23 
 
• Date on study 
6.5 
Criteria for Removal from Study 
Enrolled patients will be removed from the study in the following circumstances: 
• The patient does not complete the PET/MRI examination per study protocol 
• Pregnancy 
• The subject withdraws consent 
• Exclusion criteria are discovered after registration 
• The patient has a contrast reaction to the gadolinium based contrast agent 
utilized for the clinical breast MRI 
 
7. 
TREATMENT/INTERVENTION PLAN 
The results of the research breast imaging studies will not be used to direct therapy.  The 
results of the research studies will not be reported by a radiologist, will not be part of the 
patient’s medical record, and will not be available to the patient or their physician.  The 
exception is if the breast MRI component of the breast PET/MRI is used as the patient’s 
clinical examination, then interpretation of the breast MRI and management 
recommendations will be made based on routine clinical practice. 
 
No medications will be administered as part of the study protocol except intravenous 
injection of a gadolinium-based contrast agent for MRI and FFNP for PET imaging. 
7.1 
Administration Schedule 
For each research breast imaging session, patients will receive:   
• FFNP, approximately 7 mCi (259 MBq), IV slow infusion over approximately 
2 minutes followed by saline flush, once  
• Gadolinum based intravenous contrast agent, weight-adjusted dose 
followed by a saline flush, once 
 
7.2 
Dose Modifications 
The dose of FFNP is based on radiation dosimetry estimates and on prior 
published work (11).  Due to the potential of a reduced radiosynthetic yield or 
unavoidable time delays, the administered dose may be adjusted at the discretion 
of the lead clinical investigator, who also serves as the authorized user, based on 
whether clinically acceptable images can be acquired with the dose administered.  
Based on prior work, the administered dose of FFNP will be at least 3 mCi but not 
exceed 10 mCi (11).  Any such modifications of the agent infusion will be recorded. 
 
 
7.3 
Supportive Care Guidelines 
All supportive measures consistent with optimal patient care will be given 
throughout the study.  Any adverse effects, related or non-related to the injection 
of FFNP, will be treated as clinically indicated with no study-related restrictions. 
 

24 
 
If there is a contrast reaction or extravasation, these will be managed via UW 
Health guidelines.  A physician is always present to manage contrast reactions and 
extravasations, should one occur.  
 
To facilitate clearance of FFNP, thus reducing patient radiation dose exposure, 
patients will be instructed to adequately hydrate prior to and after the 
radiopharmaceutical administration unless on a fluid restrictive diet by their treating 
physician. 
 
7.4 
Duration of Follow-up  
Adverse events occurring within 24 hours after FFNP infusion will be recorded by 
the study coordinator who will contact the subject within 1 to 3 days after FFNP 
administration. 
Standard of care patient management will occur after the FFNP breast PET/MRI 
examination(s).  These visits generally include consultation with a surgeon, 
radiation oncologist, and/or medical oncologist.  Subject’s medical records are 
followed until completion of definitive treatment. 
 
Diagnosis of breast cancer recurrence, established per routine clinical care, will be 
recorded at the conclusion of the study for those patients with follow-up information 
available through the electronic medical record system (minimum 1 year after 
primary breast surgery). 
8. 
ADVERSE EVENTS 
8.1 
Purpose 
Adverse event (AE) data collection and reporting, which are required as part 
of every clinical trial, are done to ensure the safety of the patients enrolled, 
as well as those who will enroll in future studies using similar agents.  
 
8.2 
Terminology 
• Adverse Event (AE): Any untoward medical occurrence associated 
with the use of a drug in humans, whether or not considered drug 
related. Therefore, an AE can be ANY unfavorable and unintended 
sign (including an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of a medicinal product, whether 
or not considered related to the medicinal product.  
• Attribution: An assessment of the relationship between the adverse 
event and the protocol treatment, using the following categories. 

25 
 
ATTRIBUTION 
DESCRIPTION 
Unrelated 
The AE is clearly NOT related to 
treatment. 
Unlikely 
The AE is doubtfully related to 
treatment. 
Possible 
The AE may be related to treatment. 
Probable 
The AE is likely related to treatment. 
Definite 
The AE is clearly related to treatment. 
• CAEPR (Comprehensive Adverse Events and Potential Risks 
List): An NCI generated list of reported and/or potential AEs 
associated with an agent currently under an NCI IND. Information 
contained in the CAEPR is compiled from the Investigator’s 
Brochure, the Package Insert, as well as company safety reports.  
• CTCAE: The NCI Common Terminology Criteria for Adverse Events 
provides a descriptive terminology that is to be utilized for AE 
reporting. A grade (severity) is provided for each AE term.  
• Hospitalization (or prolongation of hospitalization): For AE 
reporting purposes, a hospitalization is defined as an inpatient 
hospital stay equal to or greater than 24 hours.  
• Life Threatening Adverse Event: Any AE that places the subject at 
immediate risk of death from the AE as it occurred.  
• Serious Adverse Event (SAE): Any adverse event occurring at any 
dose that results in ANY of the following outcomes:  
• Death  
• A life-threatening adverse event  
• Inpatient 
hospitalization 
or 
prolongation 
of 
existing 
hospitalization (for ≥ 24 hours).  
• A persistent or significant incapacity or substantial disruption 
of the ability to conduct normal life functions.  
• A congenital anomaly/birth defect.  
• Important Medical Events (IME) that may not result in death, 
be life threatening, or require hospitalization may be 
considered a serious when, based upon medical judgment, 
they may jeopardize the patient or subject and may require 
medical or surgical intervention to prevent one of the 
outcomes listed in this definition. 
 
8.3 
Reporting Procedure 
Per 21CFR312.32(c), all adverse events deemed both serious and 
unexpected associated with the use of the drug must be reported to the FDA 

26 
 
and to all participating investigators as soon as possible and in no event 
later than 15 days. 
 
The FDA will be notified of any unexpected fatal or life threatening 
experience associated with the drug as soon as possible but in no event 
later than 7 calendar days.  The University of Wisconsin Health Sciences-
IRB will be notified in accordance with posted institutional policy. 
 
Serious and Non Serious Adverse events will be recorded, regardless of 
whether or not they are thought to be related to the investigational imaging 
tracer.  While all adverse events will be tabulated and reported in the study 
final report, serious adverse events will be reported in the course of the trial.  
Adverse events that meet criteria of a serious adverse event listed above 
will also be recorded and reported. 
 
The Investigator will inform the IRB of all adverse events attributed to the 
investigational imaging tracer in accordance with posted institutional policy. 
 
8.4 
Additional Adverse Event Information 
CTCAE term (AE description) and grade:  The descriptions and grading 
scales found in the revised NCI Common Terminology Criteria for Adverse 
Events (CTCAE) version 5.0 will be utilized for AE reporting.  All appropriate 
treatment areas should have access to a copy of the CTCAE version 5.0.  
A copy of the CTCAE version 5.0 can be downloaded from the CTEP web 
site 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.ht
m 
 
To date, no significant adverse events have been reported as a result of the 
intravenous (IV) administration of FFNP for PET imaging applications 
(11,12).  
 
As with any IV administered agent, FFNP could cause an allergic reaction 
that could potentially pose a threat to life (anaphylaxis).  This has not been 
observed in reported human exposure to date.  Reasonable precautions 
should be taken, consistent with normal radiologic and clinical facility 
practice.  The patient should be monitored until the PET procedure is 
completed, and trained personnel and emergency equipment should be 
available per facility standards. 
 
For purposes of informed consent regarding reasonably foreseeable risks 
to subjects in trials utilizing FFNP, the following potential adverse events 
are considered extremely rare: 
• 
Injection-related risks that may include infection, or accidental 
extravasation of the dose that may lead to discomfort, localized pain, or 
infection.  

27 
 
• 
Risks related to allergic reaction/anaphylaxis that may be life 
threatening. 
 
As with all PET imaging agents, FFNP is a radiopharmaceutical that decays 
with positron emission.  As such, it poses an intrinsic radiation exposure 
risk.  The organ and total body doses associated with FFNP-PET imaging 
are comparable to or lower than those associated with other widely used 
clinical nuclear medicine procedures.   
 
FFNP in combination with other agents could cause an exacerbation of any 
adverse event currently known to be caused by the other agent, or the 
combination may result in events never previously associated with either 
agent. 
 
9. 
MEASURMENT OF TREATMENT OR INTERVENTION EFFECT 
Not applicable since the research imaging studies will not be used to guide therapy. 
10. 
STUDY PARAMETERS 
Information regarding time intervals for performance of the study and contact points is 
included as a table in 5.3. 
 
11. 
DRUG FORMULATION AND PROCUREMENT 
11.1 Gadolinium based intravenous contrast agent  
A gadolinium based intravenous contrast agent will be used for the MRI 
portion of this study.  It will be obtained from a commercial source and will 
be administered following current clinical practice in use at UW Health from 
breast MR imaging.   
 
11.2 21-[18F]Fluoro-16α,17α–[(R)-1’-α-furylmethylidene) dioxyl]-19-norpregn-4-
ene-3,20-dione (FFNP) 
FFNP is an investigational new drug which will be used for this study.  The 
radioisotope for FFNP, Fluorine-18, decays by positron emission and has a 
half-life of 110 minutes.  Fluorine-18 is the most frequently used 
radioisotope for PET radiopharmaceuticals.   
 
11.2.1 
Other Names 
[F-18]FFNP, FFNP 
 
11.2.2 
Classification 
Investigational new drug:  Radiopharmaceutical/radiotracer 
 

28 
 
11.2.3 
Mode of Action 
FFNP binds to progesterone receptor (PR) with high affinity and 
selectivity (7-9).  In primary and metastatic breast cancer, uptake of 
FFNP measured by PET/CT imaging has been shown to correlate 
with 
PR 
expression 
in 
biopsy 
material 
assayed 
by 
immunohistochemistry (11).  FFNP is primarily cleared from the body 
via hepatobiliary elimination. 
 
11.2.4 
Storage and Stability 
In accordance with regulations, the facility conducts several quality 
control tests on the FFNP product prior to release for human 
administration. Once delivered, doses will be stored in the 
appropriate storage area in the nuclear medicine facility until they are 
administered to the patient.  
 
The drug solution is stored at room temperature in a gray butyl 
septum sealed, sterile, pyrogen-free glass vial with an expiration time 
of 6 hours. 
 
11.2.5 
Dose Specifics 
The injected dose of FFNP will be approximately 7 mCi (259 MBq) 
with a specific activity greater than 200 Ci/mmol.  Maximum injection 
dose for a single PET scan will be 10 mCi or less.  In all cases, less 
than 7 μg mass dose of FFNP should be injected, which is a 
subpharmacologic, “tracer” amount.   
 
FFNP is the only active ingredient.  There is no evidence that 
nonradioactive and radioactive FFNP molecules display different 
biochemical behavior.  
 
11.2.6 
Preparation 
Fluorine-18 labeled FFNP is synthesized with high specific activity 
so the quantity of progestogenic material injected with the 
radiopharmaceutical is < 7 μg (<16.3 nmol).  The final FFNP product 
solution contains 90% (v:v) USP 0.9% sodium chloride injection and 
10% (v:v) USP ethanol alcohol injection.  Up to 10 mL of FFNP may 
be administered for a single PET scan. 
 
Specific manufacturing processes will follow our approved Drug 
Master File for FFNP.   
 
11.2.7 
Route of Administration 
Intravenous (IV)    
 
11.2.8 
Incompatibilities 

29 
 
N/A 
 
11.2.9 
Availability 
cGMP-grade FFNP will be manufactured on-site in the UW-Madison 
Radiopharmaceutical Production Facility.  This facility has been 
qualified and approved for production by NCI Cancer Imaging 
Program (CIP) and ECOG-ACRIN for clinical trials using other 
investigational radiopharmaceuticals, such as 18F-fluoroestradiol and 
18F-fluorothymidine.  The investigational pharmacist or qualified 
nuclear medicine technologist will be the responsible party 
designated by the Investigator.  
 
FFNP is not currently commercially available. 
 
11.2.10 
Side Effects 
See Section 8.4 for side effects. The radiation effective dose 
equivalent to the whole body from intravenously injected FFNP is 
estimated to be 0.02 mSv/MBq (11). The dose-limiting organ is the 
gall bladder, with an average absorbed dose of 0.113 mGy/MBq.  
The average absorbed dose to the breasts is 0.010 mGy/MBq and 
the whole-body dose is 0.015 mGy/MBq.  The organ and total body 
doses associated with FFNP PET imaging are comparable to or 
lower than those associated with other widely used clinical nuclear 
medicine procedures and are well below the maximum suggested 
individual study and annual total body dose of 30 and 50 mGy, 
respectively, suggested for investigational radiopharmaceuticals by 
the FDA. 
 
11.2.11 
Nursing/Patient Implications 
Lactating patients are excluded from this study. 
 
Standard safety precautions required when handling radioactive 
materials (predominantly during the injection and uptake period) 
should be followed.  FFNP requirements are similar to those used for 
other PET tracers.   
 
   
12. 
STATISTICAL CONSIDERATIONS 
12.1 Primary Objective 
12.1.1 To compare FFNP uptake of biopsy-proven primary PR+ breast 
malignancies measured using PET/MRI with the reference standard 
of PR immunohistochemistry (IHC). 
 

30 
 
The primary objective is to compare FFNP SUVmax from PET/MRI 
with the PR immunohistochemistry semi-quantitative score obtained 
by using the Allred score (0-8) (1). The correlation of the two 
measures will be evaluated with Pearson’s correlation coefficient. 
The null hypothesis is H0: p0=0.20 and the alternative hypothesis is 
H1: p1 =0.70. 
 
A sample size of 21 patients achieves 80% power to detect this 
difference, using a two-sided hypothesis test with a Type I error of 
5%, accounting for 1 dropout.   Sample size calculations were done 
in PASS 14 (NCSS, LLC, Kaysville, Utah.  http://www.ncss.com).  . 
 
Other measures of FFNP uptake including SUVpeak (small fixed-size 
ROI centered on most metabolically active part of tumor), SUVmean 
(average value), tumor-to-normal tissue uptake ratio, and total lesion 
uptake (functional tumor volume × SUVmean) will also be correlated 
with the PR immunohistochemistry semi-quantitative score obtained 
by using the Allred score.     
 
12.2 Secondary Objectives 
12.2.1 
To determine the test-retest reproducibility of quantitative 
assessment of tumor FFNP uptake. 
 
The reproducibility of the two measurements of FFNP uptake will be 
evaluated in the 5 subjects who elect to undergo a second imaging 
session, using summary statistics of tumor FFNP uptake for each 
reading for PET/MRI. The analysis will be done separately for each 
reader.  
 
12.2.2 
To determine the intra- and inter-observer variability of 
quantitative assessment of FFNP. 
 
The intra- and inter-reader agreement of SUV values for tumor FFNP 
uptake will be analyzed with Bland-Altman plots and 95% limits of 
agreement.  Analyses will be conducted on a per-lesion basis, and 
repeat tumors within the same patient will be assumed to be 
independent.   
 
12.2.3 
To evaluate the optimal cut-point of FFNP uptake for 
distinguishing between PR negative and PR positive invasive 
breast cancer. 
 
Receiver operating characteristic (ROC) curve analysis will be 
performed to determine the optimal cut-point for FFNP uptake to 
distinguish PR-positive from PR-negative invasive breast cancer, as 

31 
 
defined by the clinical pathology report.  The area under the curve 
for the ROCs and their respective two-sided 95% confidence 
intervals will be calculated using logistic regression.  The optimal cut-
off point will be determined by considering the FFNP uptake value 
with the maximum sensitivity and specificity.  The analysis will be 
done separately for each reader.  
 
12.2.4 
To estimate the association of tumor FFNP uptake (continuous 
SUVmax) with research-based Oncotype DX scores (0-100). 
 
Scatter plots of continuous FFNP uptake (SUVmax) on the y-axis 
and research-based Oncotype DX scores (unitless) on the x-axis will 
be created to explore the distribution of the measurements.  
Pearson’s or Spearman’s rank correlation will be used to evaluate 
the association between FFNP uptake and research-based 
Oncotype DX score. The correlation coefficient (rho) and 95% 
confidence interval will be reported. 
 
12.3 Exploratory Objectives 
 
12.3.1 
To evaluate heterogeneity of tumor FFNP uptake. 
 
The coefficient of variation (COV), defined as standard deviation of 
the standardized uptake value (SUV) and the mean value of the SUV 
will be assessed.  Other descriptive measures such as skewness and 
kurtosis, which are measures of asymmetry and heaviness of the 
tails, relative to the normal distribution will be assessed.  The 
analysis will be done separately for each reader.  
 
12.3.2 
To correlate tumor FFNP uptake with serum progesterone and 
estradiol levels. 
 
A correlation analysis of serum progesterone and estradiol levels 
with tumor FFNP uptake measured with SUV values will be 
performed using Pearson’s or Spearman’s rank correlation.  Scatter 
plots, correlation coefficients (rho), 95% confidence intervals, and p 
values will be reported. This analysis will be done separately for each 
reader.  
 
12.3.3 
To correlate tumor FFNP uptake with disease recurrence. 
 
If there is sufficient follow-up data for disease recurrence, the 
Kaplan-Meier method will be used to analyze time to disease 
recurrence, defined as date of imaging day until disease recurrence.  

32 
 
Patients who do not experience disease recurrence will be censored 
at the date of last available follow-up.  A Cox proportional hazards 
model will be used to evaluate the association of tumor FFNP uptake 
with time to disease recurrence.  If there is insufficient follow-up data, 
descriptive statistics will be used to summarize the tumor FFNP 
uptake for those patients with disease recurrence.  
 
 
12.4 Evaluation of Toxicity   
Subjects will be evaluable for toxicity from the time of injection of FFNP until 
24 hours after injection.  For this evaluation, the study coordinator will 
contact the subject within 1 to 3 days after FFNP administration. 
 
13. 
PATHOLOGY REVIEW 
13.1 Justification 
The primary objective is to measure FFNP uptake of biopsy-proven primary 
PR+ invasive breast malignancies using PET/MRI.  The reference standard 
will be PR expression measured with immunohistochemistry.     
 
The pathology of the biopsy-proven breast cancer will be evaluated per the 
current standard of care (histologic diagnosis, grade, ER status, PR status, 
HER2 status, Ki67 score).  At UW Health, Ki67 score is routinely reported 
as a percentage of darkly stained nuclei across the entire tumor represented 
on the stained slide.  At UW Health, PR status is routinely reported as 
positive or negative and includes a visual estimation of the percentage of 
cells staining positive as well as intensity of staining.  This information will 
be obtained from the pathology report in the subjects’ electronic medical 
record and will be used to calculate a semi-quantitative Allred score (1).  If 
the information needed to calculate the Allred score is not included in the 
clinical pathology report, a pathologist on the research study team will 
review the existing PR IHC slides. 
 
13.2 Required Pathology Materials 
Pathology reports will be available through the electronic medical record.  
Existing pathology slides (PR IHC and H&E) from the breast biopsy used 
for initial diagnosis will be requested from the Department of Pathology for 
semi-quantitative Allred scoring by the research study pathologist if the 
information needed to calculate the Allred score is not included in the clinical 
pathology report.   
 
For the research-based Oncotype DX score, a study pathologist will review 
the H&E slides from the surgical specimen and select a block for release to 

33 
 
the TRIP Laboratory.  We anticipate needing 6 unstained sections per 
patient specimen for sufficient RNA isolation for the assay. 
 
13.3 Routing 
Requested pathology slides will be sent to the research study pathologists. 
 
14. 
RECORDS TO BE KEPT 
The PI will supervise the data collection and management.  The following types of data 
and materials will be collected: 
 
14.1 Images 
Images from the research imaging examinations will be stored on the local picture 
archiving and communication system (PACS) (McKesson, San Francisco, CA).  
The local PACS system is password protected behind the UW Department of 
Radiology firewall.  
 
14.2 Regulatory and Consent 
A research chart will be created for each subject.  The chart will include the signed 
consent form, a copy of the subject’s experimental bill of rights, and a signed 
HIPAA form.  Research charts will be kept in a locked file cabinet within a secure 
office.  An enrollment log will be maintained.  The enrollment log will confirm that 
informed consent was obtained on each subject.  The patient has the right to 
decline to participate in the study and to request removal from the study at any 
time.  Informed consent will be provided and signed prior to enrollment in the study.  
Patients may refuse to answer any questions asked during the duration of the 
study if they are too uncomfortable to answer.  All of these potential risks will be 
described to the patient in the informed consent document.  
 
14.3 Confidentiality 
Information about study subjects will be kept confidential and managed according 
to the requirements of the Health Insurance Portability and Accountability Act of 
1996 (HIPAA). Subjects will be assigned a unique study number upon enrollment 
that will be used to label their research data in lieu of directly identifiable 
information.  All subject data collected during participation in the study will be kept 
in a locked file cabinet within a secure office or a password-protected database 
that uses departmental servers and will only be accessible to study team members.  
After the study is completed, all data will be de-identified for the purposes of 
research presentations/publications.  The study breast MRI examinations will be 
archived on the standard clinical PACS system which is password protected 
behind the UW Health firewall.  The study data and records will be maintained for 
up to 5 years after the conclusion of the study, at which point the PI will destroy 
the key to the coded identifiers, thus permanently anonymizing the data. 
 

34 
 
15. 
PATIENT CONSENT AND PEER JUDGMENT 
Current FDA, state, federal, and institutional regulations concerning informed consent will 
be followed. 
 
16. 
DATA AND SAFETY MONITORING 
Safety monitoring of research protocols investigating novel PET tracers utilize a 
combination of tools. These are framed to provide adequate clinical trial oversight 
ensuring that the research team is complying with the conditions of IRB approval and 
FDA requirements. The tools enable frequent evaluations of study-related activities, 
identification of deviations or noncompliance with the conduct of the study or protocol, 
review of adverse events tracking and reporting, and review of drug production and 
accountability. 
 
These tools include: 
• Study visit checklists – Research Coordinators use study visit checklists, 
developed in conjunction with the PI, to ensure that all study required procedures 
and processes are met before, during and after the subject has been enrolled. 
Items listed on these checklists include informed consent obtained, consent 
questions answered (and by whom), vitals recorded, medications reviewed, MRI 
safety form, etc. These checklists are completed and reviewed by the study 
coordinator requiring signature approval for each study subject to ensure tight 
adherence to the protocol.  
 
• Safety monitoring – The safety monitoring of subjects enrolled in the research 
includes both internal and external safety checks governing the administration of 
FFNP. Internal monitoring is performed by co-investigators and external 
monitoring by a team of four physicians, scientists, and staff with the appropriate 
broad clinical and technical expertise. The internal monitoring plan includes a brief 
review of each subject visit after it occurs.  In this regard, the study team will 
discuss data quality, FFNP production and administration, and subject compliance 
and tolerance of research procedures.  
 
The external monitoring plan will be coordinated by the Department of Radiology Medical 
Imaging Research Support (MIRS) administrative team.  MIRS is a working group that 
provides investigators with the support needed to conduct clinical research that uses 
imaging as an outcome measure.  Members include a core administrative group 
(physicians, scientists, imaging modality managers, regulatory and administrative 
support) and ad hoc members recruited when their expertise is required for the 
review/monitoring of a research project.  MIRS administrative team in addition to a 4-
person committee of physicians/scientists will meet annually with representatives from 
the research team, to discuss research progress, AE/SAE reports, as well as other data 
reports compiled by the study team.  If an AE/SAE occurs, an ad hoc committee meeting 
will be organized to discuss whether the event is considered serious, whether it can be 
attributed to research procedures, whether it constitutes non-compliance on the part of 
the study team, and the plan for resolution and a future remediation plan. 

35 
 
 
As part of this plan, the monitor(s) will verify that:  
• The rights and well-being of human subjects are protected  
• Reported study data are accurate, complete, and verifiable from source documents  
• The conduct of the study is in compliance with the currently approved protocol, 
GCPs, applicable regulatory requirements, and guidelines for clinical research 
studies at the University of Wisconsin-Madison and its affiliates  
 
16.1 Risks 
 
16.1.1 
MRI 
The risk from the MRI component of the exam is minimal and is primarily 
related to claustrophobia and discomfort with positioning.  Only staff skilled 
in the placement of IVs will place IVs for the study breast PET/MRI.  Injection 
of gadolinium contrast has common mild side effects, including nausea, 
headache, and hives.  More serious reactions, while rare, can occur, 
including allergic reactions.  Any significant allergic reaction or contrast 
extravasation will be monitored and treated appropriately by clinical staff. 
 
All hardware used to obtain MR images is FDA approved and will be used 
in accordance with the conditions approved by FDA.  The investigational 
software being used in image acquisition is designed to stay within the 
current guidelines for MRI safety, established by the FDA.  In addition, the 
investigational software does not meet the definition of a Significant Risk 
Device as outlined by the FDA under 21 CFR 812.3 as being: 
• Intended as an implant and presents a potential for serious risk to 
the health, safety, or welfare of a subject; 
• Purported or represented to be for use supporting or sustaining 
human life and presents a potential for serious risk to the health, 
safety or welfare of a subject; 
• For a use of substantial importance in diagnosing, curing, mitigating, 
or treating disease, or otherwise preventing impairment of human 
health and presents a potential for serious risk to the health, safety 
or welfare of a subject; or 
• Otherwise presents a potential for serious risk to the health, safety, 
or welfare of a subject. 
 
16.1.2 
PET 
There has been one “first-in-human” study involving 20 patients using FFNP 
PET/CT (11). There were no adverse events, changes in vital signs, 
laboratory 
values 
or 
electrocardiograms, 
or 
clinically 
detectable 
pharmacologic effects.  Similarly, there were no adverse events or clinically 
detectable pharmacological effects associated with FFNP administration in 

36 
 
a subsequent phase 2 study involving 43 patients each receiving 2 FFNP 
PET/CT scans (12). 
 
Risks associated with PET imaging result primarily from the radiation dose 
from the radiopharmaceutical.  For this research study, approximately 7 mCi 
of FFNP will be administered intravenously which is also the standard dose 
used for other clinical trials using FFNP (11,12).  The radiation effective 
dose equivalent to the whole body from intravenously injected FFNP is 
estimated to be 0.02 mSv/MBq (11).  Thus for an administered dose of 7 
mCi (259 MBq), the whole-body effective dose equivalent is approximately 
5 mSv.  The dose-limiting organ is the gall bladder, with an average 
absorbed dose of 0.113 mGy/MBq.  The average absorbed dose to the 
breasts is 0.010 mGy/MBq and the whole-body dose is 0.015 mGy/MBq.  
Thus for an administered dose of 7 mCi (259 MBq), the whole-body 
absorbed dose is approximately 3.885 mGy.  For context, the average 
person in the United States receives an estimated effective dose of about 3 
mSv per year from naturally occurring radioactive materials, such as radon 
and radiation from outer space.  The current guidance from radiation 
protection organizations, including American Association of Physicists in 
Medicine, Health Physics Society, International Organization for Medical 
Physics, and United Nations Scientific Committee on the Effects of Atomic 
Radiation (UNSCEAR) states that estimates of risk below levels of about 
100 mSv are not statistically different from zero.  The organ and total body 
doses associated with FFNP-PET imaging are comparable to or lower than 
those associated with other widely used clinical nuclear medicine 
procedures and are well below the maximum suggested individual study 
and annual total body dose of 30 and 50 mGy, respectively, suggested for 
investigational radiopharmaceuticals by the FDA.   
 
16.1.3 
CT (performed only in rare instances when the subject is unable 
to be imaged using the simultaneous PET/MRI scanner). 
Risks associated with CT include exposure to 1.5 mSv of radiation from the 
low-dose chest CT scan required for attenuation correction calculations.  
Thus, the total whole body effective dose equivalent for breast PET/CT is 
approximately 6.5 mSv.  This corresponds to approximately 2 years of 
natural background radiation and remains well below the annual 
occupational dose limit for radiation workers. 
 
16.1.4     Scanner/Tracer Production Issues      
There is a possibility of tracer production issues and scanner malfunction 
issues.  These two issues are rare but not unanticipated.  When possible, 
subjects will simply be rescheduled to a day/time that fits their schedules.  
If PET tracer has been administered prior to the discovery of a scanner 
issue, subjects will be paid and withdrawn from this research.  The research 

37 
 
team will call the subject within 3 days to inquire about adverse events 
related to the tracer. 
 
16.1.5 
Unexpected findings 
All patients in this study will receive the clinical “gold standard”, diagnostic 
breast MRI and PR measurement via IHC, as part of their clinical care as a 
requirement for enrollment in the study.  Thus, the breast specific PET/MRI 
research study is not expected to yield any additional information beyond 
that which was described on the diagnostic exam.  Additionally, breast 
specific PET is not routinely used in clinical practice for local staging and 
extent of disease and this information will not be used to guide clinical care.  
For these reasons, incidental findings may not be identifiable (poor quality 
images) or may not be identified until long after the research exam is 
performed.  Thus, PET images will not be reviewed by a radiologist as a 
diagnostic exam.   
 
16.1.6 
Drug side effects 
16.1.6.1 FFNP: See Section 8.4 for possible side effects.  
 
 
 

38 
 
17. 
REFERENCES 
1. 
Harvey JM, Clark GM, Osborne CK, Allred DC. Estrogen receptor status by 
immunohistochemistry is superior to the ligand-binding assay for predicting response to 
adjuvant endocrine therapy in breast cancer J Clin Oncol. 1999;17 1474-1481. 
 
2. 
Osborne CK, Schiff R. Mechanisms of endocrine resistance in breast cancer. 
Annu Rev Med. 2011;62:233-247. 
 
3. 
Horwitz KB, McGuire WL. Estrogen control of progesterone receptor in human 
breast cancer. Correlation with nuclear processing of estrogen receptor. J Biol Chem. 
1978;253:2223-2228  
 
4. 
Howell A, Harland RN, Barnes DM, et al. Endocrine therapy for advanced 
carcinoma of the breast: relationship between the effect of tamoxifen upon 
concentrations of progesterone receptor and subsequent response to treatment. Cancer 
Res. 1987;47:300-304. 
 
5. 
Fowler AM, Chan SR, Sharp TL, et al. Small-animal PET of steroid hormone 
receptors predicts tumor response to endocrine therapy using a preclinical model of 
breast cancer. J Nucl Med. 2012;53:1119-1126. 
 
6. 
Chan SR, Fowler AM, Allen JA, et al. Longitudinal noninvasive imaging of 
progesterone receptor as a predictive biomarker of tumor responsiveness to estrogen 
deprivation therapy. Clin Cancer Res. 2015;21:1063-1070. 
 
7. 
Vijaykumar D, Mao W, Kirschbaum KS, Katzenellenbogen JA. An efficient route 
for the preparation of a 21-fluoro progestin-16 alpha,17 alpha-dioxolane, a high-affinity 
ligand for PET imaging of the progesterone receptor. J Org Chem. 2002;67:4904-4910. 
 
8. 
Lee JH, Zhou HB, Dence CS, Carlson KE, Welch MJ, Katzenellenbogen JA. 
Development of [F-18]fluorine-substituted Tanaproget as a progesterone receptor 
imaging agent for positron emission tomography. Bioconjug Chem. 2010;21:1096-1104. 
 
9. 
Buckman BO, Bonasera TA, Kirschbaum KS, Welch MJ, Katzenellenbogen JA. 
Fluorine-18-labeled progestin 16 alpha, 17 alpha-dioxolanes: development of high-
affinity ligands for the progesterone receptor with high in vivo target site selectivity. J 
Med Chem. 1995;38:328-337. 
 
10. 
Zhou D, Lin M, Yasui N, et al. Optimization of the preparation of fluorine-18-
labeled steroid receptor ligands 16alpha-[18F]fluoroestradiol (FES), [18F]fluoro furanyl 
norprogesterone (FFNP), and 16beta-[18F]fluoro-5alpha-dihydrotestosterone (FDHT) as 
radiopharmaceuticals. J Labelled Comp Radiopharm. 2014;57:371-377. 
 
11. 
Dehdashti F, Laforest R, Gao F, et al. Assessment of progesterone receptors in 
breast carcinoma by PET with 21-18F-fluoro-16alpha,17alpha-[(R)-(1'-alpha-
furylmethylidene)dioxy]-19-norpregn- 4-ene-3,20-dione. J Nucl Med. 2012;53:363-370. 

39 
 
 
12. 
Dehdashti F, Wu N, Ma CX, Naughton MJ, Katzenellenbogen JA, Siegel BA. 
Association of PET-based estradiol-challenge test for breast cancer progesterone 
receptors with response to endocrine therapy. Nat Commun. 2021;12:733. 
 
13. 
DeMartini W, Lehman C. A review of current evidence-based clinical applications 
for breast magnetic resonance imaging. Top Magn Reson Imaging. 2008;19:143-150. 
 
14. 
Fowler AM, Kumar M, Bancroft LH, et al. Measuring glucose uptake in primary 
invasive breast cancer using simultaneous time-of-flight breast PET/MRI: a method 
comparison study with prone PET/CT. Radiol Imaging Cancer. 2021;3:e200091. 
 
15. 
Peterson LM, Mankoff DA, Lawton T, et al. Quantitative imaging of estrogen 
receptor expression in breast cancer with PET and 18F-fluoroestradiol. J Nucl Med. 
2008;49:367-374. 
 
16. 
Kurland BF, Peterson LM, Lee JH, et al. Between-patient and within-patient (site-
to-site) variability in estrogen receptor binding, measured in vivo by 18F-fluoroestradiol 
PET. J Nucl Med. 2011;52:1541-1549. 
 
17. 
Li H, Zhu Y, Burnside ES, et al. MR imaging radiomics signatures for predicting 
the risk of breast cancer recurrence as given by research versions of MammaPrint, 
Oncotype DX, and PAM50 gene assays. Radiology. 2016;281:382-391. 
 
18. 
Paik S, Shak S, Tang G, et al. A multigene assay to predict recurrence of 
tamoxifen-treated, node-negative breast cancer. N Engl J Med. 2004;351:2817-2826. 
 
19. 
Paik S, Tang G, Shak S, et al. Gene expression and benefit of chemotherapy in 
women with node-negative, estrogen receptor-positive breast cancer. J Clin Oncol. 
2006;24:3726-3734. 
 
20. 
Cronin M, Sangli C, Liu ML, et al. Analytical validation of the Oncotype DX 
genomic diagnostic test for recurrence prognosis and therapeutic response prediction in 
node-negative, estrogen receptor-positive breast cancer. Clin Chem. 2007;53:1084-
1091. 
 
21. 
Habel LA, Shak S, Jacobs MK, et al. A population-based study of tumor gene 
expression and risk of breast cancer death among lymph node-negative patients. Breast 
Cancer Res. 2006;8:R25. 
 
22. 
Smith IE, Dowsett M, Ebbs SR, et al. Neoadjuvant treatment of postmenopausal 
breast cancer with anastrozole, tamoxifen, or both in combination: the Immediate 
Preoperative Anastrozole, Tamoxifen, or Combined with Tamoxifen (IMPACT) 
multicenter double-blind randomized trial. J Clin Oncol. 2005;23:5108-5116. 
 

40 
 
23. 
Dowsett M, Ebbs SR, Dixon JM, et al. Biomarker changes during neoadjuvant 
anastrozole, tamoxifen, or the combination: influence of hormonal status and HER-2 in 
breast cancer--a study from the IMPACT trialists. J Clin Oncol. 2005;23:2477-2492. 
 
24. 
Dowsett M, Smith IE, Ebbs SR, et al. Short-term changes in Ki-67 during 
neoadjuvant treatment of primary breast cancer with anastrozole or tamoxifen alone or 
combined correlate with recurrence-free survival. Clin Cancer Res. 2005;11:951s-958s. 
 
25. 
Ellis MJ, Suman VJ, Hoog J, et al. Ki67 proliferation index as a tool for 
chemotherapy decisions during and after neoadjuvant aromatase inhibitor treatment of 
breast cancer: results from the American College of Surgeons Oncology Group Z1031 
trial (Alliance). J Clin Oncol. 2017;35:1061-1069. 
 
26. 
Guerrero-Zotano AL, Arteaga CL. Neoadjuvant trials in ER(+) breast cancer: a 
tool for acceleration of drug development and discovery. Cancer Discov. 2017;7:561-
574. 
 
27. 
Gao Q, Lopez-Knowles E, Cheang MCU, et al. Impact of aromatase inhibitor 
treatment on global gene expression and its association with antiproliferative response 
in ER+ breast cancer in postmenopausal patients. Breast Cancer Res. 2019;22:2. 
 
28. 
Gellert P, Segal CV, Gao Q, et al. Impact of mutational profiles on response of 
primary oestrogen receptor-positive breast cancers to oestrogen deprivation. Nat 
Commun. 2016;7:13294. 
 
29. 
Lintermans A, Neven P. Safety of aromatase inhibitor therapy in breast cancer. 
Expert Opin Drug Saf. 2015;14:1201-1211. 
 
30. 
Mohsin SK, Weiss H, Havighurst T, et al. Progesterone receptor by 
immunohistochemistry and clinical outcome in breast cancer: a validation study. Mod 
Pathol. 2004;17:1545-1554.