Assessment of Treatment-Induced Tissue Hypoxia After Transcatheter Arterial Embolization of Hepatocellular Carcinoma: A Feasibility Study With [18F]FMISO PET/CT
Phase: PHASE2
Conditions: Adult Liver Carcinoma, Liver Cirrhosis
Sponsor: Stanford University

 
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28 October 2015 
Assessment of Treatment-induced Tissue Hypoxia after  
Transcatheter Arterial Embolization of Hepatocellular Carcinoma:  
a Feasibility Study with [18F]FMISO PET/CT 
 
 
Principal Investigator 
Rajesh Shah, MD 
300 Pasteur Dr, H3630 
Stanford, CA  4305-5484 
 
Co-investigators 
Sanjiv Sam Gambhir, MD, PhD (IND holder) 
Frederick T Chin, PhD 
318 Campus Dr, # E153 
1201 Welch Road, Room PS049 
Stanford, CA  94305 
Stanford, CA  94305-5484 
 
 
George Segall, MD 
Lewis Shin, MD 
3801 Miranda Ave  
300 Pasteur Dr, H-1307  
Palo Alto, CA  94304 
Stanford, CA  94305  
 
Statistician 
Alex McMillan, PhD 
HRP T160A 
Stanford, CA 94305 
 
Original date:   
24 July 2015 
Protocol Amendment 1date: 
28 October 2015 
Activation date:   
 
SRC approval date: 
 
 
IND number: 
IND 126878 (IND holder:  Sanjiv Sam Gambhir, MD, PhD) 
eProtocol number: 
IRB-29768 (PD/PI:  Rajesh Shah, MD) 
 
 
NCT02695628 
Date: 10/28/2015 

 
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28 October 2015 
Table of Contents  
1.0 
PROTOCOL ABSTRACT/OVERVIEW ............................................................................ 3 
2.0 
BACKGROUND AND RATIONALE ................................................................................. 4 
3.0 
STUDY OBJECTIVES ..................................................................................................... 8 
3.1 
Primary Objective ................................................................................................... 8 
3.2 
Secondary Objectives ............................................................................................. 9 
4.0 
ELIGIBILITY CRITERIA ................................................................................................... 9 
4.1 
Inclusion Criteria ..................................................................................................... 9 
4.2 
Exclusion Criteria .................................................................................................... 9 
5.0 
RESEARCH DESIGN AND METHODS ......................................................................... 10 
5.1 
Study Design .........................................................................................................10 
5.2 
Research Facility ...................................................................................................11 
5.3 
Study Calendar / Schedule ....................................................................................11 
5.4 
Pre-Registration Procedures ..................................................................................12 
5.5 
Registration Visit and Procedures ..........................................................................12 
5.6 
Imaging and Intervention Visit(s) ............................................................................12 
5.7 
General Concomitant Medication and Supportive Care Guidelines ........................13 
5.8 
Post-Therapy Visits ................................................................................................13 
5.9 
Criteria for Removal from Study .............................................................................13 
5.10 
Image Acquisition, Archiving, and Interpretation ....................................................13 
6.0 
STATISTICAL CONSIDERATIONS ............................................................................... 16 
6.1 
Study Design and Endpoints ..................................................................................16 
6.2 
Objectives and Analysis Plans ...............................................................................16 
6.3 
Sample Size Considerations ..................................................................................17 
6.4 
Study monitoring, interim analyses, and early stopping rules .................................17 
7.0 
ADVERSE EVENTS; SAFETY ISSUES ........................................................................ 17 
7.1 
Definition of Adverse Events and Potential Risks ...................................................17 
7.2 
Definition of Serious Adverse Events (Serious Adverse Events List) ......................18 
7.3 
Adverse Events Characteristics .............................................................................18 
7.4 
Adverse Event Reporting .......................................................................................19 
8.0 
ETHICAL CONSIDERATIONS (INCLUDING INFORMED CONSENT) .......................... 21 
8.1 
Protection of Subject Rights ...................................................................................21 
8.2 
Confidentiality ........................................................................................................21 
8.3 
Inclusion of Women and Minorities ........................................................................21 
8.4 
Audit and Monitoring ..............................................................................................21 
8.5 
IND ........................................................................................................................21 
9.0 
DATA MANAGEMENT; ADMINISTRATIVE ISSUES ..................................................... 21 
10.0 
REFERENCES .............................................................................................................. 23 
11.0 
APPENDICES ............................................................................................................... 25 
11.1 
Glossary of Terms .................................................................................................25 

 
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28 October 2015 
1.0 ........................................................................ PROTOCOL ABSTRACT/OVERVIEW 
Overview:  
Hepatocellular carcinoma (HCC) is the sixth most common malignancy in the world, the third 
leading cause of cancer deaths, and has more than tripled in incidence since 19751.  Over 
33,190 new cases of liver cancer were anticipated to occur in the U.S. in 2014 with 80% of 
these being HCC2.  The overall 5-year survival is poor at 16%, but increases to 29% when 
diagnosed early2.  With the dismal prognosis, better evaluation of existing treatments is needed 
to prolong the overall survival.  Current treatment options include transcatheter arterial 
chemoembolization (TACE) with a Lipiodol emulsion, drug-eluting bead transcatheter arterial 
chemoembolization (DEB-TACE), and bland small particle transcatheter arterial embolization 
(TAE).  Evaluation of the effect of these treatments typically does not occur until 2-3 months 
after the procedure is performed.  However, new hypoxia imaging agents could be utilized in the 
24 hours after the procedure to determine treatment effect.  In particular 18F-fluoromisonidazole 
(other names are 18F-FMISO, [F-18]FMISO or [18F]FMISO) has been shown to accumulate in 
hypoxic areas of the liver after arterial ligation3.  This agent could be used to determine where 
areas of hypoxia exist after TAE to determine if there is adequate embolization, and to evaluate 
the standardized uptake values to see if a correlation exists with recurrence.  If there is 
evidence for uptake after embolization, and if uptake correlates with recurrence, earlier 
intervention could be performed to reduce the risk of recurrence.  We would like to perform a 
prospective, single-arm, feasibility study to determine if [18F]FMISO shows increased uptake in 
tumors after TAE. 
Objectives: 
Our primary objective is to determine the variability of [18F]FMISO uptake in HCC tumors 
compared to normal liver after transcatheter arterial embolization by determining the difference 
in the mean of the maximum standardized uptake value (SUVmax) and tumor-to-liver ratio 
(TLR) of a region of normal liver and of up to 5 index tumors per subject. 
Our secondary objectives are to determine if areas of tumor recurrence as determined by CT or 
MRI within a 6 month period after transcatheter arterial embolization show evidence of 
increased [18F]FMISO on initial post-treatment [18F]FMISO PET/CT, to determine the variability 
in SUVmax and TLR of untreated HCC compared to normal liver, and to determine any toxicities 
related to [18F]FMISO use for PET/CT. 
Eligibility: 
Eligible subjects will be over 18 years of age with an Eastern Cooperative Oncology 
Group (ECOG) performance status of 0, 1, or 2 and imaging and clinical features of tumor(s) 
diagnostic for hepatocellular carcinoma.  The total bilirubin should be less than 3.0, and they 
must be either a Child-Pugh A or B.  The tumor(s) must be amenable to transcatheter arterial 
embolization and the subjects should be able to provide informed consent. 
Study Design: 
This will be a single-arm, prospective observational study to test the feasibility of using 
[18F]FMISO in subjects with hepatocellular carcinoma.  Subjects will undergo [18F]FMISO 
PET/CT before and after transcatheter arterial embolization and will be followed for 6 months 
after initial treatment for evidence of recurrence.  We anticipate it will take approximately 6 
months to enroll the desired number of subjects. 
Required Sample Size: 
As this is a feasibility study, we will be enrolling 5 subjects in the study.   

 
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28 October 2015 
 
 
 
 
2.0 
Background and Rationale 
Burden of Disease 
Hepatocellular carcinoma (HCC) is the sixth most common malignancy in the world, the third 
leading cause of cancer deaths, and has more than tripled in incidence since 19751.  Over 
33,190 new cases of liver cancer were anticipated to occur in the U.S. in 2014 with 80% of 
these being HCC2.  The overall 5-year survival is poor at 16%, but increases to 29% when 
diagnosed early2.  With the dismal prognosis, better evaluation of existing treatments is needed 
to prolong the overall survival. 
 

 
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28 October 2015 
Embolization is a treatment for intermediate HCC that relies on creating anoxic 
environments to kill tumor  
Treatment for patients with intermediate stage HCC (Barcelona Clinic Liver Cancer BCLC stage 
B), defined as Child-Pugh class A or B liver disease with an ECOG performance status of 0 and 
multinodular disease, is conventional transcatheter arterial chemoembolization (TACE) with 
ethiodized oil, TACE with drug eluting beads (DEB-TACE) or small particle transcatheter arterial 
embolization (TAE) without a chemotherapeutic agent4. No clear advantage has been found for 
TACE versus DEB-TACE or for DEB-TACE versus TAE in retrospective or prospective trials, 
with recent prospective randomized controlled studies showing no statistically significant 
difference in response (TACE vs DEB-TACE) or overall survival (DEB-TACE vs TAE)5–7. The 
mechanism of TACE and DEB-TACE relies on both hypoxia and cytotoxic chemotherapeutic 
action, whereas the mechanism for TAE relies on anoxia alone. In addition, there has been no 
chemotherapeutic agent that has been shown to be superior, with practitioners using 
doxorubicin, epirubicin, mitomycin C, cisplatin, and other agents either singly or in 
combination8,9.   For small particle TAE, anoxia is necessary to ensure cell death, as hypoxia 
has an insignificant effect on cell death10 (Figure 1). 
 
Figure 1.  Hepatocytes cultured in an anoxic 0% oxygen environment (white) resulted in 
marked cell death, while hepatocytes cultured in 2% oxygen (gray) and normoxia (black) 
did not have significant cell death10. 
It has been shown that hypoxia generates a series of changes in tumors that promote 
tumor progression   
Hypoxia has been a recent topic of interest due to the realization of its deleterious effects and its 
role in promoting tumor progression. These include upregulation of VEGF to promote 
angiogenesis and upregulation of glycolysis, which is associated with activation of oncogenes11.  
Hypoxia also improves the survival ability of cells by inhibiting apoptosis12. 
 
Embolization causes upregulation of factors that increase tumor cell survival   
Embolization of tumors creates an increase in hypoxia inducible factor (HIF-1α), particularly at 
the border of necrosis and viable tumor, which in turn upregulates other pro-angiogenic 
factors13,14. HCC cells have been found to proliferate more efficiently when exposed to a hypoxic 
environment13.  In addition, tumors that lie in “watershed” zones, or areas with blood supply from 

 
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28 October 2015 
different segments of the liver, have shown increased tumor viability when only one arterial 
segment is treated15.  Based on these findings, it is possible that identifying areas of 
incompletely treated tumor where hypoxia is present could lead to earlier treatment than is 
currently possible. 
 
Hypoxia imaging agents can allow for earlier determination of these borderline regions 
between necrosis and viable tumor   
Determining where areas of hypoxia exist is difficult with current MRI and CT imaging 
techniques.  The molecular imaging agent [18F]FMISO (18F-fluoromisonidazole) has been widely 
investigated for its use in imaging areas of hypoxia16,17.  The radiotracer accumulates in cells via 
passive diffusion and cannot undergo re-oxidation in hypoxic conditions thereby remaining 
trapped within the cell.  It does not accumulate within necrotic cells.  Given that embolization 
creates hypoxic and anoxic environments, evaluation of these areas pre-treatment and 
post-treatment to identify changes could provide early imaging evidence for areas at increased 
risk of recurrence.  Tumors in the liver have a markedly greater proportion of their blood flow 
from the arterial supply, in contrast to normal liver, which has a greater blood supply from the 
portal venous supply (Figure 2)18.  This suggests that [18F]FMISO should be able to accumulate 
within areas of hypoxia as it can still flow via the portal venous circulation within the liver. 
 
 
Figure 2. Arterial fraction of blood flow is significantly greater in HCC compared to 
normal liver18.  Treated HCC has a greater proportion of blood flow from the portal 
venous supply which theoretically would allow for increasing [18F]FMISO accumulation. 
[18F]FMISO has been shown to be able to detect areas of hypoxia in liver 
Hypoxia imaging using [18F]FMISO in liver was demonstrated in a pig model by ligating the 
arterial supply with continued portal venous supply to one lobe of the liver and allowing 
continued portal venous and arterial supply to the contralateral lobe3.  In this study, the partial 
pressure of oxygen in liver was directly measured with an Eppendorf electrode and found to 
correlate with SUV values of [18F]FMISO uptake (Figure 3).  In addition, the geometric mean of 
the SUV for normal and hypoxic liver was found to be 1.31 (95% CI 1.09-1.57) and 
5.7 (95% CI 4.71-6.9), respectively, for pigs breathing room air.  This indicates a significant 
difference in [18F]FMISO uptake for hypoxic liver compared to normoxic liver.  This study 
demonstrated the utility of using [18F]FMISO in the liver despite ligation of the arterial supply, 
particularly because of the continued delivery of the radiotracer to the liver via portal venous 
blood supply. 

 
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28 October 2015 
 
Figure 3.  Correlation of SUV uptake in hypoxic liver compared with direct partial 
pressure oxygen measurement with an Eppendorf electrode.  There is a high correlation 
between low oxygen levels and increased [18F]FMISO uptake3.  SUV = Standardized 
uptake value, TPO2 = Tissue partial pressure oxygen 
Earlier detection of residual tumor after treatment may be possible with hypoxia-specific 
imaging agents like [18F]FMISO 
After TAE, portions of the tumor and surrounding tissue may become hypoxic, but not severe 
enough to result in necrosis.  Sub-lethal hypoxia increases levels of vascular endothelial growth 
factors (VEGF) and hypoxia-inducible factor-1 alpha (HIF-1 alpha), which then selects and 
promotes a more aggressive disease that is often increasingly resistant to subsequent 
treatments12,13,19. Normal liver tissue is supplied by portal venous blood and has been shown to 
have normal levels of HIF-1 alpha, an indicator of hypoxia, after embolization in animal models 
in contrast to tumor which relies on arterial blood supply and has markedly increased levels of 
HIF-1 alpha13.  Early detection of this hypoxic tumor tissue could enable earlier intervention with 
the objectives of preventing disease progression and improving overall survival. Hypoxia 
specific imaging agents have been developed and used in the evaluation of cancers of the head 
and neck, lung, kidneys and brain16,17. Among them, [18F]FMISO has been used and validated 
most extensively. [18F]FMISO is lipophilic and enters cells through passive diffusion. It is 
reduced by nitroreductase inside the cell. In hypoxic conditions, the metabolites cannot undergo 
re-oxidation to diffuse out of the cell. Instead, they become trapped and accumulate within the 
cell. [18F]FMISO is not retained in necrotic cells because they lack functional nitroreductase 
enzymes. [18F]FMISO has also shown superior imaging characteristics for liver tumors 
compared to other hypoxia imaging agents (Figure 4)20.  Many clinical studies have been 
performed with [18F]FMISO, several of which have shown that [18F]FMISO is capable of 
providing prognostic information either prior or after treatment21.  Several studies have shown 
the potential of [18F]FMISO in determining treatment response with radiation and 
chemoradiation therapies in both head and neck cancers (HNC) and non-small cell lung cancers 
(NSCLC)22–24.  These studies show that tumors with areas of hypoxia as demonstrated by 
[18F]FMISO uptake correspond with worse outcome or disease recurrence. Given the similar 
hypervascular nature of HNC and NSCLC as compared to hepatocellular carcinoma, we 
anticipate hepatocellular carcinoma will show a similar prognostic correlation with [18F]FMISO 
uptake. 
 

 
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28 October 2015 
 
Figure 4.  [18F]FMISO imaging in a rat liver.  H = Heart, St = Stomach, L = Liver, 
LT = Liver Tumor, PT = Peritoneal Tumor, Int = Intestine.  Liver tumor can be 
distinguished from normal liver20. 
If detected early, tumor recurrence is amenable to repeat embolization sooner than is 
currently done  
Currently, treatment response is assessed using a combination of CT and MR to evaluate tumor 
size and enhancement 1-3 months after treatment with the optimal imaging time at 
approximately 2 months25. This approach has several limitations. Tumor size is not a reliable 
indicator of treatment response because TAE reduces the viability of the tumor, but does not 
reduce the overall tumor volume. Persistent enhancement at the treatment site is not specific for 
viable tumor because post-treatment granulation tissue or inflammation can also enhance, 
particularly at the periphery at 1 month follow-up CT scans26. Finally, post-treatment changes 
detected on current imaging modalities take time to manifest. Successful identification of 
hypoxic areas after embolization could lead to earlier re-intervention and arrest of expected 
tumor progression.  If identified immediately after treatment, this could lead to earlier 
intervention within days to weeks of demonstration of residual tumor.  Currently, patients 
typically wait months prior to retreatment to ensure the areas of concern represent residual 
tumor.   
 
Significance   
If [18F]FMISO is shown to be effective in determining post-embolization hypoxia which correlates 
with tumor recurrence, then re-treatment of incompletely treated tumors could be performed in 
days or weeks rather than the current practice of several months.  This, in turn, could result in 
improved tumor control and possibly in improved cancer-free survival. 
 
3.0 
Study Objectives 
3.1 
Primary Objective 
Determine the variability of 18F-FMISO uptake in HCC tumors compared to 
normal liver after transcatheter arterial embolization by determining the difference 
in the mean of the maximum standardized uptake value (SUVmax) and 
tumor-to-liver ratio (TLR) of a region of normal liver and of up to 5 index tumors. 
Endpoint: Measurement of SUVmax and TLR of tumors 20 hours +/- 4 hours after 
embolization. 

 
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28 October 2015 
3.2 
Secondary Objectives 
1. Determine if areas of tumor recurrence as determined by CT or MRI within a 
6-month period after transcatheter arterial embolization show evidence of 
increased 18F-FMISO labeling on the initial post-treatment 18F-FMISO PET/CT. 
The endpoint will be assessed by comparison of SUVmax and TLR of tumors with 
recurrence to tumors without recurrence. 
2. Determine the variability in SUVmax and TLR of untreated (non-embolized) 
HCC lesions compared to normal liver by determining the difference in the mean 
of the SUVmax and TLR of normal liver and tumor. 
The endpoint will be assessed by measuring SUVmax and TLR of untreated HCC 
tumor compared to normal liver.  Untreated tumor will be defined as any tumor 
that has not undergone any locoregional or systemic treatment within 3 months. 
3. Determine any toxicities related to [18F]FMISO use for PET/CT. 
The endpoint will be assessed by documenting unanticipated toxicities related to 
[18F]FMISO use over a 10 half-life period beginning from injection.  Only grade 3 
or greater toxicities according to the Common Terminology Criteria for Adverse 
Events version 4 will be considered significant27. 
 
4.0 
Eligibility Criteria 
 
4.1 
Inclusion Criteria 
Potential subjects will be enrolled if they meet the following criteria: 
1. Over 18 years of age 
2. ECOG performance status of 0, 1, or 2 
3. Histopathologic or imaging and clinical features of tumor(s) diagnostic for 
hepatocellular carcinoma with at least one tumor ≥ 1.5 cm.  Imaging features 
diagnostic for hepatocellular carcinoma will be defined as Liver Imaging 
Reporting and Data System (LI-RADS) 4 or greater. 
4. Total bilirubin < 3.0 
5. Child-Pugh A or B 
6. Tumor amenable to transcatheter arterial embolization 
7. Able to provide informed consent 
 
4.2 
Exclusion Criteria 
Potential subjects will be excluded if they meet any of the following criteria: 
1. Uncontrolled large ascites 
2. Main or segmental portal vein thrombosis 
3. Locoregional treatment of hepatocellular carcinoma within the prior 3 months or 
chemotherapy within the previous 3 months 
4. Inability or contraindication to undergo transcatheter arterial embolization 
5. Inability to lay flat for at least 2 consecutive hours 
6. Severe acute illness 
7. Uncontrolled chronic illness such as hypertension, diabetes, or heart failure 
8. Contraindication to CT or MRI contrast 
9. Pregnancy 
 

 
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28 October 2015 
5.0 
Research Design and Methods 
 
5.1 
Study Design 
This is a prospective, observational single-arm feasibility study to evaluate the variability 
of [18F]FMISO in determining areas of hypoxia in hepatocellular carcinoma after 
treatment with transcatheter arterial embolization. 
 
The study will begin with a screening period during which subjects will be evaluated for 
possible enrollment in the study.  Subjects will be screened by an interventional 
radiologist or clinical coordinator in the Interventional Radiology (IR) clinic at the 
Veterans Affairs Palo Alto Health Care System.  Subjects do not require a histologic 
confirmation of HCC, but will require an imaging scan be diagnostic for HCC in subjects 
with risk factors for primary liver cancer.  Subjects that meet the entry criteria and do not 
have any exclusion criteria will be eligible for the trial.  If not already completed within 8 
weeks of treatment, subjects who are potential candidates will need to undergo a 
triphasic MRI or CT scan.  The type of scan performed (CT or MRI) will be the same as 
the prior scans the subject underwent for surveillance or diagnosis.  This must occur 
within 8 weeks prior to treatment.  Subjects enrolled in the trial will then undergo an 
[18F]FMISO PET/CT scan within 4 weeks prior to treatment.  The [18F]FMISO PET/CT 
study will be interpreted by a board certified nuclear medicine physician where the 
largest lesions, up to five, will be index lesions that will be chosen for follow-up.  The 
SUVmax and tumor-to-liver ratio (TLR) will be documented.  Most studies have used 
tumor-to-blood ratio (TBR) or tumor-to-muscle ratio (TMR) with a cut-off of 1.2 as an 
indicator of hypoxia21.   However, the liver has increased radiotracer uptake and so will 
require normalization to non-tumor liver, similar to a method described for patients with 
renal cell cancer28.   
 
Subjects will next undergo transcatheter arterial embolization, then have repeat 
[18F]FMISO PET/CT scanning between 20 hours +/- 4 hours after completion of 
treatment.  The [18F]FMISO study will be interpreted by a board certified nuclear 
medicine physician where the index lesions will be evaluated for the SUVmax and TLR.   
 
The subject will then undergo routine follow-up CT or MRI 2 months +/- 2 weeks after 
treatment.  The follow-up study (CT or MRI) will be the same as the prior study that the 
subject had.  The index lesions will be reviewed by an interventional or diagnostic 
radiologist for evidence of recurrence.  If there is new or recurrent disease, the subject 
can undergo any treatment deemed suitable by the liver tumor board for the residual 
tumor including, but not limited to, chemotherapy, surgery, or locoregional ablative or 
intra-arterial treatment. If there is no evidence for recurrent disease, the subject will 
undergo repeat CT or MRI after 3 months +/- 2 weeks.  The index lesions will be 
reviewed by an interventional or diagnostic radiologist for evidence of recurrence.  
Again, if there is recurrent disease, the subject can undergo any treatment deemed 
suitable by the liver tumor board for the residual tumor including chemotherapy, surgery, 
or locoregional ablative or intra-arterial treatment.  Subjects will be followed for a total of 
6 months from completion of initial transcatheter arterial embolization.  Subjects will 
continue to attend all routine medical appointments during the study including clinic 
visits. 
 
The primary endpoint will be determination of the difference in the mean in SUVmax and 
TLR between tumor and unaffected liver after treatment. 
 

 
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28 October 2015 
The secondary endpoints will be correlation of tumors with recurrence with areas of 
increased TLR, determination of the variability in SUVmax and TLR in untreated HCC 
compared to normal liver, and toxicity.  Initial 18F-FMISO scans will be used to document 
the index lesions and determine the TLR.  Post-treatment triphasic CT or MRI scans will 
be used to evaluate for tumors with recurrence.  All adverse events will be recorded and 
categorized according to the Common Terminology Criteria for Adverse Events v427.   
 
5.2 
Research Facility 
The clinical study will be conducted at the Veteran’s Administration (VA) Palo Alto Health 
Care System (VAPAHCS).  This is a major research-oriented VA facility with $52 million 
in annual research expenditures, more than 65 active research projects, and nearly 
250 Principal Investigators pursuing laboratory, clinical, and health services research.  
All Stanford University facilities and resources are open and available to the 
investigators, including core computing, microscopy, library, biostores, and analytical 
facilities.  The VAPAHCS has invested significant resources into the Nuclear Medicine 
and Radiology programs.  The Nuclear Medicine program currently has a 
General Electric (GE) Discovery VCT PET/CT scanner.  In addition, they have 3 GE 
Infinia Hawkeye SPECT/CT systems.  The radiology department has 2 HD750 64-slice 
GE CT scanners, one of which has a dual-energy package, one 3.0 Tesla 
GE Discovery MR750 and a 1.5 Tesla GE MRI.  The interventional radiology section has 
2 angiography suites, one of which is equipped with a 16-slice GE CT scanner combined 
with a GE Innova 4100 fluoroscopic suite.  In addition, the 2nd room has a GE Innova 
3131 biplane system.  Participant testing rooms, physical exam rooms, and a reception 
area are located within an outpatient clinic area and are immediately available for the 
project.  
 
5.3 
Study Calendar / Schedule 
 
Visit 1:  
Screening 
Visit 
2 
Visit 3: 
Treatment 
Visit 
4 
Visit 
5 
Informed Consent 
X 
 
 
 
 
Eligibility Criteria  
Assessment 
X 
 
 
 
 
Demographics 
X 
 
 
 
 
Medical History 
X 
 
 
 
 
Physical Examination 
X 
 
 
 
 
Vital Signs 
X 
 
 
 
 
Serum Pregnancy  
Test (if applicable) 
X 
 
X 
 
 
Hematology 
Serum Chemistry 
X 
 
X 
 
 
[18F]FMISO PET/CT Scan 
 
X 
X 
 
 
Transcatheter Arterial 
Embolization 
 
 
X 
 
 
Adverse Events 
 
X 
X 
 
 
Triphasic CT or MRI 
Xa 
 
 
X 
X 
aIf not already completed within 8 weeks of treatment 
 

 
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28 October 2015 
5.4 
Pre-Registration Procedures 
We will recruit subjects who are referred to the interventional radiology clinic for 
intra-arterial treatment of their HCC.  Because the patient gender distribution at the 
Veterans Affairs Palo Alto Health Care System (VAPAHCS) has a significantly greater 
male proportion, we anticipate most or all of the subjects will be male.  However, we will 
attempt to recruit female subjects as much as possible.  Efforts will be made to recruit 
ethnic minorities in proportion to their representation in the local veterans community.  
Because no children are seen in Interventional Radiology at VAPAHCS, pediatric 
subjects will be excluded from the study. 
 
5.5 
Registration Visit and Procedures 
Subjects will be screened at their clinic visit to determine if they are eligible to 
participate.  Subjects must have clinical history and imaging characteristics diagnostic of 
HCC or histologic confirmation of HCC.  Subjects referred to the clinic will undergo 
detailed discussion of the proposed study by the clinical coordinator or PI.  With the 
subject’s verbal permission, the eligibility criteria will be reviewed both directly from the 
subject and through the subject’s electronic medical record.  If the subject meets the 
eligibility criteria, the subject will be asked to sign an informed consent and the subject 
will be enrolled in the trial.  If a scan within 8 weeks of the anticipated treatment is not 
available, the subject will be scheduled for a triphasic CT or MRI scan.  Serum 
hematology and chemistry tests must be available within 4 weeks prior to the initial visit.  
If they are not available, the subject will be scheduled for blood tests.  The subject will 
also be scheduled for all lab tests, the initial [18F]FMISO PET/CT scan, transcatheter 
arterial embolization, post-treatment [18F]FMISO PET/CT scan, and post-treatment 
follow-up triphasic CT or MRI.   The transcatheter arterial embolization treatment will be 
scheduled with the subject within 8 weeks of the [18F]FMISO PET/CT scan. If the subject 
is a female, a serum pregnancy test will be obtained unless the subject is 
post-menopausal. 
 
5.6 
Imaging and Intervention Visit(s) 
5.6.1 [18F]FMISO PET/CT Visit 
[18F]FMISO will be prepared by experienced radiopharmaceutical chemists from 
the MIPS cyclotron and radiochemistry facility in the Department of Radiology at 
Stanford University under the supervision of Dr. Frederick T. Chin.  The 
[18F]FMISO will be delivered to the Veterans Affairs Palo Alto Health Care 
System (VAPAHCS) section of Nuclear Medicine.  3.7 MBq/kg (0.1 mCi/kg, 
up to 10 mCi) will be injected intravenously into each subject and a PET/CT will 
be performed 120 minutes +/- 30 minutes after injection.  Prior to the injection, 
the patient’s heart rate, blood pressure, oxygen saturation, temperature, and 
respiratory rate will be measured and documented.  Between 120 and 
360 minutes after injection, a repeat measurement of the vital signs detailed 
above will be performed and documented.  Patients will be monitored for a 
minimum of 3 hours after the injection.  Any change from the patient’s baseline 
status producing symptoms or change in vital signs causing symptoms will be 
managed immediately with care to be determined based on symptom severity.  
If any irregularity is detected on pre-injection or post-injection vital sign 
measurements, appropriate action will be performed for further evaluation 
including, but not limited to, electrocardiogram;  administration of a fluid bolus;  
evaluation in the emergency department;  or admission to the hospital.  

 
Page 13 of 25 
28 October 2015 
5.6.2 Transcatheter Arterial Embolization Visit 
The subject will undergo transcatheter arterial embolization prior to the second 
PET/CT scan.  The transcatheter arterial embolization procedure must be at least 
10 half-lives, or 18 hours, after the initial [18F]FMISO PET/CT scan.  The subject 
will have the right or left common femoral artery accessed percutaneously, and a 
catheter will be placed into the arterial branches feeding the hepatic tumors using 
fluoroscopic guidance.  Embolization will be performed with small particles until 
stasis is achieved.  Particle size can range from 40 microns to 300 microns.  
Larger particles may be used if deemed clinically necessary.  Fluoroscopic 
imaging will be performed with a GE Innova fluoroscopic unit during the 
procedure.  Upon completion of the procedure, the subject will be admitted for 
overnight observation.  Within 20 hours +/- 4 hours after the procedure, the 
subject will undergo repeat [18F]FMISO under the same protocol as above. 
 
5.7 
General Concomitant Medication and Supportive Care Guidelines 
Subjects should remain on all home medications prior to the PET/CT scan.  Subjects will 
remain on all home medications except anticoagulants prior to the transcatheter arterial 
embolization procedure.  Subjects cannot have been on any chemotherapeutic 
treatment for 3 months prior to PET/CT scan or transcatheter arterial embolization. 
 
5.8 
Post-Therapy Visits 
Subjects will undergo triphasic CT or MRI of the liver with contrast at 
2 months (+/- 2 weeks), and 3 months (+/- 2 weeks) after the first post-therapy scan.  A 
triphasic CT scan will be performed if the initial pre-therapy scan was a triphasic CT 
scan or if the subject has developed a contraindication to MRI.  The triphasic CT scan 
will be performed in arterial, portal venous, and delayed venous (i.e. equilibrium) phase 
according to the standard VAPAHCS protocol.  Other phases may be obtained as 
clinically indicated.  A 1.5 Tesla or 3 Tesla triphasic MRI will be performed if the initial 
pre-therapy scan was an MRI.  The MRI will be performed in pre-contrast, arterial phase, 
and several venous phase T1 or gradient echo sequences as well as axial T2 and 
diffusion-weighted images (DWI).  Additional sequences may be performed as deemed 
clinically necessary for interpretation of the study. 
 
5.9 
Criteria for Removal from Study 
The Protocol Director may withdraw participants from the study for one or more of the 
following reasons:  
1. Subjects’ failure to follow the instructions of the PI and/or study staff. 
2. Determination that continuing participation could be harmful to the 
participants. 
3. The study is cancelled. 
4. The subject withdraws consent. 
5. The transcatheter arterial embolization is not performed. 
6. Exclusion criteria are discovered after enrollment but prior to treatment. 
7. Other administrative reasons. 
8. Unanticipated circumstances. 
 
5.10 
Image Acquisition, Archiving, and Interpretation 
5.10.1 [18F]FMISO PET/CT scan 
[18F]FMISO will be prepared by experienced radiopharmaceutical chemists from 
the MIPS cyclotron and radiochemistry facility in the Department of Radiology at 
Stanford University under the supervision of Dr Frederick Chin.  The 18F-FMISO 

 
Page 14 of 25 
28 October 2015 
will be delivered to the VAPAHCS section of Nuclear Medicine.  The distance 
between the 2 institutions is < 5 miles and will not affect the dose administered to 
the subject.  3.7 MBq/kg (0.1 mCi/kg, up to 10 mCi) will be injected intravenously 
into each subject and a PET/CT will be performed 150 minutes +/- 60 minutes 
after injection.  This dosage was chosen as the historical radiation dosimetry was 
performed at that value29.  All scans will be performed on a GE Discovery 
PET/CT system.  Per prior studies, no special subject preparation is required, 
except that subjects will empty their bladders prior to scanning30.  A longer 
acquisition focusing on the liver will be performed to decrease statistical noise.  
Upon image acquisition, the PET/CT scan will be evaluated on a workstation 
allowing for fusion of the images.  A region-of-interest (ROI) 3 cm +/- 1 cm in 
diameter will be drawn over a region of normal liver.  The average SUV of this 
operator-defined ROI will be calculated. This will be repeated in 2 additional 
areas of normal liver.  The mean of these 3 values will be obtained and used as 
the SUVmean of the normal liver.  A 2nd ROI encompassing the index tumor(s) will 
be drawn.  Each index tumor must be ≥ 1.5 cm in size.  The SUVmax will be 
calculated from this region with the threshold set at 10% of peak standardized 
uptake value of all voxels in the tumor volume.   The TLR will be calculated as 
the (SUVmax tumor/SUVmean liver).  The same nuclear medicine physician will 
perform all [18F]FMISO analyses.  All PET/CT scans will be performed on the 
same GE Discovery scanner with the following parameters:  kV = 120;  
mA = auto mA with min = 30 and max = 100;  noise index = 25;  and 
rotation time = 0.5 sec.  The CT scan portion of the PET/CT is for attenuation.  
 
For the purposes of this study, 18F-fluoromisonidazole will be manufactured in the 
Cyclotron & Radiochemistry Facility of the Molecular Imaging Program at 
Stanford (MIPS) at Stanford University, and is also identified as 18F-FMISO;  
[F-18]FMISO;  and/or [18F]FMISO.  
 
5.10.2 Triphasic CT scan and MRI 
Triphasic CT scan will be performed on a minimum 64-detector GE CT scanner.  
The kVP will be between 80 to 140 and will be determined based on subject body 
characteristics.  The auto mA setting will be used to minimize radiation dose.  
Contrast will be injected intravenously at a dose to be determined by standard 
CT protocol.  The required series are arterial;  portal venous;  and 
delayed venous phase.  Each phase will include the entire liver.  Additional scans 
can be obtained as deemed clinically necessary.  Multiplanar reformats may be 
performed but are not required. 
 
Triphasic MRI will be performed on a 1.5 or 3 Tesla GE scanner and include T2;  
diffusion weighted (DWI);  pre-contrast T1 or gradient echo, post-contrast T1 or 
gradient echo arterial phase;  portal venous phase;  and delayed venous 
(ie, equilibrium) phase sequences.  Additional sequences may be obtained as 
clinically necessary.  Gadolinium contrast will be administered intravenously 
according to standard protocol. 
 
Triphasic CT or MRI will undergo official interpretation.  The interventional 
radiologist or diagnostic radiologist will review the index lesions for evidence of 
recurrence.  LI-RADS criteria will be used to define active tumor in the liver.  
Recurrence will be defined as nodular areas of continued contrast enhancement 
with delayed venous phase contrast washout in regions previously occupied by 

 
Page 15 of 25 
28 October 2015 
HCC.  Ring-like enhancement is often seen normally and will not be considered 
recurrent tumor26.  Recurrence will also include tumors that grow more than 20% 
in any dimension with or without arterial enhancement as long as they 
demonstrate washout on delayed phase imaging. 
 
5.10.3 Archiving 
All imaging studies will be stored on the VAPAHCS PACS servers.  Storage on 
backup servers will be done according to standard VAPAHCS protocol. 
 

 
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28 October 2015 
6.0 
Statistical Considerations 
 
6.1 
Study Design and Endpoints 
This is a prospective, observational single-arm feasibility study to evaluate the variability 
of [18F]FMISO in determining areas of hypoxia in hepatocellular carcinoma after 
treatment with transcatheter arterial embolization. 
 
The primary endpoint will be to determine variability of [18F]FMISO uptake in HCC 
tumors compared to normal liver after transcatheter arterial embolization by determining 
the difference in the mean of the maximum standardized uptake value (SUVmax) and 
tumor-to-liver ratio (TLR) of a region of normal liver and of up to 5 index tumors, each 
greater than or equal to 1.5 cm in diameter.  The 5 largest tumors which are LI-RADS 4 
or greater will be selected as the index tumors. 
 
The secondary endpoints will be to compare the SUVmax and TLR in areas of tumor 
recurrence to areas without tumor recurrence as determined by CT or MRI within a 6 
month period after transcatheter arterial embolization, to determine the variability in the 
SUVmax and TLR of untreated HCC compared to normal liver, and to determine any 
toxicities related to [18F]FMISO use for PET/CT. 
 
6.2 
Objectives and Analysis Plans 
Primary objective: Determine the variability of [18F]FMISO uptake in HCC tumors 
compared to normal liver after transcatheter arterial embolization by determining the 
difference in the mean of the maximum standardized uptake value (SUVmax) and 
tumor-to-liver ratio (TLR) of a region of normal liver and of up to 5 index tumors, each 
greater than or equal to 1.5 cm in diameter. 
Endpoint: Measurement of SUVmax and TLR of tumors 20 hours +/- 4 hours after 
embolization.   
Analysis Plan: Tumor-to-liver ratios (TLR) of SUVmax will be calculated for all imaged 
tumors and analyzed on the logarithmic scale.  A variance components model (linear 
mixed effects with a random intercept for subject effect) will be fitted to the TLR; in such 
a model the antilog of the overall intercept can be interpreted as an overall TLR 
averaged across tumors and subjects. We expect up to 5 tumors per subject will be 
obtained.  The 5 largest tumors which are LI-RADS 4 or greater will be selected.  The 
between subject and within-subject variance components will be used to plan further 
studies.  While we do not expect to be powered to obtain statistical significance, the 
overall TLR will be reported with a P value obtained from the variance components 
model.  A P-value less than 0.05 will be considered significant. 
 
Secondary objective: Determine if areas of tumor recurrence as determined by CT or 
MRI within a 6 month period after transcatheter arterial embolization show evidence of 
increased [18F]FMISO on initial post-treatment [18F]FMISO PET/CT. 
Endpoint:  Comparison of SUVmax and TLR of tumors with recurrence to tumors without 
recurrence. 
Analysis Plan: Logistic regression analysis will be performed on the independent 
variables, SUVmax and TLR, and the dependent variable, recurrence of tumor.  An odds 
ratio and 95% confidence interval will be obtained. 
 
Secondary objective: Determine the variability in SUVmax and TLR of untreated HCC 
compared to normal liver by determining the difference in the mean of the maximum 

 
Page 17 of 25 
28 October 2015 
standardized uptake value (SUVmax) and tumor-to-liver ratio (TLR) of a region of normal 
liver and of up to 5 index tumors, each greater than or equal to 1.5 cm in diameter. 
Endpoint: Measurement of SUVmax and TLR of untreated HCC tumor compared to 
normal liver.   
Analysis: The analysis will be the same as that for the primary objective with analysis 
performed on a logarithmic scale.  A variance component model will be fitted to the TLR.  
The overall TLR will be reported with a P value obtained from the variance components 
model.  A P value less than 0.05 will be considered significant. 
 
Secondary objective: Determine any toxicities related to [18F]FMISO use for PET/CT. 
Endpoint: Unanticipated toxicities related to [18F]FMISO use over a 10 half-life period 
beginning from injection. 
Analysis: Toxicity rates will be calculated and reported as a proportion of number of 
complications/number of total treatments with a corresponding 95% confidence interval. 
 
6.3 
Sample Size Considerations 
No prior human studies exist to evaluate liver tumors using [18F]FMISO.  Given that this 
is an observational feasibility study, we will be studying a small population for which we 
have funding.  We therefore will enroll 5 subjects in this study.  With 5 subjects, for an 
80% power and an α = 0.05, and assuming a standard deviation of 1 for the mean of 
each value, the smallest difference between the means we will be able to detect will be 
1.77. 
 
6.4 
Study monitoring, interim analyses, and early stopping rules 
Study monitoring, including subject accrual and adverse events, will be performed by the 
study PI.  No interim analyses are planned. 
 
7.0 
Adverse Events; Safety Issues 
 
7.1 
Definition of Adverse Events and Potential Risks  
The definition of Adverse Event (AE), from VHA Handbook 1058.01, is “any untoward 
physical or psychological occurrence in a human subject participating in research.  An 
AE can be an unfavorable and unintended event, including an abnormal laboratory 
finding, symptom, or disease associated with the research or the use of a medical 
investigational test article.  An AE does not necessarily have a causal relationship with 
the research.”  According to VAPAHCS HCSM 151-11-03, a local AE is “an AE 
experienced by a participant enrolled in a VAPAHCS approved research project or that 
is experienced by a participant at a non-VAPAHCS participating site of a multi-site study 
where the VAPAHCS is the lead or coordinating site.” 
 
Anticipated adverse events and potential risks are those which typically occur due to 
embolization and include pain, fever, fatigue, nausea, elevated liver enzymes, infection, 
abscess, cholecystitis, gallbladder infarction, hemorrhage, thromboembolism, arterial 
dissection, post-embolization syndrome, splenic infarction, and liver infarction.  
Anticipated adverse events also includes progression of cirrhotic or cancerous liver 
disease manifested by jaundice, biliary obstruction, progression of tumors, metastatic 
disease, liver failure, worsening liver enzymes, worsening cirrhosis, increased portal 
hypertension, and death.  Anticipated adverse events related to use of [18F]FMISO at the 
doses indicated in the protocol include nausea, vomiting, anorexia, and allergic reaction 
(rash, fever, etc).  
 

 
Page 18 of 25 
28 October 2015 
7.2 
Definition of Serious Adverse Events (Serious Adverse Events List) 
 
A Serious Adverse Event (SAE) according to VHA Handbook 1058.01 is an injury 
or illness that: 
 
Results in death 
 
Results in a life-threatening experience 
 
Results in inpatient hospitalization or prolongation of an existing 
hospitalization 
 
Results in a persistent or significant disability or incapacity 
 
Results in a congenital anomaly or birth defect 
 
Requires additional medical, surgical, behavioral, social, or other 
intervention needed to prevent any of the above outcomes 
 
Events meeting the criteria for an SAE require notification of the reviewing IRB 
and the FDA within the specified timeframe identified in section 8.4. 
 
7.3 
Adverse Events Characteristics 
 
7.3.1 Grading of Adverse Events 
Adverse events for the use of 18F-FMISO will be graded according to the 
Common Terminology Criteria for Adverse Events version 427.  Grading will be as 
follows: 
 
Mild – Grade 1 
 
Moderate – Grade 2 
 
Severe – Grade 3 
 
Life threatening or disabling – Grade 4 
 
Fatal – Grade 5 
 
Adverse events related to the TAE will be graded according to the Society of 
Interventional Radiology Clinical Practice Guidelines and will be classified as 
follows31: 
Minor Complications: 
A. No therapy, no consequence 
B. Nominal therapy, no consequence; includes overnight admission for 
observation only 
Major Complications: 
C. Require therapy, minor hospitalization (< 48 hours) 
D. Require major therapy, unplanned increase in level of care, prolonged 
hospitalization ( > 48 hours) 
E. Permanent adverse sequelae 
F. Death 
 
7.3.2 Definitions of Serious Problem, Unanticipated Problem, and 
Unanticipated Adverse Events, and Unanticipated Adverse Device Effect 
Terms are defined in VAPAHCS HCSM 151-11-03 and are as follows: 
 
A Serious Problem (SP) is a problem that may reasonably be regarded as: 

 
Page 19 of 25 
28 October 2015 
 
Involving substantive harm, or a genuine risk of substantive harm, to the 
safety, rights, or welfare of human research subjects, research staff, or 
others 
 
Substantively compromising the effectiveness of a facility’s human 
research protection or human research oversight programs 
 
An Unanticipated and Unexpected refer to an event or problem in VA research 
that is new or greater than previously known in terms of nature, severity, or 
frequency, given the procedures described in protocol-related documents and the 
characteristics of the study population. 
 
Unanticipated Problems (UPs) are events that are: 
 
Unforeseen (or unanticipated) in terms of nature, severity, or frequency of 
occurrence, as documented in the protocol or other study materials AND 
 
Are harmful (or serious) AND 
 
Are related to the study (or study procedures) 
 
Unanticipated Adverse Device Effect are any serious effect on health or safety or 
any life-threatening problem or death caused by, or associated with, a device, if 
that effect, problem, or death was not previously identified in nature, severity or 
degree of incidence in the investigational plan or FDA application, or any other 
unanticipated serious problem associated with a device that relates to the rights, 
safety, or welfare of subjects. 
 
7.3.3 Attribution of Adverse Events 
 
Attribution of the AE: 
 
Definite – The AE is clearly related to the study intervention. 
 
Probable – The AE is likely related to the study intervention. 
 
Possible – The AE may be related to the study intervention. 
 
Unlikely – The AE is doubtfully related to the study intervention. 
 
Unrelated – The AE is clearly NOT related to the study intervention. 
 
7.4 
Adverse Event Reporting 
 
7.4.1 When and How to Report Adverse Events 
 
It is the responsibility of the investigator to document all Adverse Events (AEs) 
that occur during the course of the study.   
 
Events Requiring Prompt Reporting to the IRB:  
 
PIs and investigators must report the following events to the IRB as soon as 
possible, but no later than 5 business days after becoming aware of them: 
 
 
Local Unanticipated SAEs, except those occurring on observational studies. 
Local unanticipated SAEs that the PI determines are not related to the study 
and/or are anticipated (and therefore are not UPs) should be submitted to the 
IRB as “Other events or information” (item 7 on the eProtocol Report Form) 
with a statement in section 8a of the eProtocol Report Form that the PI has 

 
Page 20 of 25 
28 October 2015 
determined the event is not related to the study and/or was not unanticipated. 
Details on the event should be provided in section 8a or the eProtocol Report 
Form or the PI can attach documentation detailing the event to the Report 
Form. 
 
Local unexpected deaths or life-threatening experiences related to the 
research and involving participants enrolled at VAPAHCS or on studies 
where the VAPAHCS is the coordinating institution of a multi-site study. 
(Item 1 on the eProtocol Report Form). 
 
Unanticipated problems (events that are unanticipated, harmful and related to 
the study). (Item 1 on the eProtocol Report Form). 
 
Unanticipated adverse device effect. (Item 6 on the eProtocol Report Form). 
 
Serious Unanticipated Problems involving risks to subjects or others, 
including: 
o Interruptions of subject enrollments or other research activities due to 
concerns about the safety, rights, or welfare of human research 
subjects, research staff, or others. (Item 2 on the eProtocol Report 
Form). 
o Any Data Monitoring Committee (DMC) report describing a safety 
problem. (Item 2 on the eProtocol Report Form); 
o Any sponsor analysis describing a safety problem. Interruptions of 
subject enrollments due to concerns about the safety, rights, welfare 
of human subjects, research staff, or others. (Item 2 on the eProtocol 
Report Form). 
o Any unanticipated problem involving substantive harm, or a genuine 
risk of substantive harm, to the safety, rights, or welfare of human 
research subjects, research staff, or others. 
o Any problems reflecting a deficiency that substantively compromised 
the effectiveness of a facility’s human research protection or human 
research oversight programs. 
 
Events that must be submitted to the IRB within 10 working days from when the 
PI learns of the event or new information: 
 
New Information that indicates change to risks or potential benefits of the 
research, in terms of specificity, severity, or frequency. (Item 2 on the 
eProtocol Report Form). 
 
Protocol Deviation or Violation (Item 3 on the eProtocol Report Form), only if: 
o Intended to eliminate apparent immediate hazard to a research 
participant, or 
o Harmful (caused harm to participants or others, or placed them at 
increased risk of harm – including physical, psychological, economic 
or social harm). 
 
Complaint that is unresolved by the research team, or that indicates 
increased or unexpected risks. (Item 4 on the eProtocol Report Form). 
 
Incarceration of the research participant and in the opinion of the PI, it is in 
the best interest of the participants to remain on the study. (Item 5 on the 
eProtocol Report Form). 
 
Other events or information. 
 
Adverse events are serious and unexpected suspected adverse reactions, ie, are 
possibly, probably, or definitely related to the study drug [18F]FMISO, will be 

 
Page 21 of 25 
28 October 2015 
reported to the FDA via IND Safety Report [21CFR§312.32] within 14 calendar 
days, or within 7 calendar days if the event is an unexpected fatal or life-
threatening suspected adverse reaction. 
 
8.0 
Ethical Considerations (Including Informed Consent) 
 
8.1 
Protection of Subject Rights 
Each participant will receive an oral and written explanation of the purpose of the study, 
potential risks and benefits of participation in this protocol.  The Principal Investigator or 
a co-investigator will obtain consent. Specifically, participants will be told that:  
a) The information derived may eventually lead to better understanding of hypoxia in 
relation to hepatocellular carcinoma;  
b) PET imaging as used in our protocol are research tools, and that consequently, no 
diagnostic interpretations will be provided;  
c) A confidential participant identification number will be used to ensure that 
information cannot be linked or traced to any person or family; and  
d) Data will be evaluated to yield group statistical analyses only. In addition, 
participants will be given ample opportunity to ask questions of the investigators. 
 
8.2 
Confidentiality 
All data will be maintained by the Principal Investigator at the VAPAHCS. Data 
maintained include clinical and demographic forms, adverse event forms, PET data, and 
CT/MRI data forms. Records will be stored in a locked, secure location within the 
Department of Radiology. Data will only be accessed by members of the research team 
assigned to data collection or analysis. 
 
8.3 
Inclusion of Women and Minorities 
We will make every effort to ensure that gender and race are equally represented in the 
total sample of participants in proportion with demographic data available for the patient 
population at the VAPAHCS. 
 
8.4 
Audit and Monitoring 
Study data and case report forms will be monitored in accordance with VA standard 
operating procedures, and with national government regulations. The PI will be 
responsible for monitoring the safety of subjects who have enrolled in the study.  
 
8.5 
IND 
This study has been submitted to FDA as IND 126878.  
 
9.0 
Data Management; Administrative Issues 
All electronic data will be stored on a restricted access folder in a protected network drives on 
password protected VA computers in the Palo Alto VA.  Access will be limited to the Principal 
Investigator, Co-investigators, and any clinical coordinators.  Subject data will be maintained in 
a HIPAA compliant manner with minimization of PHI in a database within the restricted access 
folder. 
 
All paper forms will be kept in a locked cabinet in a locked office within the VAPAHCS.  All data 
will be maintained for the period of time as required in the Record Control Schedule (RCS). 
 

 
Page 22 of 25 
28 October 2015 
10.0 Regulatory Considerations  
 
10.1 
Institutional Review of Protocol 
 
The protocol, the proposed informed consent and all forms of participant information 
related to the study (eg, 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. 
 
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 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 review serious adverse events and protocol deviations associated 
with the research to ensure the protection of human subjects.  Results of 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 his/her designee, will prepare and maintain adequate and 
accurate participant case histories with observations and data pertinent to the study.  
Study specific Case Report Forms (CRFs) will document treatment outcomes for data 
analysis.  Paper CRFs will be kept in a locked office, only accessible to the research 
team 
 

 
Page 23 of 25 
28 October 2015 
10.0 References 
 
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and Survival Trends in the United States From 1975 to 2005.”  J Clin Oncol.  
2009;27,1485-1491. 
2. American Cancer Society.  “Cancer Facts & Figures 2014.”  Am Cancer Soc.  2014. 
3. Piert M, et al.  “Introducing fluorine-18 fluoromisonidazole positron emission tomography for 
the localisation and quantification of pig liver hypoxia.”  Eur J Nucl Med. 1999;26,95–109. 
4. Bruix J, Sherman M.  “Management of hepatocellular carcinoma:  An update.”  Hepatology.  
2011;53,1020–1022. 
5. Malagari K, et al.  “Prospective Randomized Comparison of Chemoembolization with 
Doxorubicin-Eluting Beads and Bland Embolization with BeadBlock for Hepatocellular 
Carcinoma.”  Cardiovasc Intervent Radiol. 2010;33,541–551. 
6. On Behalf of the PRECISION V Investigators, et al.  “Prospective Randomized Study of 
Doxorubicin-Eluting-Bead Embolization in the Treatment of Hepatocellular Carcinoma: 
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7. Kluger MD, et al.  “Bland embolization versus chemoembolization of hepatocellular 
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Liver Transpl.  2014;20,536–543. 
8. Sahara S, et al.  “Prospective comparison of transcatheter arterial chemoembolization with 
Lipiodol-epirubicin and Lipiodol-cisplatin for treatment of recurrent hepatocellular 
carcinoma.”  Jpn J Radiol. 2010;28,362–368. 
9. Kawai S, Okamura M, Ogawa J, et al.  “Prospective and randomized trial of 
lipiodol-transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: 
a comparison of epirubicin and doxorubicin (second cooperative study). The Cooperative 
Study Group for Liver Cancer Treatment of Japan.”  Semin Oncol.  1997;24,S6–38. 
10. Smith MK, Mooney DJ.  “Hypoxia leads to necrotic hepatocyte death.”  
J Biomed Mater Res A.  2007;80A,520–529. 
11. Hanahan D, Weinberg RA.  “Hallmarks of Cancer: The Next Generation.”  Cell  
2011;144,646–674. 
12. Baek JH, et al.  “Hypoxia-induced VEGF enhances tumor survivability via suppression of 
serum deprivation-induced apoptosis.”  Oncogene.  2000;19,4621–4631. 
13. Virmani S, et al.  “Comparison of Hypoxia-inducible Factor-1α Expression before and after 
Transcatheter Arterial Embolization in Rabbit VX2 Liver Tumors.”  J Vasc Interv Radiol. 
2008;19,1483–1489. 
14. Gupta S, Kobayashi S, Phongkitkarun S, Broemeling LD,  Kan Z.  “Effect of transcatheter 
hepatic arterial embolization on angiogenesis in an animal model.”  Invest Radiol.  
2006;41,516–521. 
15. Chou CT, et al.  “Efficacy of Transarterial Chemoembolization for Hepatocellular Carcinoma 
in Interlobar Watershed Zone of Liver: Comparison of Unilateral and Bilateral 
Chemoembolization.”  J Vasc Interv Radiol.  2012;23,1036–1042. 
16. Michalski MH, Chen X.  “Molecular imaging in cancer treatment.”  
Eur J Nucl Med Mol Imaging.  2011;38,358–377. 
17. Laking G, Price P.  “Radionuclide imaging of perfusion and hypoxia.”  
Eur J Nucl Med Mol Imaging.  2010;37,20–29. 

 
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18. Taouli B, et al.  “Hepatocellular Carcinoma: Perfusion Quantification With Dynamic 
Contrast-Enhanced MRI.”  Am J Roentgenol.  2013;201,795–800. 
19. Gwak GY, et al.  “Hypoxia stimulates proliferation of human hepatoma cells through the 
induction of hexokinase II expression.”  J Hepatol.  2005;42,358–364. 
20. Riedl CC, et al.  “Tumor hypoxia imaging in orthotopic liver tumors and peritoneal 
metastasis: a comparative study featuring dynamic 18F-MISO and 124I-IAZG PET in the 
same study cohort.”  Eur J Nucl Med Mol Imaging.  2008;35,39–46. 
21. Lee ST, Scott AM.  “Hypoxia Positron Emission Tomography Imaging With 
18F-Fluoromisonidazole.”  Semin Nucl Med.  2007;37,451–461. 
22. Gagel B, et al.  “[18F] fluoromisonidazole and [18F] fluorodeoxyglucose positron emission 
tomography in response evaluation after chemo-/radiotherapy of non-small-cell lung cancer: 
a feasibility study.”  BMC Cancer.  2006;6,51. 
23. Rischin D.  “Prognostic Significance of [18F]-Misonidazole Positron Emission 
Tomography-Detected Tumor Hypoxia in Patients With Advanced Head and Neck Cancer 
Randomly Assigned to Chemoradiation With or Without Tirapazamine: A Substudy of 
Trans-Tasman Radiation Oncology Group Study 98.02.”  J Clin Oncol.  2006;24,2098–2104. 
24. Kikuchi M, et al.  “18F-fluoromisonidazole positron emission tomography before treatment is 
a predictor of radiotherapy outcome and survival prognosis in patients with head and neck 
squamous cell carcinoma.”  Ann Nucl Med.  2001;25,625–633. 
25. Boas FE, et al.  “Optimal Imaging Surveillance Schedules after Liver-Directed Therapy for 
Hepatocellular Carcinoma.”  J Vasc Interv Radiol.  2015;26,69–73. 
26. Chung WS, et al.  “Enhancement Patterns of Hepatocellular Carcinoma After Transarterial 
Chemoembolization Using Drug-Eluting Beads on Arterial Phase CT Images: A Pilot 
Retrospective Study.”  Am J Roentgenol.  2012;199,349–359. 
27. National Cancer Institute.  Common Terminology Criteria for Adverse Events (CTCAE) v4.0.  
NCI NIH DHHS NIH publication #09-7473.  2009. 
28. Lawrentschuk N, et al.  “Assessing regional hypoxia in human renal tumours using 
18F-fluoromisonidazole positron emission tomography.”  BJU Int.  2005;96,540–546. 
29. Graham MM, et al.  “Fluorine-18-Fluoromisonidazole Radiation Dosimetry in Imaging 
Studies.”  J Nucl Med.  1997;38,1631–1636. 
30. Rajendran JG, et al.  “Hypoxia and glucose metabolism in malignant tumors evaluation by 
[18F] fluoromisonidazole and [18F] fluorodeoxyglucose positron emission tomography 
imaging.”  Clin Cancer Res.  2004;10,2245–2252. 
31. Sacks D, McClenny TE, Cardella JF, Lewis CA.  “Society of Interventional Radiology Clinical 
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Page 25 of 25 
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11.0 APPENDICES 
 
11.1 
Glossary of Terms 
18F-FMISO  
18F-Fluoromisonidazole 
CT  
Computed tomography 
DEB-TACE  
Drug-eluting bead transcatheter chemoembolization 
ECOG  
Eastern Cooperative Oncology Group 
HCC  
Hepatocellular carcinoma 
HIF  
Hypoxia inducible factor 
HNC  
Head and neck cancer 
kVP  
KiloVolt peak 
mA  
milliAmperes 
MRI  
Magnetic resonance imaging 
NSCLC  
Non-small cell lung cancer 
PET  
Positron emission tomography 
SUV  
Standardized uptake values 
TACE  
Transcatheter arterial chemoembolization 
TAE  
Transcatheter arterial embolization 
TLR  
Tumor-to-liver ratio 
TMR  
Tumor-to-muscle ratio 
VAPAHCS  
Veterans Affairs Palo Alto Health Care System 
VEGF  
Vascular endothelial growth factor