Optimizing Outcomes of Patients With Advanced HCC Undergoing Immunotherapy Through Novel 68Ga PSMA PET Imaging
Phase: PHASE2
Conditions: Advanced Hepatocellular Carcinoma, Stage III Hepatocellular Carcinoma AJCC v8, Stage IV Hepatocellular Carcinoma AJCC v8, Unresectable Hepatocellular Carcinoma
Sponsor: Mayo Clinic

 
 
 
 
 
21-007799 
 
 
Optimizing Outcomes of Patients with Advanced HCC Undergoing 
Immunotherapy Through Novel 68Ga PSMA PET Imaging 
 
 
NCT05176223 
 
 
Document Date: 01/27/2026 

 
 
 
Optimizing outcomes of patients with advanced HCC undergoing immunotherapy through novel 68Ga PSMA PET imaging 
 
 
 
 
 
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Dr. Tran  
Dr. Goenka 
 
CONFIDENTIAL 
 
 
 
 
Optimizing outcomes of patients with advanced HCC undergoing 
immunotherapy through novel 68Ga PSMA PET imaging 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
Optimizing outcomes of patients with advanced HCC undergoing immunotherapy through novel 68Ga PSMA PET imaging 
 
 
 
 
 
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Principal 
Investigator 
 
 
 
 
 
 
 
 
 
 
Co-Investigator(s) 
(alphabetical 
 
 
 
 
 
 
 
Nguyen H. Tran, M.D.  
Assistant Professor of Oncology 
Mayo Clinic College of Medicine and Science    
Division of Medical Oncology 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-293-0487 
 
 
 
 
 
Ajit H. Goenka, M.D. 
Professor of Radiology, 
Mayo Clinic College of Medicine and Science   
Division of Nuclear Medicine and Abdominal Imaging 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-284-4399 
 
Lewis R. Roberts, M.B., Ch.B., Ph.D 
Professor of Medicine 
Peter and Frances Georgeson 
Professor of Gastroenterology Cancer Research 
Mayo Clinic College of Medicine and Science 
Division of Gastroenterology and Hepatology 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-422-6542 
 
Michael S. Torbenson, M.D.  
Professor of  Laboratory Medicine and Pathology 
 
Mayo Clinic College of Medicine and Science 
Department of Laboratory Medicine and Pathology 
Division of Anatomic Pathology 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-284-0697 
 
 
 
 
 

 
 
 
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CONFIDENTIAL 
 
 
Scott M. Thompson, M.D., Ph.D. 
Assistant Professor of Biochemistry and Molecular 
Biology 
Associate Professor of Radiology 
Mayo Clinic College of Medicine and Science   
Division of Vascular & Interventional Radiology 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-255-8454 
 
 
Sudhakar Venkatesh, M.D.  
Professor of Radiology 
Mayo Clinic College of Medicine and Science 
Division of Abdominal Imaging 
Mayo Clinic, Rochester,  
Minnesota-55905, USA. 
Phone: +1-507-284-1728 
 
 
Fang-Shu Ou, Ph.D. 
Department of Quantitative Health Sciences Research 
Mayo Clinic Rochester IT Support Analyst  
Bioinformatics Systems  
 
Britten Block 
Sr. Program Coordinator - Research 
Division of Nuclear Medicine 
 
 
 
Funding Sponsor: Benefactor Funded Grant- Mayo Clinic, Rochester 
 
Initial version: 04/21/2021  Version 1.0 
Revised: 
[11/16/2021] Version (2.1)  
Revised: 
[03/16/2022] Version (3.1)  
Revised: 
[02/17/2023] Version (3.2)  
  
 
 

 
 
 
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Table of Contents 
STUDY SUMMARY ............................................................................................................................................ 6 
1 
INTRODUCTION ........................................................................................................................................ 7 
1.1 
BACKGROUND ..................................................................................................................................... 7 
1.1.1 
Anticipated Risks ............................................................................................................................ 8 
1.1.2 
Potential Benefits ........................................................................................................................... 9 
1.2 
ANTICIPATED DURATION OF THE CLINICAL INVESTIGATION ............................................................... 9 
2 
STUDY OBJECTIVES .............................................................................................................................. 9 
3 
STUDY DESIGN ........................................................................................................................................ 9 
3.1 
GENERAL DESIGN ................................................................................................................................ 9 
3.2 
PRIMARY STUDY OBJECTIVES ........................................................................................................... 12 
4 
PATIENT SELECTION, ENROLLMENT, AND WITHDRAWAL .................................................. 12 
4.1 
INCLUSION CRITERIA ......................................................................................................................... 12 
4.2 
EXCLUSION CRITERIA ........................................................................................................................ 12 
4.3 
PATIENT RECRUITMENT, ENROLLMENT AND SCREENING .................................................................. 12 
4.4 
EARLY WITHDRAWAL OF PATIENTS .................................................................................................. 12 
4.4.1 
When and How to Withdraw Patients .......................................................................................... 12 
4.4.2 
Data Collection and Follow-up for Withdrawn Patients ............................................................. 12 
5 
STUDY PROCEDURES .......................................................................................................................... 13 
5.1 
STUDY VISIT ...................................................................................................................................... 13 
6 
STATISTICAL PLAN ............................................................................................................................. 14 
7 
SAFETY AND ADVERSE EVENTS ...................................................................................................... 14 
8 
DATA HANDLING AND RECORD KEEPING ................................................................................... 15 
8.1 
CONFIDENTIALITY .............................................................................................................................. 15 
8.2 
SOURCE DOCUMENTS ......................................................................................................................... 16 
8.3 
RECORDS RETENTION ........................................................................................................................ 16 
9 
STUDY FINANCES ................................................................................................................................. 16 
10 
PUBLICATION PLAN ............................................................................................................................ 16 
Revised: 
[10/02/2023] Version (3.3)  
Revised: 
[07/19/2024] Version (3.4)  
Revised: 
[02/18/2025] Version (4.0)  
Revised: 
[07/15/2025] Version (4.1) 
Revised: 
[1/26/2026] Version (5.1) 
 
 
 

 
 
 
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11 
REFERENCES ......................................................................................................................................... 17 
 
 
 
LIST OF ABBREVIATIONS 
AFP 
Anti-VEGF 
Anti-PD-L1 
CBC 
CI 
CLMM 
CMP 
Alpha-fetoprotein 
Anti–vascular endothelial growth factor 
Anti-Programmed Death Ligand-1 
Complete Blood Count 
Confidence Interval 
Cumulative Link Mixed Model 
Comprehensive Metabolic Panel  
CT 
DCP 
EDTA  
Computed Tomography 
Des-gamma-carboxy Prothrombin 
Ethylenediaminetetraacetic acid 
FDA 
Food and Drug Administration 
FDG 
Fluorodeoxyglucose 
68Ga 
H&E 
68 Gallium 
Hematoxylin and Eosin 
HBN 
HCC 
HCV 
HIPAA 
Hepatobiliary Neoplasia 
Hepatocellular Carcinoma 
Hepatitis C Virus 
Health Insurance Portability and Accountability Act 
IDE 
IHC 
INR 
Investigational Device Exemption 
Immunohistochemical 
International Normalized Ratio 
IRB 
Institutional Review Board 
LI-RADS 
MCR 
Liver Imaging Reporting and Data System 
Mayo Clinic Rochester 
mRECIST 
Modified Response Evaluation Criteria in Solid Tumors 
MRI 
MTV 
NGS 
OS 
Magnetic resonance imaging 
Metabolic Tumor Volume 
Next-Generation Sequencing 
Overall Survival 
PET  
PFS 
PHI 
Positron Emission Tomography 
Progression-free Survival 
Protected Health Information 
PI 
PRC 
PSMA 
SOC 
Principal Investigator 
Pathology Research Core  
Prostate Specific Membrane Antigen 
Standard of Care 
SUVmax 
Maximum Standardized Uptake Value  

 
 
 
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TOF 
Time of Flight 
UADE 
Unanticipated Adverse Device Effect 
 
Study Summary 
Title 
 
 
 
Optimizing outcomes of patients with advanced HCC undergoing 
immunotherapy through novel 68Ga PSMA PET imaging 
 
Running Title 
Optimizing outcomes of patients with advanced HCC undergoing 
immunotherapy through novel 68Ga PSMA PET imaging 
IRB Protocol Number 
21-007799 
Phase 
Phase II 
Methodology 
Prospective study 
Overall Study 
Duration 
Study will reach completion 3-years from the time the study opens to 
accrual 
Patient Participation 
Duration 
Patients will undergo up to 5 PET/CT scans or until disease progression 
whichever comes first. 
Objectives 
1. To test the performance of novel biomarkers derived from PSMA 
PET/CT to measure response compared to RECIST criteria, in 
advanced HCC patients treated with immunotherapy. 
2. To assess the performance of novel biomarkers derived from PSMA 
PET/CT in predicting PFS in advanced HCC. 
 
Number of Patients 
30 
Diagnosis and Main 
Inclusion Criteria 
Adult patient with pathologically confirmed HCC not amenable to 
curative resection, transplantation or ablative therapies, who have 
radiographically measurable disease by RECIST and eligible for 
atezolizumab/bevacizumab front line therapy. 
Duration of each study 2.5-3.5 hours  
Statistical 
Methodology 
We assume that 20 PSMA PET/CT positive patients will be identified by 
screening 30patients.  We further assumed that patients with negative PSMA 
would have PFS at 6 months (PFS6) of 55% (historical data)1.  Given 20 
patients, we can detect a PFS6 difference of 26% (i.e. PFS6 drops from 55% 
to 29%) with 80% power assuming a one-sided p-value of 0.1 (using exact 
method).    
 
Aim 1: Time to response, per RECIST 1.1 and per PSMA PET/CT, will be 
correlated to each other using Cox proportional hazard model with response 

 
 
 
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1 
Introduction 
 
This document is a protocol for a human research study. This study will be carried out in accordance with the 
procedures described in this protocol, applicable United States government regulations, and Mayo Clinic 
policies and procedures.  
1.1 
Background 
Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. It is the sixth most 
common cancer worldwide and the fourth leading cause of cancer deaths.2 Its incidence is rising faster than any 
other cancer in the United States3 and is anticipated to continue to increase due to rising numbers of hepatitis C 
virus associated cirrhosis, particularly baby boomers with peak HCV cohort (1945-1965) and rising prevalence 
of non-alcoholic fatty liver disease.4 Patients often present with advanced disease when first diagnosed. Even with 
recent advances in systemic treatments, median overall survival (OS) ranges from a dismal 10.7 to 13.6 months.5, 
6 Since 2007, sorafenib, an oral multikinase inhibitor, has been the first line systemic therapy for patients with 
advanced HCC. Recently, atezolizumab, an anti-PD-L1 antibody, in combination with bevacizumab, a 
monoclonal anti-VEGF antibody, showed superior outcomes (67.2% OS at 12 months vs. 54.6% with sorafenib)1, 
which led to FDA approval of the combination as the first-line systemic treatment for advanced HCC. In contrast 
to clinical outcomes data, the combination showed a confirmed response rate of only 27.3% by conventional 
RECIST 1.1 and 33.2% by mRECIST criteria. These data highlight the significant unmet need for novel 
biomarkers of treatment response assessment in patients with HCC. In fact, in our current clinical practice at 
Mayo Clinic, all patients with advanced HCC continue to receive the combination until there are treatment-
limiting toxicities or progression on imaging. National and international guidelines also do not have 
recommendations on specific response assessment criteria to use in the setting of novel immunotherapy.7, 8 Thus, 
lack of validated noninvasive biomarkers are a critical barrier in individualizing therapeutic decisions in HCC 
patients treated with immunotherapy. 
 
Gallium-68 (68Ga) - Prostate Specific Membrane Antigen (PSMA)- N,N'-bis [2-hydroxy-5-
(carboxyethyl)benzyl] ethylenediamine-N,N'-diacetic acid (HBED-CC) (also called PSMA-11), is a zinc 
metalloenzyme and a transmembrane protein that has a large extracellular domain, a transmembrane domain, 
and a short intracellular domain.9 PSMA is overexpressed in prostate cancer cells. Therefore, PSMA is being 
evaluated worldwide including at our institution as a theranostic, i.e. combined diagnostic and therapeutic, 
target for prostate cancer.10 Recent studies suggest that PSMA is not specific to prostate cancer but can be 
expressed in other solid tumors including sarcomas, thyroid and lung cancers.11, 12 Two recent 
immunohistochemistry (IHC) studies suggest that HCC is one of the solid tumors that has higher-than-average 
expression of PSMA.9, 13 In one study, 76 of 103 (74%) HCC lesions expressed PSMA – 27 lesions showed 
PSMA expression in >50% of tumor-associated vasculature and 49 lesions showed  PSMA expression in 
per RECIST 1.1 as the dependent varible and the time to response per PSMA 
PET/CT will be included in the model as a time-vaying covariate. 
 
Aim 2: PFS rate at 6 months will be calculated among PSMA PET/CT 
negative patients using Kaplan-Meier method with corresponding confidence 
interval calculated using Greenwood’s formula.   

 
 
 
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</=50% of tumor-associated vasculature.9 In addition, high PSMA expression was associated with shorter 
overall survival. In another study, 79% of HCC lesions had moderate-to-high levels of PSMA expression.13 
 
More recently, our group performed PSMA IHC on 148 HCCs from surgical resection or liver explant 
specimens. 90% of HCCs showed PSMA immunostaining which was localized to the tumor endothelium. More 
than 50% of HCCs showed 31%-100% PSMA immunostaining by area. In all cases the intensity of staining was 
strong with a score of 3 on a scale of 1 to 3. Two small imaging studies14, 15 and a few anecdotal reports16, 17 
suggest that expression of PSMA in HCC can be translated to clinical imaging and can be detected non-
invasively on PSMA PET. For instance, a pilot study compared 68Ga-PSMA PET/CT with 18F- FDG PET/CT 
in 7 patients with 41 HCC lesions, and correlated it to contrast enhancement on CT or MRI.14 All but a single 
HCC lesion (n=36/37) were PSMA-avid with mean PSMA uptake in tumors being 3.6 times higher than 
background liver PSMA uptake. In contrast, only 10 lesions were FDG–avid. In addition, PSMA PET identified 
unexpected metastatic lesions in bone marrow, adrenal gland, and abdominal implant. Increased PSMA uptake 
in HCC on PET correlated with PSMA staining of endothelial cell lining of tumor neo-vasculature.  
 
Our experience in Mayo Clinic with PSMA PET imaging of patients with HCC who are treated either 
with surgery, transplant or loco-regional modalities also supports the cited empirical data. 
 
1.1.1 Anticipated Risks 
CT technologies have been used in clinical applications for over 30 years and have a well-documented safety 
profile. Similarly, PET scanners are widely used in clinical practice. The PET/CT scanners do not involve any 
risks other than those normally associated with routine clinical PET or CT scans, which are performed in 
millions of patients in many hospitals all over the world. The following are some discomfort one may 
experience during a PET/CT scan session: 
• Due to CT scanner: claustrophobia & anxiety.  The amount of radiation received from the low dose non-
contrast CT scan has a low risk of harmful effects. 
• Due to intravenous access placement: Placing an IV for the radiotracer infusion may cause pain from the 
needle stick, bleeding, bruising, lightheadedness, or, on rare occasions, infection.   
• Due to radiopharmaceutical 68Ga-PSMA: Small risk of an allergic reaction.  The amount of radiation 
received from the 68Ga-PMSA-11 scan has a low risk of harmful effects. 
 
PSMA uptake in non-LIRADS® 5 or biopsy proven lesions: 
It is possible there may be detection of PSMA uptake in i) previously undetected, non-LI-RADS 5 intrahepatic 
observations or ii) PSMA uptake without a corresponding morphologic observation on CT or iii) extrahepatic 
PSMA uptake.  Because we do not yet know the diagnostic accuracy of PSMA in patients with hepatocellular 
carcinoma, PSMA uptake found at the research PET or PET/CT outside of the known LI-RADS 5 lesion(s) 
and/or biopsy proven HCC will be disclosed to the referring provider for consideration of further evaluation.  If 
the findings are not confirmed on follow-up (or prior) imaging or biopsy, then the research PET/CT findings 
will not be factored into clinical decision making. Rather, the clinical diagnostic CT will guide clinical decision 
making based on standard morphologic and contrast-enhancement criteria (LI-RADS®). 
 
HCC Biopsy 

 
 
 
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US/CT-guided liver mass biopsy has been used in routine clinical practice for more than 20 years and has a 
well-documented safety profile.  The major risk of HCC biopsy is bleeding, which occurs in less than 0.4% of 
HCC biopsies 18.  Another risk of HCC biopsy is needle track seeding.  The risk of needle track seeding, once 
reported in up to 3% of HCC biopsies with older biopsy devices and techniques is now reported at 0% to 0.4% 
with modern biopsy devices and techniques 18. Moreover, studies have shown that in patients with 
intermediate/advanced HCC who are not candidates for curative intent surgical resection or transplant, if needle 
tract seeding does occur it does not affect patient outcomes 18. For the purposes of our study, only patients who 
meet our criteria of advanced HCC and without available archived tissue will be considered for clinical biopsy 
for other indications with PSMA stain performed from archived tissue stored in Tissue Registry. This may be 
done as a retrospective portion for correlation of existing archived tissue and PSMA IHC. 
 
Research Peripheral Venipuncture/ Blood Draw 
Venipuncture/blood draw is standard in clinical practice with a well-documented safety profile.  The research 
blood draw will be performed in a clinical laboratory and paired with a clinical blood draw, when possible, to 
minimize the number of venipuncture events.  
 
1.1.2 Potential Benefits 
Evaluation of PSMA PET/CT in the patients with advanced HCC will potentially enable us to: 
1. To establish 68Ga-PSMA as an imaging biomarker that can predict response of HCC to novel 
immunotherapy, 
2.  Provide prognostic tools to personalize treatment decisions and thus, optimize the outcomes of these 
patients.  
 
1.2 
Anticipated Duration of the Clinical Investigation 
The overall duration of this study in order to complete screening, enrollment, and all study procedures with 
follow-up for all patients will be approximately 3 years.  
 
2 
Study Objectives 
In adult patients with advanced, pathologically confirmed HCC who are not amenable to curative restriction, 
transplantation or ablative therapies, and have radiographically measurable disease by RECIST; eligible for 
atezolizumab/bevacizumab front line therapy. 
 
 Specific Aim 1.  To test the performance of novel biomarkers derived from PSMA PET/CT to measure 
response compared to RECIST criteria, in advanced HCC patients treated with immunotherapy. 
  
 Specific Aim 2. To identify precision imaging biomarkers that can predict response of HCC to novel 
immunotherapy. 
 
 Correlative aim 2a: To assess biomarkers of response using extracellular vescicles and peripheral blood 
mononuclear cells. 
 

 
 
 
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3 
Study Design 
3.1 
General Design 
This is a prospective single-center study. A total of 30 patients who meet the inclusion and exclusion criteria will 
be enrolled to the study.  All 30 patients will undergo 68Ga-PSMA PET/CT imaging prior to initiation of 
immunotherapy to identify PSMA PET/CT positive patients (estimated N=20) for long term follow up. Patients 
will be recruited from the Mayo Clinic Cancer Center.  
        
Patients may also be simutaneously enrolled in IRB 20-006433, EARLY DETECTION, ACCURATE STAGING, 
AND BIOLOGIC CHARACTERIZATION OF HCC WITH HYBRID 68GA-PSMA-DUAL-CONTRAST 
PET/MRI AND PET/CT USING CYCLOTRON-PRODUCED 68GA (PI: Dr. Ajit Goenka). In cases that patients 
are enrolled in both studies and are also undergoing a baseline 68Ga-PSMA PET/CT for IRB 20-006433; a repeat 
baseline 68Ga-PSMA PET/CT baseline scan does not have to be performed. Baseline imaging data for IRB 20-
006433 will be used as the baseline timepoint for IRB 21-007799. 
 
Patients who are PSMA PET/CT negative at baseline will continue their treatment per standard of care.  Their 
data, from standard of care, will be collected as part of this study. 
 
Patients who are PSMA PET/CT positive at baseline will receive up to a total of 5 scans during the course of 
study or until progression, whichever comes first. Each patient will undergo routine clinical blood workup 
including CBC, CMP, AFP, AFP-L3, INR and DCP as well as research blood collection at the time of scans (2 
EDTAtubes, 2 NaHep tubes). 
 
Patients will receive standard of care cross-sectional imaging (CT or MRI) and AFP testing every 3 cycles as per 
clinical protocol. Clinical variables will be collated and include age, sex, risk factors for HCC development, 
albumin, bilirubin, platelet count, Barcelona Clinic Liver Cancer stage, date of diagnosis, date of disease 
progression, any prior treatment history. 
 
Test schedule for patients who are PSMA PET/CT positive at baseline: 
Procedures  
Prior to 
C1D1 of 
treatment  
Treatment 
End of Treatment 
 
 
Event Monitoring 
every 6 months 
for 3 years  
Electronic Medical Record Review  
X  
X 
X  
X 
Eligibility Pre-Screening  
X  
 
  
 
Informed Consent   
X 
 
  
 
CBC, CMP, AFP, AFP-L3, DCP, INR 
X 
X 
X 
 
Hep B and Hep C panel 
X 
 
 
 
Blood (Bio-banking 2 EDTA, 2 NaHep 
tubes)   
X  
X  
X  
 
Request external medical records when 
needed  
X 
X 
X  
X 

 
 
 
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Off Study Documentation* 
  
  
X  
 
68Ga-PSMA PET/CT 
X* 
X** 
  
 
 
*1 baseline treatment and scan 
**End of every 3 cycles for a total of 4 scans during the 36 weeks 
Blood Specimen Collection and Processing 
Every effort will be made to collect peripheral blood at the time of routine blood draws for clinical visits/drug 
administration to limit patient morbidity and streamline patient care. If this is not possible, research blood 
collection will require a separate venipuncture at no charge to the patient.  
 
Two (10ml) EDTA tubes, and 2 (10ml) NaHep tubes will be collected.  
 
Blood samples will be sent to Rochester BAP lab. Blood must be sent ambient (NOT frozen). BAP will process 
the EDTA and Nahep tubes and stored frozen at -80C. 
 
Biobanked blood will be used to assess for extracellular vesicles biomarkers (EVs) and peripheral blood mononuclear cells (PBMC). 
EVs are nano-objects (50-100 nm in diameter) in blood that hold promise as surveillance tools because they are numerous and stable.19 
Our team have developed a sensitive electrochemical immunoassay20 well suited for detecting hepatic EVs carrying markers of steatosis, 
fibrosis and inflammation. We analyzed liver hepatitis-related biomarkers and identified a marker exhibiting more than 90% sensitivity 
and selectivity. Our study demonstrated higher sensitivity compared to conventional analytical methods for hepatic EV, such as ELISA 
or western blot, and showed significant increased expression of EpCAM and AFP on hepatic cancer EVs.20, 21 We will apply this novel 
technology to detect pathology-informed markers in HCC EVs in circulation and evaluate the changes. We will assess the changes in 
peripheral blood cells, specifically NKG7+ CD8+ T cells and CX3CR1+ Granzyme B+ CD8+ T cells as markers of response, particularly 
relevant to this study using ICI 
 
Study Finances: 
Tests and procedures that will be paid for by Benefactor funded grant including PET study (PET/CT), 68Ga 
PSMA tracer production and IHC evaluation of soft tissue biopsy specimens with PSMA antibody. Other tests 
and procedures that are part of standard clinical care will be billed to the patients and/or to the applicable 
insurance. 
 
Radiological analysis:  
The PET scan will be reviewed by a Nuclear Radiologist. The maximum standard uptake value (SUVmax) at 
the lesion(s) will be obtained by manually placing a volume of interest (VOI) over the hepatic lesion, any other 
extrahepatic lesion that is deemed to be HCC-related and background liver. The PSMA accumulation at the site 
of the lesion will be scored based on visual interpretation of PSMA-activity relative to an internal reference 
standard based on the SUVmax threshold.  The following data will be recorded: lesion(s) and background liver 
SUVmax and tumor to liver background ratio (TBR) SUVmax.  An Abdominal Radiologist will review the 
cross-sectional imaging done as part of standard clinical care and document response both as a continuous 
variable (Δ tumor size, in cm), and in categories (CR-complete response; PR-partial response; SD-stable 
disease; PD-progressive disease) according to RECIST1.1. Response, per RECIST, will also be dichotomized 
as: 1) responders (CR and PR) versus non-responders (SD and PD); 2) disease control (CR, PR and SD) versus 
non-responders (PD). Metrics derived from 68Ga-PSMA PET/CT will be compared with dichotomized RECIST 
categories. The Nuclear and Abdominal Radiologists will then review the images in consensus, blinded to the 
pathology findings. 

 
 
 
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Pathology:  
Liver tissue samples will be processed per standard pathology protocols (formalin fixed, paraffin-embedded) 
and then stained with hematoxylin and eosin (H&E) and a previously validated monoclonal antibody targeting 
the extracellular domain of human PSMA in the Pathology Research Core (PRC). Tumor and background liver 
PSMA immunohistochemical grading will be performed by a hepatobiliary pathologist independent of the 
imaging findings as follows: 0 = no staining, trace = < 5% staining, 1= 5 to 30% staining, 2 = 31 to 60% 
staining and 3 = 61-100% staining. Additionally, HCC will be graded and staged as per standard Mayo Clinic 
protocols, including determination of tumor size, grade, vascular invasion, etc. as well as standard evaluation of 
background liver for fibrosis, inflammation, steatosis, etc.  After independent grading, staining will be reviewed 
in consultation with a radiologist in order to match sites of histopathologic analysis to the lesion at cross-
sectional imaging, but will be blinded to PET/CT findings. 
 
3.2 
Primary Study Objectives 
A. Determine the time to response per RECIST 
B. Determine PFS at 6 months per RECIST 
 
4 
Patient Selection, Enrollment and Withdrawal 
4.1 
Inclusion Criteria 
• Patient with pathologically confirmed HCC not amenable to curative resection, transplantation or ablative 
therapies. 
• Have radiographically measurable disease by RECIST. 
• Eligible for atezolizumab/bevacizumab front line therapy. 
• Male or female with age greater than 18 years, with the capacity and willingness to provide written 
informed consent. 
4.2 
Exclusion Criteria 
• Pregnant and/or breast-feeding patients. A negative pregnancy test within 48 hours of the PET scan.  
• Patients with higher than the weight/size limitations of PET/CT scanner.  
4.3 
Patient Recruitment, Enrollment and Screening 
Patients will be recruited from Mayo Clinic Cancer Center. Scheduling calendar of these clinics and collaborating 
clinician referrals will identify patients meeting study requirements. Our study coordinator will contact potential 
candidates to discuss the study procedure, as well as its risks/benefits, and obtain informed written consent. 

 
 
 
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Patients will solely decide the waiting period between discussion and decision. The participant clinicians will 
address additional patient questions.  
4.4 
Early Withdrawal of Patients 
4.4.1 When and How to Withdraw Patients 
The patients may be withdrawn from the study prior to completion of all of the study related procedures if:  
• Patient decides to withdraw from the study (withdrawal of consent). 
• Patient suffers from a serious or life-threatening adverse effect due to the procedure.  
• Patient fails to adhere to the protocol requirements. 
4.4.2 Data Collection and Follow-up for Withdrawn Patients 
Not applicable. 
 
 
 
 
5 
Study Procedures 
 
The study will involve up to 5 visits for PSMA PET/CT, the initial imaging will be prior to systemic therapy 
and during the course of study (after 3, 6, 9, 12cycles of treatment), or until progression, whichever comes first. 
Long-term follow up after treatment includes 3 years or death, whichever comes first. 
 
Investigational Drug 
68Ga-PSMA-HBED-CC is an investigational radiopharmaceutical that will be produced under cGMP in the 
Mayo Clinic Cyclotron Facility. At Mayo Clinic Rochester (MCR), we have received FDA approval 
(IND#151346) for research centered on the use of 68Ga-PSMA in HCC. 
 
5.1 
Study Visits  
 
PET/CT examination: 
The patients enrolled into this study will undergo up to 5 PET/CT scan in Charlton 6-B. The PET/CT exam-
related patient visit will last approximately 2.5 to 3.5 hours, including 30-40-minute nursing assessment, around 
90-minutes for PSMA uptake, and 30 minutes for PET/CT scan. Scheduling for the exam will be completed by 
a study coordinator. 
 
Participant preparation:  
No fasting is required. Liberal fluids are encouraged.  
Pre-Imaging Assessment:  

 
 
 
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Patients will undergo standard nursing assessment prior to the examinations as per Department of Radiology 
protocol.  
 
During the 68Ga-PSMA PET/CT exam: 
In patients who are otherwise eligible for the study PET/CT will be performed as per standard PSMA PET/CT 
protocol at MCR. Patients will receive an injection of 5 ± 10% mCi of 68Ga-PSMA. After the injection, patients 
will relax on a recliner in a quiet, dimly lit room for around 90 minutes while the PSMA circulates through the 
body. Scan coverage will extend from base of the skull to upper thighs.  Bed position scan time will be 
dependent on the PET/CT scanner capabilities.  At a minimum, 3 minutes per bed position will be used.   
 
After completion of PET/CT examination: 
The patient will be advised to drink plenty of water and stay near a rest room without extended travel for a few 
hours. The images will be stored on password protected Mayo Clinic computers.  
 
Long Term Follow-up: 
 
The patient will be contacted by telephone every 6 months for 3 year to ask about  their health and medications. 
 
6 
Statistical Plan 
 
 
Endpoint: 
Aim 1: The endpoints are 1) time to treatment response per RECIST 1.1 and per PSMA PET/CT, defined as 
time from study regitration to CR/PR per RECIST 1.1 and per PSMA PET/CT; 2) time to progression per 
RECIST 1.1 and per PSMA PET/CT, defined as time from study registration to disease progression per 
RECIST 1.1 and per PSMA PET/CT. 
Aim 2: The endpoint is PFS at 6-months post registration (PFS6) per RECIST 1.1. 
 
Power Statement:  
We powered this study to test the hypothesis that patients with positive PSMA PET/CT at baseline will have a 
shorter PFS, i.e. a lower rate of PFS6, compare to historical control where positive PSMA is defined as any lesion 
(within a patient) has a SUVmax > 4.  The assumptions are that 2/3rd of the patients enrolled would have positive 
PSMA (i.e. N=20) and patients with negative PSMA would have PFS6 of 55% (historical data)1.  Given 20 
patients, we can detect a PFS6 difference of 26% (i.e. PFS6 drops from 55% to 29%) with 80% power assuming 
a one-sided p-value of 0.1 (using exact method).   
 
Analysis Plan: 
Aim 1: Time to reatment response per RECIST 1.1 and per PSMA PET/CT will be defined for each patients.  The 
response per PSMA PET/CT will need to be ‘confirmed’ by CT finding.  Specifically, if PSMA PET/CT identified 
a reduction of SUVmax which result in a response per PSMA PET/CT, the reduction needs to persist until there 
is a response per CT then the response per PSMA PET/CT is ‘confirmed’.  Time to response, per RECIST 1.1 
and per PSMA PET/CT, will be correlated to each other using Cox proportional hazard model with response per 

 
 
 
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RECIST 1.1 as the dependent varible and the time to response per PSMA PET/CT will be included in the model 
as a time-vaying covariate. 
Similar analysis plan applys to time to progression. 
 
Aim 2: The PFS6 will be calculated among PSMA PET/CT positive patients using Kaplan-Meier 22 method with 
corresponding confidence interval calculated using Greenwood’s formula.  Since we will also gather data on 
PSMA negative patients, we will explore the potential prognostic effect of PSMA status on PFS using Cox 
proportional hazard model with PSMA PET/CT status (positive vs. negative) as the main variable of interest while 
adjusting for other potential confounders.   
7 
Safety and Adverse Events 
 
7.1        Definitions 
Unanticipated Problems Involving Risk to Subjects or Others (UPIRTSO) 
Any unanticipated problem or adverse event that meets the following three criteria:  
• 
Serious: Serious problems or events that results in significant harm, (which may be physical, 
psychological, financial, social, economic, or legal) or increased risk for the subject or others 
(including individuals who are not research subjects). These include: (1) death; (2) life threatening 
adverse experience; (3) hospitalization - inpatient, new, or prolonged; (4) disability/incapacity - 
persistent or significant; (5) birth defect/anomaly; (6) breach of confidentiality and (7) other problems, 
events, or new information (i.e. publications, DSMB reports, interim findings, product labeling 
change) that in the opinion of the local investigator may adversely affect the rights, safety, or welfare 
of the subjects or others, or substantially compromise the research data, AND 
• 
Unanticipated: (i.e. unexpected) problems or events are those that are not already described as potential 
risks in the protocol, consent document, not listed in the Investigator’s Brochure, or not part of an 
underlying disease. A problem or event is "unanticipated" when it was unforeseeable at the time of its 
occurrence. A problem or event is "unanticipated" when it occurs at an increased frequency or at an 
increased severity than expected, AND 
• 
Related: A problem or event is "related" if it is possibly related to the research procedures. 
  
Adverse Event 
An untoward or undesirable experience associated with the use of a medical product (i.e. drug, device, biologic) 
in a patient or research subject. 
 
Serious Adverse Event 
Adverse events are classified as serious or non-serious.  Serious problems/events can be well defined and 
include; 
• 
death 
• 
life threatening adverse experience 
• 
inpatient hospitalization or prolongation of existing hospitalization 
• 
persistent or significant disability or incapacity 
• 
substantial disruption of the ability to conduct normal life functions 
• 
birth defect/congenital anomaly 
  

 
 
 
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and/or per protocol may be problems/events that in the opinion of the sponsor-investigator may have adversely 
affected the rights, safety, or welfare of the subjects or others, or substantially compromised the research data. 
  
All adverse events that do not meet any of the criteria for serious, should be regarded as non-serious adverse 
events. All adverse events occurring during the study will be recorded in patient medical records.  Records of 
these events will be maintained and reports submitted to IRB according to the regulatory requirements.  
Expected clinical adverse events and non-significant (not serious) clinical adverse events will not be reported. 
Expected clinical adverse events and anticipated adverse procedure effects are those listed in Section 1.1.1. 
 
Adverse Event Reporting Period 
For this study, the study treatment follow-up period is defined as 2 days after the PET/CT exam. 
8 
Data Handling and Record Keeping 
8.1 
Confidentiality 
Information about study patients will be kept confidential and managed according to the requirements of the 
Health Insurance Portability and Accountability Act of 1996 (HIPAA). Those regulations require a signed 
patient authorization informing the patient of the following: 
• What protected health information (PHI) will be collected from patients in this study? 
• Who will have access to that information and why? 
• Who will use or disclose that information? 
• The rights of a research patient to revoke their authorization for use of their PHI. 
 
In the event a patient revokes authorization to collect or use PHI, the investigator, by regulation, retains the 
ability to use all information collected prior to the revocation of patient authorization.  For patients that have 
revoked authorization to collect or use PHI, attempts should be made to obtain permission to collect at least 
vital status (long term survival status that the patient is alive) at the end of their scheduled study period. 
8.2 
Source Documents 
The Source data comprise all information, original records of clinical findings, observations, or other activities 
in a clinical treatment necessary for the reconstruction and evaluation of the treatment response.  Source data 
are contained in source documents.  Examples of these original documents, and data records include: hospital 
records, clinical and office charts, laboratory notes, radiological imaging data,  memoranda, patients’ diaries or 
evaluation checklists, pharmacy dispensing records, recorded data from automated instruments, copies or 
transcriptions certified after verification as being accurate and complete, microfiches, photographic negatives, 
microfilm or magnetic media, patient files, and records kept at the pharmacy, at the laboratories, and at medico-
technical departments involved in the study. 
8.3 
Records Retention 
The principal-investigator will maintain records and essential documents related to the conduct of the study. 
These will include patient case histories and regulatory documents. 

 
 
 
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The principal-investigator will retain the specified records and reports as outlined in the Mayo Clinic Research 
Policy Manual –“Retention of and Access to Research Data Policy” http://mayocontent.mayo.edu/research-
policy/MSS_669717,  
9 
Study Finances 
This study proposal has received funding approval from Benefactor funded grant.  
 
10  Publication Plan 
Findings will be shared and discussed with all of the investigators for the study.  An estimated timeline for the 
creation of an abstract will be defined at that time. An abstract of the completed study, after input from all of the 
authors, will be submitted to a radiology, hepatology and/or hepatobiliary surgery meeting. A manuscript of the 
study, having received input from all of the authors will be submitted to a peer-reviewed journal.  
 
 
 
 
 
 
 
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