PET/CT Quantitative Assessment of Myocardial Blood Flow Changes in Oncologic Patients Receiving Checkpoint Inhibitor Therapy
Phase: PHASE1
Conditions: Cancer
Sponsor: Mayo Clinic

 
 
 
 
 
 
 
 
 
PET/CT Quantitative Assessment of Myocardial Blood Flow Changes in 
Oncologic Patients Receiving Checkpoint Inhibitor Therapy 
 
 
NCT#: NCT04538950 
 
Protocol Version: 4.0 
Date:10 November 2021  
 

Protocol Version: 4.0 
Date:10 November 2021  
 
1 
 
 
 
PET/CT Quantitative Assessment of Myocardial Blood Flow Changes in 
Oncologic Patients Receiving Checkpoint Inhibitor Therapy 
 
 
Abstract (150 words or less with hypothesis) 
 
Immune checkpoint inhibitors (ICI) are novel chemotherapeutic agents which disinhibit 
T-cell activity, thereby enhancing autoimmune response1 and ushering in a new era of treatment 
for patients with both solid and hematologic malignancies.2 Unfortunately, resultant side effects 
of ICI use, termed immune-related adverse events (IRAE), are difficult to both diagnose and treat 
resulting in high fatality rates.3 The ability to accurately detect subclinical decline in myocardial 
performance and the resultant initiation of targeted therapy has markedly improved the outcomes 
of patients prescribed the more traditional cardiotoxic chemotherapeutic agents such as 
anthracyclines.4 Consequently, means by which to detect subclinical myocardial injury is 
garnering increasing interest and now includes the assessment of endothelial function.5-7 
Quantitative positron emission tomography computed tomography (PET-CT) is a highly 
accurate, reproducible and repeatable technique by which to assess myocardial blood flow 
(MBF) and endothelial function. 8, 9 For instance, recent studies have demonstrated a decrease in 
myocardial flow reserve (MFR) in patients receiving doxorubicin.7 We hypothesize that PET/CT 
MFR will decrease in some patients receiving ICI thereby representing early, subclinical 
myocardial injury and potentially serving as an early indicator of patients who might be 
predisposed to IRAEs. 
 
 
Principal Investigador: John P. Bois MD  
 
Co-investigators: Joerg Herrmann MD, Martin Rodriguez-Porcel MD, Amir Lerman MD, 
Geoffrey B. Johnson MD, PhD, and Panithaya Chareonthaitawee MD 
IRB # 19-009189 
 

 
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A. Rationale: Brief paragraph establishing rationale 
 
 
Established chemotherapeutic agents such as anthracyclines, trastuzumab and 
bevacizumab have proven cardiotoxic effects.10 Historically, some of these sequelae have been 
severe enough to render a patient’s prognosis poorer than that of a patient with ischemic heart 
failure.11 Consequently monitoring protocols designed to detect decline in cardiovascular 
function were initiated in the 1970s and have continued to evolve to include mutligated 
acquisition scan (MUGA), strain echocardiography and high sensitivity troponin.12, 13 Early 
detection of chemotherapeutic cardiotoxicity paired with institution of therapy has markedly 
improved the prognosis of oncologic patients.4, 14 
 
Immune checkpoint inhibitors (ICI) disinhibit T-cell activity thereby allowing for a 
heightened antitumor immunologic response.1,15 Resultant outcomes for patients with both solid 
and hematologic malignancies have been promising.2, 16, 17 However, immune-related adverse 
events (IRAE) have been reported secondary to administration of these agents including 
myocarditis (odds ratio of 11.21), cardiomyopathy and conduction abnormalities.18, 19  
Furthermore, a fatality rate as high as 39 percent has been reported for patients who develop 
IRAE myocarditis. 3 Approximately 75 percent of patients who develop myocarditis have normal 
myocardial function prior to therapy and no known preexisting cardiovascular conditions.3 When 
myocarditis does occur as an IRAE it typically does so in the first month.3 Unfortunately IRAEs 
have thus far been difficult to diagnose and to treat with leaders in the field calling for 
“development of guidelines for early diagnosis.”3 
 
Endothelial dysfunction has been demonstrated with the use of other multiple 
chemotherapeutic agents 3, 5, 20 and is likely due either to endothelial cell death or reduced nitric 
oxide availability. Quantitative positron emission tomography computed tomography (PET-CT) 
is an emerging modality which provides a highly accurate, reproducible, repeatability, 
noninvasive means by which to assess total myocardial blood flow, specifically myocardial flow 
reserve (MFR,) including assessment of the endothelium.8, 9 Recently, PET-CT MFR was 
utilized to demonstrated a decrease in MFR in some patients after expose to doxorubicin but not 
others thereby labeling them as more likely to develop cardiotoxicity.3 The current proposal 
seeks to utilized PET-CT MFR to assess dynamic changes in MFR that occur pre and post 

 
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initiation of ICI and thereby potentially identify early cardiotoxicity in patients who might be 
more prone to more devastating IRAEs such as myocarditis.   
 
There is also considerable interest in identifying unique immune cell phenotypes in the 
peripheral blood that can predict which patients are most at risk for developing checkpoint 
inhibitor-mediated IRAEs.21  iIn the long-term, this would serve as a less invasive means of 
monitoring patients both before and during treatment.  Thus, this proposal will also collect and 
analyze peripheral blood from the patients who undergo PET-CT MFR to determine if a 
particular T cell phenotype prior to therapy may correlate with imaging changes and 
cardiotoxicity of ICI.      
 
B. Hypothesis:  
 
 
PET-CT MFR will identify a certain proportion of oncologic patients being prescribed 
ICIs who develop microvascular damage/endothelial dysfunction. This initial study could serve 
as the foundation for larger evaluations of this population in determining whether or not routine 
surveillance can identify patients early who are at higher risk of IRAE and potentially improve 
outcomes. 
 
C. Aims:  
 
The aims of the current study are two-fold. First is to determine if ICI administration 
causes microvascular damage/endothelial function. If so, the second aim is to serve as a pilot 
study for larger trials to determine the prevalence of ICI-induced microvascular 
damage/endothelial dysfunction and specifically if it identifies patients who are at increased risk 
of IRAEs. 
 
 
D. Innovation:  
What is known: 
1) Traditional chemotherapeutic agents can cause microvascular damage/endothelial 
dysfunction3, 5, 20 
2) Early detection of chemotherapeutic toxicity can improve outcomes4 
3) PET-CT MFR can be used to detect chemotherapeutic reduction in MFR in patients 
receiving traditional agents such as doxorubicin3 
4) ICI induced IRAE can cause significant morbidity and mortality 

 
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5) Increased lymphocyte counts and clonal expansion of CD8+ T cells in the peripheral 
blood can precede development of ICI-induced IRAE. 22,23  
 
What remains to be discovered: 
1) Do ICIs cause microvascular disease/endothelial dysfunction? 
2) If ICIs do cause microvascular disease/endothelial dysfunction how common is this 
occurrence and what is its bearing on patient prognosis? 
3) Is there any correlation between T cell phenotypes in the peripheral blood and 
microvascular disease/endothelial dysfunction that occurs on ICI therapy? 
 
E. Significance: How will this change our practice, increase our national standing, attract 
patients or advance our knowledge about CV disease. What is Mayo unique? (numbered list). 
 
1) Cardio-oncology is a rapidly expanding field and Mayo Clinic has several clinicians at 
the forefront10 
2) Oncologic patients are attracted to Mayo Clinic already for our expertise and this will 
further enhance the practice 
3) Mayo Clinic is a leading center for cardiac PET and specifically PET-CT MFR6 
 
E. Brief Synopsis of Methods: Very brief summary – numbered list acceptable – of what will 
actually be done. 
1) Collaboration between Cardiology, Oncology and Cardiac PET to recruit 6 consecutive 
patients beginning ICI therapy  
2) Screening labs, including troponin, high sensitivity CRP, and NT-proBNP; peripheral blood 
draw sent to research lab (Dr. Haidong Dong) for T cell phenotyping.  
3) Complete PET-CT MFR6 immediately before and 4-6 weeks after initiation of ICIs 
4) Assess change in MFR (per literature 20% or more decreased indicates significant change)7 
5) Continue long-term follow-up of the patients in charts to determine if any develop IRAEs 
6) For patients who develop myocarditis a FDG PET-CT would be performed to assess for 
inflammation 
 
E.1 Detailed Methods 

 
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1) Recruitment: Investigator JPB has met with hematology team (Konstantinos Leventakos MD 
PhD) who will work with his PA team to identify eligible patients for recruitment. Those deemed 
eligible will be approached during their initial visits with oncology (prior to initiation of ICI. 
2): PET-CT MFR methodology (performed during two sessions-one before and one 4-6 weeks 
after administration of ICI): 
A GE Discovery 690XT, Discovery Molecular Insights (DMI) or 710 PET/CT system (GE 
Healthcare, Waukesha, WI) will be utilized in performing the studies. The imaging system 
consists of full ring Cerium-doped Lutetium Yttrium Orthosilicate (LYSO) crystals. 128x128 
PET matrix size with zoomed 41.9 cm field of view centered over the heart will be used to obtain 
the PET images. Furthermore, three-dimensional list mode acquisition will be employed. Three-
dimensional iterative reconstruction algorithm with time-of-flight correction, CT attenuation, 
scatter, randoms, normalization, decay and dead time correction will be utilized. Three-
dimensional Hanning post-filter with a 10 mm cut-off will also be used.  
 
A 64 slice-spiral CT will be employed with auto exposure control with modulated current in 
order to maintain consistent noise index (noise index set at 33 with mA range 10-180). For our 
CT attenuation imaging tube ration is 0.5 s, kV is 120 and pitch is 0.98. Slice thickness is 3.75 
mm and slice increment is 3.27 mm. Matrix size is 512 x 21. 
 
13NH3 will be administered at rest to allow qualitative and quantitative (rest myocardial blood 
flow) assessment of myocardial perfusion. Regadenoson will be administered as a stress agent 
followed by a 13NH3 with subsequent qualitative and quantitative (myocardial blood flow) 
assessment of myocardial perfusion. MFR will then be determined by assessing the ratio of stress 
to rest myocardial blood flow.  
 
For those patients who are suspected to have developed myocarditis they will undergo a FDG-
PET CT inflammatory protocol. PET/CT parameters will be similar as noted above. However, no 
stress agent will be used. Furthermore, FDG will be administered per the inflammatory 
myocardial protocol for assessment of inflammation.  
 
3)  Analysis of T lymphocytes in peripheral blood for phenotypic markers via flow cytometry:   
 
Peripheral blood mononuclear cells (PBMC’s) will be isolated from whole blood using a Ficoll 
gradient, counted, and frozen in liquid nitrogen.  For analysis, PBMC’s will be thawed and 
plated overnight in complete RPMI media with IL-2 (10u/mL).  The following day, cells will be 
counted and stained with fluorophore-labeled antibodies suitable for flow cytometry, which may 
include (but are not limited to):  CD45 (clone HI30, catalog 304006), CD3 (clone OKT3, catalog 
317344), CX3CR1 (clone 2A9-1, catalog 341616), CD11a (clone HI111, catalog 301212), and 
PD-1 (clone EH12.2H7, catalog 329904) antibodies from BioLegend; CD8 (clone RPA-T8, 
catalog 557746) and Ki67(clone B56, catalog 562899) antibodies from BD Biosciences; and 
anti–human granzyme B (clone GB11, catalog NBP1-50071PCP) from Novus.  Cells will then 
be assayed using a Beckman Coulter Cytoflex LX flow cytometer and data analyzed using 
FlowJo software (BD Biosciences). 
 
 
 

 
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3): Statistical Analysis 
General Considerations 
Continuous data (e.g., age) will be summarized using the following descriptive summary 
statistics: the number of subjects (n), mean, SD, median, minimum value (min), and maximum 
value (max). For each continuous variable, the corresponding mean, median, minimum and 
maximum will be presented to 1 decimal place and the SD to 2 decimal places, unless otherwise 
specified.  
Categorical variables (e.g., qualitative presence or absence of perfusion defecit) will be 
summarized using counts and percentages. Percentages will be presented to 1 decimal place. 
Summaries of continuous and categorical data will be presented, as appropriate. 
Incomplete/Missing data: Missing data (e.g., dates, post-baseline values) will not be imputed, 
unless otherwise specified; i.e., all missing values and missing post-baseline values will remain 
as missing in all statistical analyses and listings, unless otherwise specified. 
Outliers: No formal statistical analyses will be performed to detect and/or remedy the presence 
of statistical outliers. 
Additionally, all subject data, including derived variables, will be presented in subject data 
listings; listings will display all subjects who were randomized or enrolled in the study.   
Background Characteristics  
Demographics and Baseline Characteristics 
Demographics and baseline characteristics (age, sex, race, ethnicity, weight, height and body 
mass index [BMI]) will be summarized.  
Efficacy Analysis 
Analysis of Primary Efficacy Endpoint 
Nominal continuous variables will be represented as the mean +/- SD and categorical variables 
will be noted as the number and percentage of total. Pearson chi-square test will be utilized to 
determine statistical significance for continuous variables whereas a Student’s two-sample t-test 
will be implemented to determine statistical significance for continuous variables. Univariate and 
multivariate analyses will be performed when relevant. Statistical significance will be set a priori 
as a p-value less than 0.05. Given that this is a pilot study no power calculation will be 
performed. All statistical analyses will be performed using JMP Pro 9 (SAS Institute INC. Cary, 
North Carolina).  
 
Adverse Events Collection:  
Adverse Events will be collected only for activities done for research.   
 
 
The selection of study subjects will be based upon the following inclusion and exclusion 
criteria:   
 
 
 
Inclusion 

 
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1. First time administration of ICI 
2. Willing and able to return in 4-6 weeks for follow-up study 
3. Patients with previous heart conditions included (while this may impact MFR the delta 
MFR is what we are assessing) 
 
Exclusion 
1. Age < 18 years 
2. Women who are pregnant, or breast-feeding. 
3. Unable or unwilling to give consent to undergo PET/CT. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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