Use of 64Cu-DOTA-Trastuzumab PET Imaging and Molecular Markers for Prediction of Response to Trastuzumab and Pertuzum-Based Neoadjuvant Therapy
Phase: PHASE2
Conditions: HER2 Positive Breast Carcinoma, Stage IIIA Breast Cancer, Stage IIIB Breast Cancer, Stage IIIC Breast Cancer
Sponsor: City of Hope Medical Center

 
IRB 16079 
 
03/28/2019 
Packet: 20 
CITY OF HOPE NATIONAL MEDICAL CENTER 
1500 E. DUARTE ROAD 
DUARTE, CA 91010 
 
DEPARTMENT OF MEDICAL ONCOLOGY AND THERAPEUTICS RESEARCH           
 
TITLE: Use of 64cu-DOTA-trastuzumab PET Imaging and Molecular Markers for Prediction of Response 
to Trastuzumab and Pertuzumab-based Neoadjuvant therapy  
 
CITY OF HOPE PROTOCOL NUMBER/VERSION: IRB #16079 
 
 
Protocol date: 03/28/2019 
 
DATE(S)/ OF AMENDMENT(S)/REVISION(S): 
 
COH Initial Approval  
(COH Protocol dated 05/12/2016)  
Version: 00 
COH Amendment 01 
(Title Page, personnel update 07/05/2016) 
Version: 01 
COH Amendment 02  
(Title Page, personnel update 08/312016) 
Version: 02 
COH Amendment 03 
(COH Protocol dated 07/19/2016) 
Version: 03 
COH Amendment 04 
(Title Page, personnel update 02/01/2017) 
Version: 04 
COH Amendment 05 
(COH Protocol dated 06/26/2017)                                                           Version: 
05 
COH Amendment 06 
(Title Page, personnel update 10/23/17) 
Version: 06 
COH Amendment 07 
COH Protocol dated 01/19/2018 
Version: 07 
COH Amendment 08 
(Title Page, personnel update 01/26/2018) 
Version: 08 
COH Amendment 09 
COH Protocol dated 02/08/2018 
Version: 09 
COH Amendment 10 
(Title Page, personnel update 05/08/2018) 
Version: 10 
COH Amendment 11 
(Title Page, personnel update 04/30/2018) 
Version: 11 
COH Amendment 12 
(Title Page, personnel update 09/12/2018) 
Version: 12 
COH Amendment 13 
(COH Protocol dated 07/18/2018) 
Version: 13 
COH Amendment 14 
(Title Page, personnel update 11/15/2018)                                             Version: 
14 
COH Amendment 15 
(Title Page, personnel update 11/19/2018)                                             Version: 
15 
COH Amendment 16 
(Title Page, personnel update 01/22/2019)                                             Version: 
16 
COH Amendment 17 
(Title Page, personnel update 02/01/2019)                                             Version: 
17 
COH Amendment 18 
(COH Protocol dated 03/28/2019)                                                           Version: 
18 
COH Amendment 19 
(Title Page, personnel update 08/08/2019) 
              Version: 19 
COH Amendment 20 
Protocol Dated 03/28/2019 (TP) 
              Packet:  20 
 
SITE:  
Breast Cancer 
 
 
 
 
STAGE (If applicable): 
 
 
 
N/A 
 
 
 
MODALITY:  
 
 
 
 
IV 
 
 
 
 
TYPE:  
 
 
 
 
 
Pilot 
 
PRINCIPAL INVESTIGATOR: 
 
 
Joanne Mortimer, M.D. 
 
 
 
COLLABORATING INVESTIGATORS: 
 
James Bading, Ph.D., Shiuan Chen, Ph.D., Russell 
Rockne, Ph.D., David Colcher, Ph.D., Erasmus (Kofi) 

 
IRB 16079 
 
03/28/2019 
Packet: 20 
Poku, PharmD., Van (Eric) Biglang-Awa, PharmD., Laura 
Kruper, MD, Ryan Woodall, Ph.D. 
 
 
 
PARTICIPATING CLINICIANS: 
 
 
James Waisman, M.D., Yuan Yuan, M.D., Ph.D., Niki Patel, 
M.D. (formerly Tank), Mina Sedrak, M.D., Daphne Stewart, 
M.D., Mari Bozoghlanian, M.D., Sayeh M. Lavasani, M.D. 
 
 
 
 
RADIOLOGISTS: 
 
 
 
 
Dave Yamauchi, M.D., Ammar Chaudhry, M.D., Lalit H. Vora, 
M.D., Maria Parayno, M.D., Lusine Tumyan, M.D. 
 
BIOSTATISTICIAN:  
 
 
 
Paul Frankel, Ph.D. 
 
 
NON-PHYSICIAN CONSENTERS:  
 
Mary Carroll, NP; Louise Wong, NP; Lori Rezebek-Kells, NP; 
Rowena Meyer, NP; Edyssa Uy, NP 

1 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
 
Use of 64cu-DOTA-trastuzumab PET imaging and molecular markers for prediction of response 
to Trastuzumab and Pertuzumab-based neoadjuvant therapy 
 
Principal Investigator: 
 
Joanne Mortimer, MD 
 
Vice Chair, Medical Oncology and Therapeutics 
 
City of Hope  
 
1500 East Duarte Road 
 
Duarte, CA 91010 
 
 
(626) 256-4673 ext 81218 
 
(626) 471-5362 (FAX) 
 
 
jmortimer@coh.org 
 
Collaborating Investigators: 
James Bading, PhD 
 
Research Professor  
Cancer Immunology and Tumor Immunotherapeutics 
 
David Colcher, PhD 
 
Professor  
Cancer Immunology and Tumor Immunotherapeutics 
 
 
 
 
 
 
Shiuan Chen, PhD 
 
 
 
 
 
Professor 
 
 
 
 
 
Cancer Biology 
 
 
 
 
 
 
 
Russell Rockne, PhD 
Assistant Professor 
Mathematical Oncology 
 
Erasmus (Kofi) Poku, PharmD.  
Van (Eric) Biglang-Awa, PharmD. 
 
Radiologists:  
 
 
Dave Yamauchi, MD 
Department of Radiology 
 
Maria Parayno, M.D. 
Department of Radiology 
 
Lusine Tumyan, M.D. 
Department of Radiology 

2 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
Ammar Chaudhry, M.D. 
Department of Radiology 
 
Lalit H. Vora, M.D. 
Department of Radiology 
 
Biostatistician(s):  
 
 
Paul Frankel, PhD 
Section Head, Solid Tumors 
Division of Information Sciences 
 
Participating Investigators:  
Daneng Li, MD 
 
Assistant Professor 
 
Medical Oncology and Therapeutics  
 
 
Jana Portnow, MD  
 
Professor 
 
Medical Oncology and Therapeutics 
 
 
James Waisman, MD 
 
Professor 
 
Medical Oncology and Therapeutics 
 
 
Yuan Yuan, MD, PhD 
 
Assistant Professor 
 
Medical Oncology and Therapeutics 
 
 
Niki Patel, M.D.  
 
Associate Clinical Professor 
 
Medical Oncology and Therapeutics 
 
 
 
 
Mina Sedrak, M.D. 
 
Assistant Professor 
 
Medical Oncology and Therapeutics 
 
Nurse Practitioner:  
Louise Wong, NP 
 
Research Nurse/Study Coordinator: TBN 
 
Study Location: 
City of Hope National Medical Center 
 
1500 East Duarte Rd, 
 
Duarte, CA 91010 
 

3 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
Study Laboratories: 
Arnold and Mabel Beckman Center for  
 
Cancer Immunotherapeutics & Tumor Immunology, 
 
Room 5312 
 
 
Federal-Wide Assurance Number: FWA 00000692 
 
IND Number: 
109971 

4 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
Table of Contents 
Section  
Pages 
______________________________________________________________________ 
1.0 Background 
5-6 
2.0 Study Objectives 
7 
3.0 Research Design 
7 
4.0  Inclusion Criteria 
7-8 
5.0  Exclusion Criteria 
8 
6.0 Recruitment Process 
8 
7.0 Informed Consent Process 
8 
8.0 Study Procedures/Research Interventions 
8-9 
9.0 Study Calendar 
9-11 
10.0 Protocol Drug and Radiolabeled Imaging Agent 
11-15 
11.0 Positron Emission Tomography (PET) 
15 
12.0 Image Analysis 
15-16 
13.0 Response Assessment 
16 
14.0 Laboratory Evaluations 
16 
15.0 Statistical Analysis 
17 
16.0 Toxicity Assessment 
17 
17.0 Data Management 
17-18 
18.0 Data Safety Monitoring/Protocol Deviations 
18-21 
19.0 References  
22-23 

5 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
1.0 
Background 
HER2-Positive Breast Cancer 
The term “breast cancer” encompasses a number of different diseases that are clinically defined 
by hormone receptor status and HER2 expression. HER2 is a transmembrane protein in the 
epidermal growth factor family. HER2 has tyrosine kinase activity that results in intracellular signaling 
and activation of genes for cell growth and survival. Women whose cancers overexpress the HER2 
protein have a distinct natural history and are candidates for treatment with trastuzumab. 
Trastuzumab is a humanized IgG-1 antibody that binds to the ectodomain of HER2. When combined 
with chemotherapy, trastuzumab significantly improves the survival of women with both early stage 
and advanced disease. [1-3]  
The pathologic assessment of HER2 status is made on the primary tumor or metastatic foci. HER2 
overexpression and candidacy for trastuzumab have been defined as 3+ staining by 
immunohistochemistry (IHC) or gene amplification by fluorescence in situ hybridization (FISH). [4, 5] 
The American Society of Clinical Oncology and American College of Pathology have recently updated 
the guidelines for measurement of HER2. The new definition requires that the area of tumor contain at 
least 10% contiguous and homogeneous tumor cells which are identified as having protein over 
expression by IHC (3+) or gene amplification in a sample of 20 cancer cells.[6] 
Trastuzumab in combination with chemotherapy improves the overall survival for women with 
early stage and metastatic HER2-positive breast cancers. However, the activity of trastuzumab as a 
single agent in metastatic disease is modest. Objective tumor responses are reported in 35% of 
women treated with trastuzumab as first-line therapy and 18% in those who have been previously 
treated.[7, 8] Thus, trastuzumab therapy does not benefit all patients with HER2-positive breast 
cancers. Given the cost and potential toxicity of trastuzumab, a clinical assessment of HER2 is 
needed that predicts benefit from trastuzumab.  
A central pathology review of HER2 tumor status from NSABP B31, a controlled trial of adjuvant 
trastuzumab, identified 103 women whose tumors were HER2 negative. Women with HER2-negative 
disease who received adjuvant trastuzumab experienced fewer breast cancer recurrences than 
HER2-negative women who did not receive adjuvant trastuzumab.[5, 9] The CLEOPATRA trial tested 
the addition of pertuzumab to docetaxel and trastuzumab in women with metastatic HER2-positive 
breast cancers. A central pathology review identified HER2-negative patients who benefited from the 
addition of pertuzumab (personal communication, Genentech). These observations suggest that the 
use of trastuzumab-based therapy should be broadened to include at least some nominally HER2-
negative women and confirm the discordance in results from different institutions. Counterbalancing 
the potential benefit, however, is the fact that treatment with trastuzumab is expensive and may cause 
cardiac toxicity. 
 
Treatment of HER2 positive breast cancer. 
Since the approval of trastuzumab in 1998, three additional HER2-directed therapies have been 
added to the armamentarium - lapatinib, ado-trastuzumab emtansine, and pertuzumab.[10, 11] The 
benefit of adding pertuzumab to neoadjuvant trastuzumab + chemotherapy was tested in the 
NEOSPHERE and TRYPAENA trials.[12, 13] At the time of surgery, higher pathologic complete 
response rates were reported with the addition of pertuzumab. As a result, the FDA expanded the 
indications for pertuzumab to include both the metastatic and neoadjuvant settings. Chemotherapy 
combined with trastuzumab and pertuzumab is considered standard of care for neoadjuvant therapy 
of HER2 positive breast cancer.  
The most common use of neoadjuvant chemotherapy is to decrease the size and increase the use 
of breast conserving therapy.[14]  Response to neoadjuvant chemotherapy also provides prognostic 
information.  Those women who obtain complete disappearance in the primary tumor and the axillary 
nodes have a more favorable outcome than those who have residual disease in the primary and or 
nodes. [12, 15]   With trastuzumab + chemotherapy regimens, pathologic complete remissions are 

6 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
observed in approximately 50% of women with locally advanced HER2 positive disease.   The 
addition of pertuzumab to trastuzumab + chemotherapy has increased the pathologic response rate to 
60%.[13]   
 
Molecular Imaging in HER2 Positive Breast Cancer 
Positron Emission Tomography (PET) provides a non-invasive way of studying tumor location, 
metabolic function, and response to therapy. In breast cancer, PET imaging with 
18F-
flourodeoxyglucose (FDG) has been used to stage women with advanced disease and to assess 
response to chemotherapy and endocrine therapy even before tumor regression can be documented 
by clinical examination or anatomical imaging.[16-18] The ability to identify patients who may benefit 
from systemic therapy is critically important to their quality of life; toxicities from ineffective therapies 
are prevented and medical costs are contained.  
In a previous study, we developed a novel functional imaging approach using 64Cu-DOTA-
trastuzumab and PET to characterize the biodistribution and tumor uptake of trastuzumab 24-48 
hours after systemic intravenous administration. We showed that, with pre-infusion of non-labeled 
trastuzumab (45 mg) to suppress liver uptake, this approach produces high-quality images and 
detects tumors with exquisite sensitivity in patients with HER2-positive metastatic breast cancer. [19] 
More recently, we extended the study to include patients with advanced HER2-negative disease. We 
found that tumor uptake as measured with 64Cu-DOTA-trastuzumab/PET-CT is generally higher in 
patients classified as HER2-positive vs. HER2-negative, but with a good deal of inter- and intra-
patient variability [20]. The observations were consistent between tumors that were biopsied and 
histopathologically assessed for HER2 expression and those that were not. This suggests that, while 
64Cu-DOTA-trastuzumab uptake is positively correlated with tumor HER2 expression, other factors 
such as blood-tissue transport also have significant effect on tumor uptake of intravenously 
administered trastuzumab and therefore on response to trastuzumab-based therapy. 
 
Use of radiolabeled trastuzumab PET imaging to predict response to ado-trastuzumab emtansine 
We and others have utilized radiolabeled trastuzumab to predict for response to the 
immunoconjugate ado-trastuzumab emtansine (TDM1).[21] In the four patients studied to date, we 
have observed significant heterogeneity of uptake on radiolabeled-trastuzumab PET imaging.   
Although the tumors were documented to be HER2 positive by pathologic assessment before therapy, 
the  two patients who demonstrated  low uptake on radiolabeled-trastuzumab PET imaging failed to 
benefit from TDM1.   
We propose to utilize 64Cu-DOTA-trastuzumab-PET to image women with newly diagnosed locally 
advanced HER2 positive breast cancer to predict for response to trastuzumab + pertuzumab + 
chemotherapy. We anticipate that the pretreatment 64Cu-DOTA-trastuzumab/PET-CT will identify a 
large amount of heterogeneity in tumor uptake of trastuzumab. To the degree that low uptake of 
trastuzumab reflects difficulty in tumor penetration by large molecules, the observations may also 
predict low uptake of pertuzumab. All patients will undergo 18F-FDG/PET-CT shortly before the  64Cu-
DOTA-trastuzumab procedure. Same-tumor comparison between 64Cu-DOTA-trastuzumab (molecular 
weight 1.5 x 105) and 18F-FDG (molecular weight 1.8 x 102) will elucidate the role of molecular size in 
determining tumor uptake of trastuzumab and pertuzumab.   
We will also submit pretreatment biopsies of combining tumor for  RPPA, RNAseq, SERPINA, and 
to develop PDX models.   We anticipate that combining  64Cu-DOTA-trastuzumab-PET with this 
additional biomarker assessment will further enable us to predict for benefit or lack of benefit from 
anti-HER2 therapies.  This information will be used to develop strategies to improve treatment of 
HER2 positive breast cancer. 
 

7 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
2.0 
Study Objectives 
While our ultimate goal is to utilize 64Cu-DOTA-trastuzumab/PET-CT to aid “individualized” 
selection of HER2-directed therapies in general, the proposed pilot study will address imaging issues 
for neoadjuvant patients as its primary objective.  Secondary objectives include combining with 
molecular markers to predict for complete response in locally advanced cancers.  In addition to 
inadequate tumor uptake, another potential cause of non-response is biological or “molecular” 
mechanisms of resistance. Consistent with our prior study protocol, all patients will undergo a 
pretreatment biopsy to ensure positive HER2 status. Tumor will also be submitted for assessment of 
molecular markers.  The goal of this pilot study is to correlate 64Cu-DOTA-trastuzumab/PET-CT tumor 
uptake measurements with molecular markers to predict for response both at the patient and 
individual tumor levels.  
The Specific Study Objectives are: 
2.1 
Primary Aim 
2.1.1  
To evaluate the SUVmax in patients with previously untreated HER2+ breast cancer.  
Evaluating the tumor size sensitivity, and the ability to detect lymph node involvement 
will be assessed, along with comparing the SUVmax detected in previously untreated 
HER2+ breast cancer to the SUVmax detected in recurrent breast disease in our 
previous series on HER2+ patients with metastatic disease.   
 
2.2 
Secondary Airms  
2.2.1 To evaluate if the uptake of  64Cu-DOTA-trastuzumab , a proposed indicator of 
responsiveness to HER2-directed therapy, correlates with SERPINA1 expression, 
which has been shown to be associated with ER+/HER2+ patient survival, both in the 
HER2+/ER+ patients and in all the patients. 
2.2.2 To compare uptake of  64Cu-DOTA-trastuzumab in the patients with complete pathologic 
response (PCR) vs non-PCR patients. 
 
3.0 
Research Design 
This prospective clinical pilot trial will enroll 20 women with locally advanced HER2 positive breast 
cancers who are considered candidates for neoadjuvant chemotherapy. Patients will undergo 18F-
FDG/PET-CT and 64Cu-DOTA-trastuzumab/PET-CT prior to initiation of therapy with trastuzumab + 
pertuzumab + chemotherapy. The objective is to examine, both at the patient and individual tumor 
levels, the relationship among tumor uptake of 18F-FDG, 64Cu-DOTA-trastuzumab, molecular markers, 
and response to neoadjuvant therapy. 
 
4.0 
Inclusion Criteria 
Women with locally advanced HER2-positive breast cancers will be considered eligible for study 
participation if they meet the following criteria: 
4.1. 
Participants must be women, 18 years or older, who have histological confirmation of 
HER2 positive breast cancer 
4.2 
The primary tumor must be > 2.0 cm in size and/or have biopsy proven axillary nodes 
that are > 2.0 cm in size by mammography, ultrasound, or MRI 
4.3 
The current cancer must over express HER2 as determined by IHC and/or FISH. 
4.4 
Patients may not have received prior HER2 directed therapies 
4.5 
Participants must have normal cardiac ejection fraction (per label, as defined as 
institutional normal) 

8 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
4.6 
Planned neoadjuvant therapy with six cycles of combined pertuzumab, trastuzumab 
and chemotherapy  
4.7 
Ability to provide informed consent 
4.8 
Negative Serum Pregnancy test 
 
5.0 
Exclusion Criteria 
5.1 
Participants who are not considered candidates for pertuzumab + trastuzumab + 
chemotherapy. 
5.2 
Concurrent malignancy other than non-melanoma skin cancer. 
5.3 
Patients must not have known metastatic disease 
5.4 
Patients must not have received prior treatment for the current breast cancer 
5.5 
 
 
6.0 
Recruitment Process 
6.1 
Participants will be recruited by the treating Medical Oncologists from patients 
receiving breast cancer treatment at City of Hope and its community practice sites. All 
imaging will occur on the main Duarte campus. 
 
7.0 
Informed Consent Process 
7.1 
The Principal Investigator or IRB-approved named designate will explain to prospective 
enrollees the nature, duration, purpose of the study, potential risks, alternatives and 
potential benefits, and all other information contained in the informed consent 
document as well as their rights as a research subject (Experimental Subjects Bill of 
Rights) and the HIPAA research authorization form. Research participants will be 
informed that they may withdraw from the study at any time and for any reason without 
jeopardizing  their future care, their employment at City of Hope or any relationship 
they have with City of Hope.. Should sufficient doubt be raised regarding the adequacy 
of comprehension, further clarifications will be made and the consent comprehension 
assessment may be repeated until a satisfactory result is obtained. Prospective 
research subjects who cannot adequately comprehend the fundamental aspects of the 
research study with a reasonable amount of discussion, education and proctoring will 
be ineligible for enrollment. Following this procedure, the protocol management team 
will review the results of eligibility testing and determine if the research subject is a 
candidate for study enrollment.  
 
8.0 
Study Procedures/Research Interventions 
8.1 
Use of PET imaging to predict response to neoadjuvant therapy 
8.1.1 Twenty women with locally advanced breast cancer that is HER2 positive by 
IHC and/or FISH will be recruited from the Medical Oncology and Surgical 
Clinics at City of Hope and its community network. 
8.1.2 As patients will ultimately receive pertuzumab and trastuzumab-based therapy, 
a baseline cardiac ejection fraction, by MUGA or ECHO cardiogram, will be 
performed. 
8.1.3 All participants will undergo a history and physical exam and radiographic 
staging workup with whole body 18F-FDG/PET-CT.  
8.1.4 All subjects will receive an IV dose of trastuzumab (45 mg) immediately before 
infusion of 64Cu-DOTA-trastuzumab (≤15 mCi; protein dose 5 mg).  

9 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
8.1.5 A PET scan of regions of interest will be performed 24 -  after injection of 64Cu-
DOTA-trastuzumab. Systemic therapy may be initiated after completion of the 
64Cu-DOTA-trastuzumab PET-CT imaging. The regimen must include both 
pertuzumab and trastuzumab at approved doses.  The chemotherapy utilized is 
up to the treating physician’s discretion. 
8.1.6 Participants will be observed for toxicity for one year. 
8.1.7 Subjects will undergo surgery after 6 cycles of treatment. 
 
8.2 
Collecting and Processing of specimens: All specimens will be collected and 
processed  in accordance with  the study teams SOPs. 
 
9.0 
Study Calendar 
 
Baseline 
(-28 
days) 
Day  
-2 
Day 
-1 
Day  
1 
(+3 
days) 
Day 30 (post 
cold 
trastuzumab/ 
Cu-DOTA 
injection) 
Day 1 of 
C2-C6  
(+/- 3 
days) 
 Prior to 
C5D1 (-
14 days) 
 
After 
C6  
(+21-
48 
days) 
Follow up  
for one 
year post 
Day   -2 m 
History and 
Physical a 
x 
 
 
x 
 
x 
 
 
 
Staging  
18F-FDG/PET-
CT 
x 
 
 
 
 
 
 
 
 
Archival Tissue b 
x 
 
 
 
 
 
 
 
 
Tumor 
Submission 
Biopsy  c 
 
 
 
x 
 
 
 
 
 
MUGA or 
Echocardiogramd 
x 
 
 
 
 
 
x 
 
 
Serum 
Pregnancy test e 
x 
 
 
 
 
x 
 
 
 
CBC 
x 
 
 
x 
 
x 
 
 
 
CMP  
x 
 
 
x 
 
x 
 
 
 
ctDNAf 
x 
 
 
 
 
x 
 
x 
 
Coagulation 
Panel g ? 
 
 
 
x 
 
 
 
 
 
IV (cold) 
Trastuzumab 
administration 
 
x 
 
 
 
 
 
 
 
64Cu-DOTA-
Trastuzumab 
administration 
 
x 
 
 
 
 
 
 
 
64Cu-DOTA-
Trastuzumab 
PET h 
 
 
x 
 
 
 
 
 
 

10 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
MRI i 
X 
 
 
 
 
 
X  
 
 
Pertuzumab and 
trastuzumab 
containing  
regimen j 
 
 
 
X 
(+3 
days) 
 
x 
 
 
 
Surgery 
 
 
 
 
 
 
 
x 
 
Response 
Assessment 
 
 
 
 
 
 
 
x 
 
Residual tumor 
submission (if 
any) k 
 
 
 
 
 
 
 
x 
 
Toxicity 
Assessment l 
 
x 
x 
x 
X 
 
 
 
 
 
 
a.  H&P may be completed by MD or NP listed on the protocol. 
b.  Archival tissue is required during baseline. Archival sample must be from untreated tissue and 
patients must not have received any chemotherapy after the tissue was collected. 
c.   Two tumor submission biopsies will be collected after the CuDOTA scan D1 (one sample 
from a “hot” area – meaning an area (in the breast or regional lymph node) that illuminates 
with CuDOTA on the scan; and one sample from a “cold” area – meaning an area (in the 
breast or regional lymph node) that does not illuminate with CuDOTA on the scan).   
d. MUGA or cardioECHO will be done at baseline, prior to C5, and then q 3 months. 
e.  Serum pregnancy test will be collected during screening for all women of childbearing 
potential (see sect.14.3). At the discretion of the treating physician, pregnancy test will be 
repeated prior to each tx for women of childbearing potential. 
f.  10 cc of ctDNA (liquid bx) will be collected immediately post-op in OR and prior to every cycle. 
ctDNA will be collected and processed per  SOP of the study team. 
g. PT w/ INR and PTT will be collected within 1 day (24 hours) days prior to bx. 
h. 
64 Cu-DOTA-Trastuzumab PET will be obtained 18-32 hrs post 64 Cu-DOTA-Trastuzumab 
administration (confirm w/ J. Bading, PhD). 
i. 
MRI (of breast) will be performed at baseline (up to - 42 days) and prior to C5D1 (-14 days) 
j. 
Pertuzumab and trastuzumab containing regimen will begin within 4 days after the completion 
of Day 1 64 Cu-DOTA-Trastuzumab PET. The regimen will consist of Pertuzumab, 
trastuzumab, and a chemotherapy. Regimen will be given in accordance with sect. 10.3 of the 
protocol. 
k. If residual cancer is found at the time of definitive surgery, any remaining tumor tissue will be 
handled in accordance to sect. 14.2 of the protocol.  
l. 
Toxicities, AE’s/SAE’s, and conmeds will be assessed  for 30 days post cold trastuzumab/Cu-
DOTA injection. 
m. After the completion of C6, follow-up visits/assessments will be performed according to COH 
SOC surgical and medical oncology schedules for one year from post Day-2. 
 PT w/ INR and PTT will be collected within 1 days (24 hours) prior to bx. 
 
 

11 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
10.0 
Protocol Drugs and Radiolabeled Imaging Agent 
10.1 
Trastuzumab (for “cold” trastuzumab infusions) 
10.1.1 Drug description: Trastuzumab is a recombinant humanized monoclonal 
antibody that binds to the extracellular domain of the HER2. Trastuzumab is a 
sterile, white to pale yellow, preservative-free lyophilized powder for IV 
administration. The nominal content of each trastuzumab vial is 440mg 
trastuzumab, 440mg D,D-trehalose dehydrate, 9,9mg L-histidine HCl, 6.4mg L-
histidine, and 1.8mg polysorbate 20, USP. Reconstitution with 20mL of the 
supplied Bacteriostatic Water for Injection (BWFI), USP, containing 1.1% benzyl 
alcohol as a preservative, yields a multi-dose solution containing 21mg/mL 
trastuzumab, at a pH of approximately 6. 
10.1.2 Procurement of trastuzumab: Trastuzumab will be supplied free of charge as 
part of the study. 
10.1.3 Storage/stability: Vials of trastuzumab are stable at 2-8qC (36-46q F) prior to 
reconstitution. Do not use beyond the expiration date stamped on the vial. A 
vial of trastuzumab reconstituted with BWFI, as supplied, is stable for 28 days 
after reconstitution when stored refrigerated at 2q-8qC (36q-46q F), and the 
solution is preserved for multiple uses. Discard any remaining multi-dose 
reconstituted solution after 28 days. If unpreserved Sterile Water for Injection 
(SWFI) (not supplied) is used, the reconstituted trastuzumab solution should be 
used immediately and any unused portion must be discarded. Do not freeze 
trastuzumab that has been reconstituted. The solution of trastuzumab for 
infusion diluted in polyvinylchloride or polyethylene bags containing 0.9% 
Sodium Chloride Injection, USP, may be stored at 2-8qC (36-46q F) for up to 24 
hours. 
 
10.1.4 Reconstitutions and administration 
10.1.4.1. 
Reconstitution 
10.4.1.1.1 
The diluent provided has been formulated to maintain the 
stability and sterility of trastuzumab for up to 28 days. 
Other diluents have not been shown to contain effective 
preservatives for trastuzumab. Each vial of trastuzumab 
should be reconstituted with 20mL of BWFI, USP, 1.1% 
benzyl alcohol preserved as supplied, to yield a multi-
dose solution containing 21mg/mL trastuzumab.  
10.1.4.1.2 
Immediately upon reconstitution with BWFI, the vial of 
trastuzumab must be labeled in the area marked “Do not 
use after:” with the future date that is 28 days from the 
date of reconstitution. 
Note: When administering trastuzumab to a patient with a 
known hypersensitivity to benzyl alcohol, trastuzumab 
must be reconstituted with SWFI, and only one dose per 
trastuzumab vial should be used. Trastuzumab which has 
been reconstituted with SWFI must be used immediately 
and any unused portion must be discarded. Use of other 
reconstitution diluents should be avoided. 
Shaking the reconstituted trastuzumab or causing 
excessive foaming during the addition of diluent may 
result in problems with dissolution and the amount of 

12 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
trastuzumab that can be withdrawn from the vial. Use 
appropriate aseptic technique when performing the 
following reconstitution steps: 
x 
Using a sterile syringe, slowly inject the 20mL of 
diluent into the vial containing the lyophilized cake 
of trastuzumab. The stream of diluent should be 
directed into the lyophilized cake. 
x 
Swirl 
the 
vial 
gently 
to 
aid 
reconstitution. 
Trastuzumab may be sensitive to shear-induced 
stress, e.g., agitation or rapid expulsion from a 
syringe. Do not shake. 
x 
Slight foaming of the product upon reconstitution is 
not unusual. Allow the vial to stand undisturbed for 
approximately 5 minutes. The solution should be 
essentially free of visible particulates, clear to 
slightly opalescent and colorless to pale yellow. 
10.1.4.1.3 
”Cold dose” of trastuzumab: The “cold” dose is prepared 
using 50ml NS. The recommended 45 mg cold infusion 
dose of trastuzumab is administered intravenously over 
15 minutes. The cold trastuzumab will be injected prior to 
the injection of 64Cu-DOTA-trastuzumab. 
10.1.5 Drug accountability: Trastuzumab will be purchased by the City of Hope 
Pharmacy, which will store and control the drug. It will be prepared for 
administration in the outpatient pharmacy.  
10.1.6 Discard of unused agent: Unused trastuzumab will be discarded in the 
chemotherapy discard containers within the outpatient pharmacy. 
10.1.7 Warnings and Contraindications 
10.1.7.1 
Cardiotoxicity: Administration of trastuzumab can result in the 
development of ventricular dysfunction and congestive heart 
failure. Signs and symptoms of cardiac dysfunction, such as 
dyspnea, increased cough, paroxysmal nocturnal dyspnea, 
peripheral edema, S3 gallop, or reduced ejection fraction have 
been observed in patients treated with trastuzumab. Congestive 
heart failure associated with trastuzumab therapy may be severe 
and has been associated with disabling cardiac failure, death, 
and mural thrombosis leading to stroke. 
10.1.7.1 
Hypersensitivity 
reactions 
including 
anaphylaxis; 
severe 
hypersensitivity reactions have been infrequently reported in 
patients treated with trastuzumab. Signs and symptoms include 
anaphylaxis, urticaria, bronchospasm, angioedema, and/or 
hypotension. In some cases, the reactions have been fatal. 
Trastuzumab infusion should be interrupted in all patients with 
severe 
hypersensitivity 
reactions. 
In 
the 
event 
of 
a 
hypersensitivity reaction, appropriate medical therapy should be 
administered, which may include epinephrine, corticosteroids, 
diphenhydramine, bronchodilators, and oxygen. Patients should 
be evaluated and carefully monitored until complete resolution of 
signs and symptoms. 
10.1.7.3 
Infusion 
reactions: 
In 
the 
post-marketing 
setting, 
rare 
occurrences of severe infusion reactions leading to fatal outcome 

13 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
have been associated with the use of trastuzumab. In clinical 
trials, infusion reactions consisted of a symptom complex 
characterized by fever and chills, and on occasion included 
nausea, 
vomiting, 
pain, 
headache, 
dizziness, 
dyspnea, 
hypotension, rash, and asthenia. These reactions were usually 
mild to moderate in severity. However, in post-marketing reports, 
more severe adverse reactions to trastuzumab infusion were 
observed and included bronchospasm, hypoxia, and severe 
hypotension.  These severe reactions were usually associated 
with the initial infusion of trastuzumab and generally occurred 
during or immediately following the infusion. However, the onset 
and clinical course were variable. Delayed post-infusion events 
with rapid clinical deterioration have also been reported.  Rarely, 
severe infusion reactions culminated in death within hours or up 
to one week following an infusion. 
10.7.1.4 
Pulmonary events: Severe pulmonary events leading to death 
have been reported rarely with the use of trastuzumab in the 
post-marketing setting. Signs, symptoms, and clinical findings 
include dyspnea, pulmonary infiltrates, pleural effusions, non-
cardiogenic pulmonary edema, pulmonary insufficiency and 
hypoxia, and acute respiratory distress syndrome. These events 
may or may not occur as a sequelae of infusion reactions. 
Patients with symptomatic intrinsic lung disease resulting in 
dyspnea at rest may be at greater risk of severe reactions.  
10.1.7.5 
Other severe events reported rarely in the post-marketing setting 
include pneumonitis and pulmonary fibrosis. 
 
10.2 
Preparation of 64Cu-DOTA-trastuzumab  
10.2.1 All procedures are performed as specified in FDA-approved IND #109971. 
Trastuzumab is purchased from the City of Hope pharmacy and conjugated 
with active ester of DOTA (1,4,7,10-tetraazadodecane-1,4,7,10-tetracetic acid) 
in the City of Hope biologics production facility (CBG) under cGMP compliant 
conditions. Each lot of trastuzumab-DOTA underwent testing for sterility, 
potency, purity and lack of pyrogenicity. Vialing of the conjugated materials will 
be done in City of Hope biologics production facility Fill and Finish area. 
Radiolabeling with 64Cu will be carried out in the City of Hope Radiopharmacy 
under the direction of David Colcher, PhD. The 64Cu will be purchased from the 
Mallinckrodt Institute of Radiology at the Washington University School of 
Medicine, which is preparing the radiolabel for clinical use. Labeling will be 
accomplished by incubating conjugated antibody with the 64Cu for 45 minutes at 
43qC, followed by a chase with DTPA and subsequent purification on a size 
exclusion preparative grade Superdex-200 column. Appropriate fractions will be 
pooled and filtered to make up the patient dose, which will be formulated with 
human serum albumin. Patients will be injected via a peripheral vein with ≤ 
15mCi of 64Cu-DOTA-trastuzumab. The total trastuzumab content per 64Cu-
DOTA-trastuzumab injected dose is less than 5 mg.  
 
We have estimated radiation dose from 64Cu-DOTA-trastuzumab based on our 
previous 
work 
with 
64Cu-DOTA-trastuzumab 
and 
111In-MxDTPA-
trastuzumab.[19, 22] The study protocol also requires 18F-fluorodeoxyglucose 

14 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
(FDG)/PET-CT scans prior to 64Cu-DOTA-trastuzumab/PET-CT. The following 
table compares that procedure with 18F-FDG/PET-CT. 
 
 
 
 
Organ/Tissue 
Estimated Equivalent or Effective Dose (mSv)* 
   64Cu-Trastuzumab              CT**        64Cu-Trastuzumab      18F-FDG/PET-CT              
          (15 mCi)                                                 PET-CT                      (15 mCi) 
Heart wall 
88 
6 
94 
9 
Spleen 
55 
6 
61 
9 
Liver 
65 
6 
71 
9 
Bladder wall 
10 
6 
16 
93 
Kidneys 
52 
6 
58 
9 
Red marrow 
21 
6 
27 
9 
Other 
12 
6 
18 
9 
Effective dose 
15 
6 
21 
14 
* Values for 18F-FDG and CT were obtained from Brix, 2005.[23] 
**Low-dose CT procedure; 2 scans. 
 
10.3 
Trastuzumab + Pertuzumab + chemotherapy   
Treatment will be administered in the outpatient setting.  A number of treatment 
regimens have been approved for use in the neoadjuvant setting, all of which contain 
trastuzumab and pertuzumab.  The chemotherapy regimen is at the discretion of the 
treating oncologist. The treatment regimen must include both trastuzumab and 
pertuzumab. Therapeutic doses will be prepared per package insert and toxicities will 
be managed per standard of care and/or physician discretion.  
10.3.1 Trastuzumab may be administered weekly or every three weeks.  The schedule 
is not dictated.   (See additional warning 10.1.7) 
10.3.1.1   For the three week schedule, the loading dose is 8 mg/kg/90 minutes 
followed at three week intervals by a maintenance dose of 6 mg/kg 
over 30 minutes.   
10.3.1.2  With the weekly schedule, a loading dose of 4 mg/kg/90 minutes is 
administered followed by a weekly dose of 2 mg/kg/30 minutes. 
10.3.2 Pertuzumab  
 
A loading dose of pertuzumab 840 mg IV is administered over 60 minutes with 
the first cycle. Every 21 days thereafter the maintenance dose of pertuzumab is 
420 mg IV. Patients are observed for fever, chills, and infusion related side 
effects for 1 hour following the loading dose and 30 minutes after each 
subsequent dose.  If the patient experiences an infusion reaction, the infusion 
rate is decreased or discontinues until the patient’s symptoms have resolved.  
The infusion is resumed at a rate 50% of the rate at the time of the infusion.    
10.3.2 Chemotherapy 
 
The chemotherapy regimen is not dictated by the protocol as long as the 
patients receive both trastuzumab and pertuzumab in the regimen.  

15 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
11.0 
Positron Emission Tomography (PET) 
11.1  PET images will be acquired in 3D mode (septa retracted) and corrected for tissue 
attenuation based on co-registered CT acquired during the same examination. PET 
images will be reconstructed using an iterative algorithm (OSEM).  
11.2 
18F-Fluorodeoxyglucose (18F-FDG): Standard 18F-FDG PET-CT examinations will be 
performed prior to the 64Cu-DOTA-trastuzumab PET-CT research procedure. Large-
area (eyes to mid-thigh) PET-CT scans will be obtained beginning at 1 hour post-
injection; time per bed position during the PET scan will be 2-3 minutes, depending on 
patient body habitus. 
11.3 
64Cu-DOTA-trastuzumab: Patients will be injected via a peripheral vein with ≤ 15 mCi 
of 64Cu-DOTA-trastuzumab. In order to allow the antibody to accumulate in tumor, 
PET-CT scanning of 64Cu will be delayed until 18-24 hours post injection (Day 1). A 
second scan will be obtained 42-48 hours post injection (Day 2). Because of the limited 
amount of activity to be injected and the fact that only 18% of 64Cu decays produce a 
positron, the count rates will be low. To compensate, time per bed position will be 
relatively long and the axial field of view relatively short. (Day 1: 1 or 2 bed positions 
encompassing known tumors; 30 minutes per bed position if 2 bed positions.  Day 2: 1 
or 2 bed positions, 60 or 30 minutes per bed position). Based on our prior clinical 
study, we know the scanning protocol defined above will yield adequate tumor 
visualization and signal-to-noise ratio in measurements of tumor uptake. For tumors at 
least 2 cm in diameter and average SUV (= tumor activity concentration/injected 
activity per unit body weight) of at least 3 in body regions for which tumor: background 
contrast is at least 4, the precision (coefficient of variation) of tumor SUV and tumor: 
background contrast measurements are expected to be about 10% and 15%, 
respectively.  
 
12.0 
Image Analysis 
  
Tumor uptake of 18F-FDG will be measured by Dr. Bading in terms of standardized uptake 
value (SUV = tumor activity concentration x patient body weight/injected activity decay-
corrected to time of scan). Measurements will include maximum single-voxel SUV (SUVmax) 
within the tumor PET image. We will also evaluate tumor average SUV (SUVmean) for  18F-FDG 
within a 3D isocontour encompassing voxels with SUV t 50% of SUVmax. For each FDG-
positive tumor, a corresponding SUV for 64Cu-DOTA-trastuzumab will be determined by 
applying the FDG volume of interest (VOI) to the CT-coregistered 64Cu image set. We denote 
this metric of 64Cu-DOTA-trastuzumab uptake as SUVmean(FDG-matched).  Tumor sizes 
(product of maximum mutually perpendicular transaxial diameters as well as maximum axial 
diameter) will be estimated from coregistered CT. 
For 64Cu, SUVs will also be evaluated in selected non-tumor organs and tissues [heart, 
blood (cardiac ventricles), liver, skeletal muscle]. PET quantification for 64Cu will be validated 
by comparing image-derived measurements of blood activity concentrations from the Day 1 
and Day 2 scans with direct assays performed on whole blood samples taken just prior to each 
of those scans. 
13.0 
Response Assessment 
The response assessment is performed at the time of definitive surgery.  Patients disease will 
be staged in the conventional manner according to the AJCC.   The primary endpoint is 
complete pathologic response defined as no evidence of residual invasive cancer in either the 
breast or regional lymph nodes. 
 

16 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
14.0 
Laboratory Evaluations  
14.1 
Biomarker assessment: A biopsy will be performed to confirm the diagnosis of breast 
cancer and assessment of hormone receptors and HER2 status.   If a biopsy has been 
performed at another institution, tumor block will be obtained for the pretreatment 
analyses.  The pretreatment tumor analyses include: 
14.1.1 RPPA  (Performed at MD Anderson) 
14.1.2 RNAseq  (Cancer Center Core) 
14.1.3 SERPINA (Dr. Shiuan Chen’s Lab) 
14.2 
Residual Disease  If there is residual cancer at the time of definitive surgery, tumor 
will be submitted for the following.   In the event of a complete pathologic response, 
there will be no reassessment of tumor markers. 
14.2.1 RPPA   
14.2.2 RNAseq 
14.2.3 SERPINA 
14.3 
Pregnancy Tests: WOCBP must have a negative serum or urine pregnancy test result 
within 0 to 72 hours prior to each dose of study drug. 
14.3.1 WOCBP comprises women who have experienced menarche and who have 
not undergone successful surgical sterilization (hysterectomy, bilateral tubal 
ligation, or bilateral oophorectomy) or who are not post-menopausal (for 
purposes of this study, post-menopausal will be defined as women who have 
not had a menstrual period for a minimum of 12 consecutive months). 
14.3.2 WOCBP must agree to use an acceptable method of contraception to avoid 
pregnancy throughout the study and for up to 4 weeks after the last dose of 
study drug in such a manner that the risk of pregnancy is minimized. 
14.4 
 
14.4  CBC: CBC w/ differential to be collected per study calendar (sect. 9) 
14.5 
CMP: to be collected per schedule of assessments (sect. 9) 
 
15.0 
Statistical Analysis  
   
This is a pilot study of 20 patients to explore the tumor uptake of 64Cu-DOTA-
trastuzumab as measured by PET-CT in patients who are candidates for Her2-directed 
neoadjuvant therapy.  In addition, we will obtain preliminary data on the role of the 
uptake and pathologic complete response from trastuzumab, pertuzumab-based 
chemotherapy. With 20 subjects, we can estimate the percent of tumors detected with 
a standard error of 11% or less, and describe the observed impact of tumor size on this 
sensitivity in this small pilot study. The secondary endpoints are exploratory endpoints 
in the context of this small pilot study. 
 
Specifically, we are seeking to:  
15.1 
To evaluate the percentage of patients with a positive 64Cu-DOTA-trastuzumab 
scan. If any tumors are missed, we will describe their size, lymph node 
involvement, and other biological correlatives.  In addition, we will compare the 
SUVmax detected in previously untreated HER2+ breast cancer to the SUVmax 
detected in recurrent breast disease in our previous series on HER2+ patients 
with metastatic disease.   

17 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
15.2  To evaluate if the SUV, a proposed indicator of responsiveness to HER2-
directed therapy, correlates with SERPINA1 expression, which has been shown 
to be associated with ER+/HER2+ patient survival, both in the HER2+/ER+ 
patients and in all the patients. 
15.3 
To compare SUV in the PCR patients vs non-PCR patients. 
 
The information gained from this pilot study will determine whether 64Cu-DOTA-
trastuzumab/PET-CT warrants further evaluation in the treatment of patients with 
locally advanced HER2 positive breast cancers.  We anticipate that we will be able to 
prospectively identify patients who will not obtain a Pcr with pertuzumab and 
trastuzumab-based chemotherapy regimens.   Subsequent studies will focus on ways 
to develop individualized treatments that address the “resistant population” within the 
cancer. 
 
16.0 
Toxicity Assessment 
16.1 
Patients will be monitored for acute reactions during and immediately after infusion of 
the trastuzumab imaging pre-dose and 64Cu-DOTA-trastuzumab. 
16.2 
Participants will begin systemic therapy within 4 days after completion of 64Cu-DOTA-
trastuzumab/PET-CT. Side effects not known to be related to the chemotherapy 
regimen will be recorded.   
n. 16.3  Toxicities, AE’s, and conmeds will be assessed  for 30 days post cold trastuzumab/Cu-
DOTA injection. 
 
 
17.0 
Data Management 
17.1 
Methods used for data collection: All clinical data is captured from the patient’s 
medical record. 
17.2 
Volunteer Identification: Participants identity will be linked to unique patient numbers 
(UPN). 
17.3 
Confidentiality: This research will be conducted in compliance with federal and state 
of California requirements relating to protected health information (PHI). The study will 
record individual imaging results and any side effects, and this will be linked to the 
subject’s identity using a UPN. The Protocol Management Team (PMT) consisting of 
the PI (Joanne Mortimer), statistician (Paul Frankel PhD), and study nurses are eligible 
to review research records, but all information will be treated confidentially. No 
identifiers will be used in any publication of the study results. 
17.4 
Data Reporting 
17.4.1 Confidentiality of Records: The original data collection forms will be stored at 
City of Hope in secure cabinets by Clinical Trials Office. . All records will be 
retained for a minimum of 2 years. 
When results of this study are reported in medical journals or at meetings, 
identification of those taking part will be withheld. Medical records of patients 
will be maintained in strictest confidence, according to current legal 
requirements. However, they will be made available for review, as required by 
the FDA or other authorized users such as the NCI, under the guidelines 
established by the Federal Privacy Act. 
17.4.2 Patient Consent Form: At the time of registration, the original signed and dated 
patient’s Informed Consent with the Experimental Subject’s Bill of Rights (for 

18 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
the medical record) and 2 copies (for the patient, the research record, ) must be 
available. All Institutional, NCI, Federal, and State of California regulations 
concerning the Informed Consent form will be fulfilled. 64Cu-DOTA trastuzumab 
is administered under IND #109971, which is approved by and subject to the 
regulations of the FDA. 
17.4.3 Data Collection Forms and Submission Schedule: All data will be collected 
using City of Hope Biostatistics data collection . (See Appendix D for a 
summary of the forms submission schedule.) . The original data collection 
forms will reside at City of Hope in a secure location.  
17.4.3.1 
The Eligibility Checklist must be completed by a protocol nurse 
or clinical research associate and signed by a participating 
investigator prior to registering the patient. See Appendix 1. 
17.4.3.2 
Within two weeks of registration, the clinical research associate 
will submit Prior Therapy forms (Prior Therapy Summary - 
COH1987 and supplemental forms, as necessary) and On-Study 
forms 
(On-Study 
Hematology/Other 
- 
COH2658 
and 
supplemental forms, as necessary). 
17.4.3.3 
Within one week of imaging, the clinical research associate will 
submit the following forms: 
x 
Protocol Treatment – Drug Agent (COH2698). 
x 
Monitoring & Follow-Up Summary (COH2001). 
x 
Adverse Events Collection Form (COH2000). 
17.4.4 Results Reporting: City of Hope, as sponsor of IND #109971, will submit reports 
annually to the FDA within 60 days of the anniversary date that the IND went 
into effect (December 27, 2010) in accordance with 21 CFR 312.33. 
17.5 
Sharing results with participants: Information from the 64Cu-DOTA trastuzumab 
PET-CT images will be shared with the patient and the treating physician if that 
information may impact the patient’s medical care. 

19 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
18.0 
Data Safety Monitoring Plan 
18.1 
Definition of Risk Level 
This is a Risk Level 4 study as defined in the City of Hope 
Institutional Data and Safety Monitoring Plan [policy dated 
07/09/2014].  This determination was made because the study 
involves COH held IND imaging agent. 
18.2 
Monitoring and Personnel Responsible for Monitoring 
The Protocol Management Team (PMT) is responsible for 
monitoring the data and safety of this study.  The PMT consists of 
the Principal Investigator (PI), Biostatistician, Research Protocol 
Nurse, and Clinical Research Coordinator. 
The PMT is required to submit periodic status reports (i.e., the PMT 
Report) according to the frequency prescribed in the City of Hope 
Institutional Data and Safety Monitoring Plan [policy dated 
07/09/2014].  Important decisions made during PMT meetings (i.e., 
dose escalation, de-escalation, etc.) only need to be noted in the 
PMT Report submitted to the Data and Safety Monitoring Committee 
(DSMC). 
 
18.3 
Adverse Events and Serious Adverse Events 
The PI will be responsible for determining the event name, 
assessing the severity (i.e., grade), expectedness, and attribution of 
all adverse events. 
18.4 
Adverse Event (AE) - An adverse event is any untoward medical 
experience or change of an existing condition that occurs during or 
after treatment, whether or not it is considered to be related to the 
protocol intervention.  
18.5 
Reporting Non-serious Adverse Events – Adverse events will be 
collected after the patient is given the study treatment or any study 
related procedures.  Adverse events will be monitored by the PMT.  
Adverse events that do not meet the criteria of serious OR are not 
unanticipated problems will be reported only in the PMT Report. 
 
18.6 
Serious Adverse Event (SAE) [Modified from the definition of 
unexpected adverse drug experience in 21 CFR 312.32] - defined as 
any expected or unexpected adverse events that result in any of the 
following outcomes: 
x 
Death 
x 
Is life-threatening experience (places the subject at immediate risk of 
death from the event as it occurred) 
x 
Unplanned hospitalization (equal to or greater than 24 hours) or 
prolongation of existing hospitalization 
x 
A persistent or significant disability/incapacity 
x 
A congenital anomaly/birth defect 
x 
Secondary malignancy 
x 
Any other adverse event that, based upon appropriate medical 
judgment, may jeopardize the subject’s health and may require 

20 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
medical or surgical intervention to prevent one of the outcomes 
listed 
above 
(examples 
of 
such 
events 
include 
allergic 
bronchospasm requiring intensive treatment in the emergency room 
or at home, blood dyscrasias of convulsions that do not result in 
inpatient hospitalization, or the development of drug dependency or 
drug abuse). 
18.7 
Reporting Serious Adverse Events - begins after study treatment 
or any study related procedures.  All SAEs occurring during this 
study, whether observed by the physician, nurse, or reported by the 
patient, will be reported according to the approved City of Hope’s 
Institutional policy [policy effective date:  05/14/14].  Serious Adverse 
Events that require expedited reporting will be submitted 
electronically using iRIS. 
 
18.8 
Adverse Event Name and Severity 
The PI will determine the adverse event name and severity (grade) 
by using the CTCAE version 4.  
18.9 
Expected Adverse Event - Any event that does not meet the 
criteria for an unexpected event, OR is an expected natural 
progression of any underlying disease, disorder, condition, or 
predisposed risk factor of the research participant experiencing the 
adverse event. 
18.10 Unexpected Adverse Event [21 CFR 312.32 (a)] – An adverse 
event is unexpected if it is not listed in the investigator’s brochure 
and/or package insert; is not listed at the specificity or severity that 
has been observed; is not consistent with the risk information 
described in the protocol and/or consent; is not an expected natural 
progression of any underlying disease, disorder, condition, or 
predisposed risk factor of the research participant experiencing the 
adverse event. 
18.11 Adverse Event Attribution 
The following definitions will be used to determine the causality 
(attribution) of the event to the study agent or study procedure. 
Definite - The AE is clearly related to the investigational agent or 
study procedure and unrelated to any other cause.  
Probable - The AE is likely related to the investigational agent or 
study procedure and unlikely related to other cause(s).  
Possible -The AE may be related to the investigational agent or 
study procedure and may be related to another cause(s).  
Unlikely -The AE is doubtfully related to the investigational agent or 
study procedure and likely related to another cause(s).  
Unrelated -The AE is clearly not related to the investigational agent 
or study procedure and is attributable to another cause(s).  
 
18.12 COH Held IND –  
Serious Adverse Events meeting the requirements for expedited 
reporting to the Food and Drug Administration (FDA), as defined in 

21 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
21 CFR 312.32, will be reported as an IND safety report using the 
MedWatch Form FDA 3500A for Mandatory Reporting. 
The criteria that require reporting using the Medwatch 3500A are: 
x 
Any unexpected fatal or life threatening adverse experience 
associated with use of the drug must be reported to the FDA no 
later than 7 calendar days after initial receipt of the information 
[21 CFR 312.32(c)(2)] 
x 
Any adverse experience associated with use of the drug that is 
both serious and unexpected must be submitted no later than 15 
calendar days after initial receipt of the information [21 CFR 
312.32(c)(1)] 
x 
Any follow-up information to a study report shall be reported as 
soon as the relevant information becomes available. [21 CFR 
312.32(d)(3)] 
The PI or designee will be responsible for contacting the Office of 
IND Development and Regulatory Affairs (OIDRA) at COH to ensure 
prompt reporting of safety reports to the FDA.  OIDRA will assist the 
PI with the preparation of the report and submit the report to the 
FDA in accordance with the approved City of Hope’s Institutional 
policy [policy effective date:  05/14/14]. 
 
18.13 Deviations and Unanticipated Problems 
Deviation - A deviation is a divergence from a specific element of a 
protocol that occurred without prior IRB approval.  Investigators may 
deviate from the protocol to eliminate immediate hazard(s) for the 
protection, safety, and well-being of the study subjects without prior 
IRB approval.  For any such deviation, the PI will notify the COH 
DSMC and IRB within 5 calendar days of its occurrence via iRIS in 
accordance with the Clinical Research Protocol Deviation policy 
[policy effective date:  11/07/11].   
18.14 Single Subject Exception (SSE) 
An SSE is a planned deviation, meaning that it involves 
circumstances in which the specific procedures called for in a 
protocol are not in the best interests of a specific patient.  It is a 
deviation that is anticipated and receives prior approval by the PI 
and the IRB.  The SSE must be submitted as a “Single Subject 
Exception Amendment Request” via iRIS in accordance with IRB 
guidelines and the Clinical Research Protocol Deviation policy 
[policy effective date:  11/07/11].  An IRB approved SSE does not 
need to be submitted as a deviation to the DSMC. 
18.15 Unanticipated Problem (UP) – Any incident, experience, or 
outcome that meets all three of the following criteria: 
1. Unexpected (in terms of nature, severity, or frequency) given the 
following: a) the research procedures described in the protocol-
related documents such as the IRB approved research protocol, 
informed consent document or Investigator Brochure (IB); and b) 
the characteristics of the subject population being studied; AND 
2. Related or possibly related to participation in the research 
(possibly related means there is a reasonable possibility that the 

22 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
incident, experience, or outcomes may have been caused by the 
drugs, devices or procedures involved in the research); AND 
3. Suggests that the research places subjects or others at greater 
risk of harm (including physical, psychological, economic, or 
social harm) than previously known or recognized. 
Any UP that occurs during study conduct will be reported to the 
DSMC and IRB in accordance with the City of Hope’s Institutional 
policy [policy effective date:  05/14/14] using iRIS.   
 
18.16 COH Held IND 
The Office of IND Development and Regulatory Affairs (OIDRA) will 
assist the PI in reporting the event to the Food and Drug 
Administration (FDA). 

23 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
 
19.0 
References 
 
1. 
Slamon, D.J., et al., Use of Chemotherapy plus a Monoclonal Antibody against HER2 for 
Metastatic Breast Cancer That Overexpresses HER2. N Engl J Med, 2001. 344(11): p. 783-
792. 
2. 
Romond, E.H., et al., Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-Positive 
Breast Cancer. N Engl J Med, 2005. 353(16): p. 1673-1684. 
3. 
Piccart-Gebhart, M.J., et al., Trastuzumab after Adjuvant Chemotherapy in HER2-Positive 
Breast Cancer. N Engl J Med, 2005. 353(16): p. 1659-1672. 
4. 
Paik, S., et al., Real-World Performance of HER2 Testing--National Surgical Adjuvant Breast 
and Bowel Project Experience. J. Natl. Cancer Inst., 2002. 94(11): p. 852-854. 
5. 
Paik S, K.C., Jeong J, Geyer CE, Romond EH, Mejia-Mejia O, Mamounas EP, Wickerham D, 
Costantino JP, Wolmark N, Benefit from adjuvant trastuzumab may not be confined to patients 
with IHC 3+ and/or FISH-positive tumors: Central testing results from NSABP B-31. Journal 
of Clinical Oncology, 2007 ASCO Annual Meeting Proceedings Part I. , 2007. Vol 25, No. 18S 
(June 20 Supplement): p. 511. 
6. 
Wolff, A.C., et al., Recommendations for Human Epidermal Growth Factor Receptor 2 Testing 
in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists 
Clinical Practice Guideline Update. Journal of Clinical Oncology, 2013. 31(31): p. 3997-4013. 
7. 
Vogel, C.L., et al., Efficacy and Safety of Trastuzumab as a Single Agent in First-Line 
Treatment of HER2-Overexpressing Metastatic Breast Cancer. J Clin Oncol, 2002. 20(3): p. 
719-726. 
8. 
Cobleigh, M.A., et al., Multinational Study of the Efficacy and Safety of Humanized Anti-HER2 
Monoclonal Antibody in Women Who Have HER2-Overexpressing Metastatic Breast Cancer 
That Has Progressed After Chemotherapy for Metastatic Disease. J Clin Oncol, 1999. 17(9): p. 
2639-. 
9. 
Perez, E.A., et al., HER2 and Chromosome 17 Effect on Patient Outcome in the N9831 
Adjuvant Trastuzumab Trial. Journal of Clinical Oncology, 2010. 28(28): p. 4307-4315. 
10. 
Giordano, S.H., et al., Systemic Therapy for Patients With Advanced Human Epidermal Growth 
Factor Receptor 2–Positive Breast Cancer: American Society of Clinical Oncology Clinical 
Practice Guideline. Journal of Clinical Oncology, 2014. 32(19): p. 2078-2099. 
11. 
Geyer, C.E., et al., Lapatinib plus Capecitabine for HER2-Positive Advanced Breast Cancer. N 
Engl J Med, 2006. 355(26): p. 2733-2743. 
12. 
Gianni, L., et al., Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women 
with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a 
randomised multicentre, open-label, phase 2 trial. The Lancet Oncology, 2012. 13(1): p. 25-32. 
13. 
Schneeweiss, A., et al., Pertuzumab plus trastuzumab in combination with standard 
neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in 
patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study 
(TRYPHAENA). Annals of Oncology, 2013. 24(9): p. 2278-2284. 
14. 
Rastogi, P., et al., Preoperative Chemotherapy: Updates of National Surgical Adjuvant Breast 
and Bowel Project Protocols B-18 and B-27. Journal of Clinical Oncology, 2008. 26(5): p. 778-
785. 
15. 
Boughey, J., et al., The role of sentinel lymph node surgery in patients presenting with node 
positive breast cancer (T0-T4, N1-2) who receive neoadjuvant chemotherapy – results from the 
ACOSOG Z1071 trial. Cancer Res, 2012. 72(24 Suppl): p. 94s. 

24 
 
IRB# 16079 
 
03/28/2019 
Version: 18 
16. 
Juweid, M.E. and B.D. Cheson, Positron-Emission Tomography and Assessment of Cancer 
Therapy. N Engl J Med, 2006. 354(5): p. 496-507. 
17. 
Mortimer, J.E., et al., Metabolic Flare: Indicator of Hormone Responsiveness in Advanced 
Breast Cancer. J Clin Oncol, 2001. 19(11): p. 2797-2803. 
18. 
Dehdashti, F., et al., PET-based estradiol challenge as a predictive biomarker of response to 
endocrine therapy in women with estrogen-receptor-positive breast cancer. Breast Cancer 
Research and Treatment, 2009. 113(3): p. 509-517. 
19. 
Mortimer, J.E., et al., Functional Imaging of Human Epidermal Growth Factor Receptor 2–
Positive Metastatic Breast Cancer Using 64Cu-DOTA-Trastuzumab PET. Journal of Nuclear 
Medicine, 2014. 55(1): p. 23-29. 
20. 
Bading, J. and e. all, Tumor Uptake of 64Cu-DOTA-Trastuzumab Correlates with HER2 Status 
in Patients with Metastatic Breast Cancer. Journal of Nuclear Medicine, 2013. 54 (suppl 2): p. 
1324. 
21. 
Gebhart, G., et al., Molecular imaging as a tool to investigate heterogeneity of advanced 
HER2-positive breast cancer and to predict patient outcome under trastuzumab emtansine (T-
DM1): the ZEPHIR trial. Annals of Oncology, 2015. 
22. 
Wong, J., et al., Pretherapy Biodistribution and Dosimetry Studyof Indium-111-Radiolabeled 
Trastuzumab in Patients with Human Epidermal Growth Factor Receptor 2-Overexpressing 
Breast Cancer. Cancer Biotherapy and Radiopharmaceuticals, 2010. 25(4): p. 387-394. 
23. 
Brix, G., et al., Radiation Exposure of Patients Undergoing Whole-Body Dual-Modality 18F-
FDG PET/CT Examinations. Journal of Nuclear Medicine, 2005. 46(4): p. 608-613.