TH-146: Cancer Associated Macrophage-Like (CAML) Cells to Enhance Detection of Early Stage Lung Cancer
Conditions: Pulmonary Nodule, Multiple, Pulmonary Nodule, Solitary
Sponsor: Fox Chase Cancer Center

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
1 
 
 
 
 
 
 
TH-146: Cancer Associated Macrophage-Like (CAML) Cells to Enhance Detection 
of Early Stage Lung Cancer 
 
Supported by: DOD Grant awarded jointly to Dr Edelman and Creatv Micro Tech 
 
 
Sponsor Investigator:   
 
 
 
 
 
 
 
 
Co-Investigators:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Martin J Edelman, MD 
Fox Chase Cancer Center 
333 Cottman Avenue 
Philadelphia, PA 19111 
Phone: 215-728-5682 
Fax: 215-728-5336 
Email: martin.edelman.fccc.edu 
Anil Vachani, MD, MS 
Perelman School of Medicine 
University of Pennsylvania 
Corporal Michael J. Crescenz VA Medical Center 
3900 Woodland Avenue 
Philadelphia, PA 19104 
Rohit Kumar, MD 
Fox Chase Cancer Center 
333 Cottman Avenue 
Philadelphia, PA 19111 
Phone: 215-728-5703 
Fax: 215-214-4044 
Email: Rohit.kumar@fccc.edu 
Jordan Mossler Anaokar, MD 
Asst Professor, Radiology 
Fox Chase Cancer Center 
333 Cottman Avenue 
Philadelphia, PA 19111 
Phone: 215-728-3024 
Email: Jordan.Anaokar@fccc.edu 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
2 
 
 
 
 
 
Statistician:  
 
 
 
 
 
 
 
 
 
Creatv MicroTech:   
 
 
 
 
 
 
Protocol developer:          
 
 
 
 
 
 
 
 
 
 
 
Original Version Date: 09.09.2018 
Amendment 1             : 01.28.2019 
Amendment 2             : 04.26.2019 
 
 
 
Eric Ross, PhD 
Fox Chase Cancer Center 
333 Cottman Avenue 
Philadelphia, PA 19111 
Phone: 215-728-2891 
Email: eric.ross@fccc.edu  
Cha-Mei  Tang, ScD 
Creatv MicroTech, Inc. 
9900 Belward Campus Drive 
Suite 330 
Rockville, MD  20850 
Manisha Saini, PhD 
Fox Chase Cancer Center 
50 Huntingdon Pike, 2nd Fl 
Rockledge, PA 19046 
Phone: 215-214-1439 
Email: Manisha.saini@fccc.edu  

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
3 
 
 
 
                                                       Schema 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
4 
 
 
 
 
Contents 
Schema 
3 
1.0 
Objectives 
9 
2.1 Primary Objective 
9 
2.2 Secondary Objectives 
9 
3.0 
Study Design 
9 
3.1 Description of Study Design, Population and Duration of Study Therapy 
9 
4.0 
Patient Selection Inclusion & Exclusion 
11 
4.1 Inclusion Criteria 
11 
4.2 Exclusion Criteria 
12 
4.3 Inclusion of Women and Minorities 
12 
4.4 Patient Registration 
12 
5.0 
Study Plan 
13 
5.1 Duration of study 
13 
5.2 Duration of Follow up 
13 
5.3 Criteria for Discontinuation 
13 
6.0 
Laboratory Studies 
13 
7.0 
Study Calendar 
13 
8.0 
Measurement of Lung Nodules 
14 
9.0 
Statistical Considerations 
14 
10.0 
Data and Safety Monitoring Plan 
16 
10.1 
Monitoring Plan 
16 
10.2 
Data & Safety Monitoring Board (DSMB) 
17 
11.0 
Administrative 
17 
11.1 
Data Reporting 
17 
11.2 
Retention of Records 
17 
11.3 
Informed Consent 
17 
12.0 References 
17 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
5 
 
 
 
1.0 Introduction  
1.1 Background and Hypothesis 
 
Lung cancer screening 
Lung cancer remains the major cause of cancer related death in the United States, with over 
220,000 cases detected and 180,000 deaths.i The National Lung Screening Trial (NLST), 
for which the PI was a member of the endpoint verification committee, determined that 
low dose CT screening could decrease lung cancer death by 20% compared with CXR and 
is now recommended by all major professional groups and US Preventative Services Task 
Force.ii   However, there are several problems with the current screening paradigm.  Most 
critically, over 39% of screened subjects were determined to have positive screens with 
only 96.4% false positive.  This very high false positive rate results in several critical 
problems including the requirement for further testing (scans, biopsies), the potential of 
loss to follow-up, the possibility of false negative biopsy and the resultant patient stress 
and anxiety. While lung nodules <0.8 cm are considered low-risk findings and nodules 
>3.0 cm high-risk, nodules between from 0.8-3.0 cm have been described as 
“indeterminate” and represent a management challenge.iii Therefore, there is a substantial 
need for a method to enrich the population of patients identified as likely to have 
malignancy and exclude those who have nodules not likely to have malignancy. The ideal 
test should be demonstrated to have high specificity and sensitivity. This is particularly 
important for patients with nodules of indeterminate size.  
 
A number of publications have evaluated methods to predict which nodules harbor 
malignant disease. Location (upper lobe), characteristics of the nodule (specifically 
spiculation), age, female sex, number of nodules (fewer is more predictive) and carcinogen 
exposure have frequently been cited as predictive factors for malignancy.iv v A recent 
consensus statement by the International Association for the Study of Lung Cancer noted 
the variability in the very definition of indeterminate. vi  In the NLST, screen positivity was 
deﬁned by greatest nodule diameter of 4 mm or larger. In contrast, a European study 
(Dutch-Belgian Randomized Lung Screening Trial, NELSON) based screening 
interpretation on nodule volumetry and used a tiered approach.vii They classiﬁed nodules 
less than 50 mm3 (4.6-mm diameter) as negative, nodules greater than 500 mm3 (> 9.8-
mm diameter) positive, and nodules 50 to 500 mm3 indeterminate. These indeterminate 
nodules underwent an early (3-month) follow-up LDCT to assess for growth; nodule 
volume doubling times were then used to distinguish between positive screens requiring 
additional diagnostic procedures and negative screens. Using this two-step approach, 2.6% 
of NELSON baseline screens were deemed positive, and a higher proportion of positive 
screens were due to lung cancer. An evaluation of >12,000 nodules by Mc Williams et al 
from two data sets was able to develop an algorithm with excellent discrimination between 
benign and malignant (ROC >0.90).v   However, the above and similar experiences rely on 
continued follow-up, significant radiologic expertise and coordination. Further confusing 
matters, nodules discovered on subsequent scans in NELSON (and other studies) have a 
higher potential to be malignant regardless of size than those discovered on the initial 
scan.viii   

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
6 
 
 
 
The evaluation of patients with nodules generally consists of additional scanning as well 
as invasive procedures for nodules deemed suspicious. In the NLST, 28.4% of patients 
experienced a complication and with most of those (26.2%) considered “intermediate” or 
“major”. 1.5% of patients died within 60 days of the most invasive diagnostic procedure. 
Critically, the prevalence of pulmonary nodules is dependent upon the population 
evaluated and appears to be substantially higher in the Veteran population. A recently 
published study reported a demonstration project in lung cancer screening at eight VA 
hospitals.ix  Of the 2106 patients who completed screening, 1257 (59.7%) had positive test 
results, with 31 patients actually diagnosed with lung cancer. Therefore, the false positive 
rate was 97.5%. The investigators also evaluated the overall population potentially eligible 
for screening in the 8 centers and extrapolating to the entire VA population projected that 
there were almost 890,000 VA patients who would be candidates for lung cancer screening.  
This experience is informative in that it strongly indicates that screening in the VA/military 
population may be different than in the civilian population. There is a high degree of 
asbestos exposure in the military and there is some evidence that a very high proportion of 
patients with asbestos exposure will have pulmonary nodules. A Canadian study of 516 
individuals with asbestos exposure found that 371 (71.9%) had pulmonary nodules.x  The 
population that was evaluated in the VA demonstration project described above was 
heavily weighted towards male sex and had far more active smokers than in NLST. There 
was a much greater incidence of nodules requiring follow-up in the VA population (by a 
factor of 2). This indicates that full implementation of lung cancer screening with low dose 
CT followed by pulmonary (or other specialty referral) will demand far greater resources 
than projected by NLST. Many VA facilities do not appear to have adequate resources to 
implement current screening strategies. While there is high acceptance of the concept of 
screening in the VA population, in a survey of 106 (of 126 possible) VA facilities with 
pulmonary clinics, only 26.5% facilities were ideally prepared for lung cancer screening 
implementation. Furthermore, it is clear that potential for both positive tests (both false and 
true) is increased in the VA/military population. This will unquestionably be accompanied 
by an increased potential for diagnostic and therapeutic complications given the higher 
prevalence of smoking, age and comorbidities. 
 
Cancer Associated Macrophage-Like (CAML) Cells 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
7 
 
 
 
Creatv Microtech (Creatv) identified a previously unanalyzed cell in the blood of solid 
tumor patients, and named it CAMLs. xi They are specialized myeloid polyploid cells which 
emanate from primary tumor masses and transit the circulation of cancer (FIG 1) in a 
variety of malignancies which can be used to track cancer progression and evolution in 
response to therapy.xii CAMLs are absent in healthy controls and rare in persons with 
benign masses, Figure 2xiii. CAMLs have been identified in 14 types of solid tumors 
analyzed and prevalent in all stages, unlike circulating tumor cells (CTCs) which are 
relatively uncommon in lung cancer and non-metastatic disease. Creatv’s CellSieveTM 
platform is a filter based system which has innovated liquid biopsies by its uniform pore 
size and distribution, with 180,000 pores. This allows for a low pressure filtration system 
for clean operation from whole blood with assays performed inside an encased filter holder 
(see details below, Methods).   
In approximately 10-20% of 
the patient samples, CAMLs 
are found to be in the process 
of 
engulfing 
CTCs 
and 
cellular debris (FIG 3). With 
CAMLs 
expressing 
proteomic 
and 
genomic 
markers associated with the 
primary 
tumor 
type, 
indicating 
engulfment 
of 
tumor/tumor debris 
 
However, though seen by 
numerous groups, these cells 
have 
remained 
largely 
unstudied with their clinical 
and 
biological 
value 
in 
malignancies remaining uninvestigated.  
 
 
Figure 2.  CAMLs only occur in cancer patients and 
some inflammatory illnesses, none in healthy control. 
CAMLs are found in high percentage even in stage I 
patients (n=272). 
Stage I
n=56
Stage II
n=52
Stage III
n=57
Stage IV
n=67
Healthy
n=40
79%
96%
90%
93%
0%
0%
25%
50%
75%
100%

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
8 
 
 
 
CAMLs consistently exist in stage I lung and undiagnosed breast cancer patients, 
making it an ideal target for early detection.  
A double blinded study of breast cancer was conducted by Creatv MicroTech and Duke 
University on patients with suspicious mammography masses. In these patients, breast 
biopsies were performed in parallel with the detection of CAMLs from 7.5 mL of 
peripheral blood. The results demonstrated that CAMLs presence in blood had a 
significantly increased sensitivity and specificity versus mammography in individuals with 
cancer or non-cancerous masses (FIG 4).xiv   
 
 
                               Figure   4                                                                  Figure 5 
 
Further, the study PI and co-PI performed a blinded preliminary comparison of 56 newly 
diagnosed lung cancer patients, 16 patients with benign conditions, and 40 healthy 
controls (FIG 5). Sensitivity of this study showed the number of patients (% positive):  
Stage I (63%), Stage II (86%), Stage III (92%), Stage IV 100%, unknown stage (100%); 
while the benign lung disease (18%) and healthy controls (0%). For malignant versus 
benign lung disease AUC=0.85, and for invasive versus health controls AUC=0.92.  The 
current proposal will extend the above data to evaluate the prevalence and potential utility 
of CAMLs in individuals with pulmonary nodules to determine their use as a surrogate 
biomarker for cancerous nodules.   
The prevalence and specificity of CAMLs in malignant disease is believed to be caused by 
immune inflammation and the specific microenvironment formed in cancerous and pre-
cancerous legions. Typically giant polyploidy cells, like CAMLs, derive from common 
MPCs by either means of a pre-specified cascade of cellular differentiation (i.e. 
megakaryocytes or kupffer cells) or by an inflammatory response causing cell to cell fusion 
with nearby cells (Langhans or Foreign-body giant cells). Within the solid tumor mass, the 
commonly seen giant cancer associated polyploid cells are presumed to be caused by an 
aberrant inflammatory response caused during malignant growth, and the likely origin of 
CAMLs prior to dissemination into circulation. Further, because tumor derived giant 
polyploids are found in most early solid tumors, can negatively correlate with survival, and 
accumulate in pre-metastatic disease; it should be of little surprise that CAMLs in the blood 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
9 
 
 
 
would have parallel clinical correlations. Additionally, while CTCs can act as a blood based 
surrogate to the tumor itself, CAMLs appear to act as a surrogate to the stromal 
microenvironment. Because stroma/immune inflammation is often larger than the tumor 
itself, and stromal genesis begins in both pre-cancerous and cancerous environments, it is 
not surprising that CAMLs would appear earlier and more commonly than actual CTCs.             
1.2 Rational for the Study 
While physicians have a clear path to follow for patients with low risk or high risk nodules, 
patients with indeterminate nodules do not have a defined method to predict their fate 
resulting in frequent scanning and invasive procedures. Screening by CT scans is faulty 
and unreliable with very high rate of false positives resulting in requirement for further 
tests and higher investment in resources. There is a need for a reliable screening method 
that would be predictive of the state of cancer. Circulating CAMLs have been shown to be 
of prognostic value in differentiating malignant and benign breast conditionsxiv, xxiv.  
Our fundamental hypothesis is that CAMLs can substantially enrich for the presence of 
malignancy in the population of patients with pulmonary nodules. We also posit that 
parallel detection of CTCs has the potential to further enhance the ability to distinguish 
benign from malignant disease.  
  
1.0 Objectives 
2.1 Primary Objective 
 Determine the prevalence of CAMLS in patients with pulmonary nodules. 
 
2.2 Secondary Objectives  
 Determine the positive and negative predictive value of CAMLS in patients with 
pulmonary nodules who undergo biopsy. 
 Model combinations of clinical factors with the presence/absence of CAMLs to 
refine strategies for assessment of patients with pulmonary nodules. Evaluate 
whether these measures result in enhanced T-cell activity and/or NK cell function 
and number. 
 
3.0 Study Design 
3.1 Description of Study Design, Population and Duration of Study Therapy  
This is a multi-site diagnostic study.  Individuals who are diagnosed with indeterminate 
pulmonary nodules will be eligible. They will undergo standard evaluation and follow-up 
as determined by their pulmonary physician. In addition, they will have at least one blood 
draw to evaluate for the presence (and quantity) or absence of CAMLs.    
Subjects will be drawn from pulmonary nodule clinics at the Fox Chase Cancer Center and 
the VAMC Philadelphia. Approximately 1200 pulmonary nodule patients are evaluated 
annually at Fox Chase. Approximately 200 pulmonary nodule patients/year with 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
10 
 
 
 
indeterminate nodules (i.e. 0.8-3.0 cm) are seen each year at the VA Philadelphia. Patients 
who are seen in these clinics will be asked to complete a questionnaire that will include 
demographic information (age, sex, zip code, smoking history, occupational exposures, 
military history (where relevant). Medical history will be obtained from the medical 
records. This information will include diagnoses (e.g. COPD, CAD etc.), medications 
(steroids, inhalers etc), smoking and other pulmonary carcinogen history and other 
information. Radiologic information including location of nodule (lobe), size, 
characteristics (ground glass, solid, spiculation etc) will be recorded (Appendices A, B).  
Patient’s blood would be drawn at 2 time points- at the time of detection of indeterminate 
lung nodules, and at the time of biopsy or beginning of therapeutic procedure. Each blood 
sample will be 10 cc of blood into two tubes equaling 20 cc per blood draw. Two tubes of 
blood will be drawn for each sample: one CellSave tube will be sent to Creatv for further 
analysis and one CellSave will be processed at the FCCC protocol support lab (PSL). 
Detection of CAMLs will be performed using the CellSieveTM microfiltration system 
according to established criteria. The CellSieveTM microfilter (Fig. 6) has low fluorescent 
background, enabling detailed visualization and characterization of the cells on the filter, 
which led to the discovery of the CAMLs.  Figure 6 shows a scanning electron micrograph 
(SEM) of a CellSieveTM microfilter. The characteristics of these microfilters and the 
benefits are summarized here. 
Properties 
Benefits 
 Uniform pore size (7 µm 
diameter) and distribution 
Pore size large enough to eliminate all red blood cells 
and 99.99% of white blood cells.  Pore size small 
enough to capture all CTCs, CAMLs and cell clusters. 
 10 µm thick 
Thin films minimize pressure on the cells.  Cell 
morphologies are well maintained.   
 High porosity (180,000 
pores in a 9 mm diameter 
area 
High porosity enables fast filtration, 5 mL/min.  The 9 
mm diameter filtration area minimizes time for 
imaging. 
 Low 
auto-fluorescent 
background 
Enables detailed images of cell features.  Ability to 
quantify the staining intensity of markers of interest on 
the cells, such as PD-L1 and PD-L2. 
 Very strong 
No support needed; lies flat on glass slides. 
 Lies flat on glass slides  
Ease in preparing slides, and facilitates imaging by 
microscope. 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
11 
 
 
 
The CellSieveTM low pressure filtration system 
is straightforward and offers clean operation 
(Fig. 6). The filter is held inside a filter holder, 
which also serves as the assay reaction well. 
Whole blood is placed into the input syringe and 
drawn through the filter into a waste syringe. 7.5 
mL of whole blood diluted by 7.5 mL of 
prefixation buffer is filtered in 3 min. The assay 
steps (fixation, permeabilization, and staining), 
are all performed inside the holder. After 
staining, the filter is removed and mounted on a 
glass slide with a cover slip.  
 
 
 
 
 
 
 
The device is for Research Use Only. These products are not intended for in vivo or 
diagnostic use. Performance, safety, and effectiveness have not been established, and 
products are not approved by the FDA. Creativ MicroTech will comply with applicable 
requirements in 21 CFR 809.10©. The testing procedure is non-invasive and does not 
present significant risk, or intend to introduce energy into a subject. The  testing is not used 
as a diagnostic procedure without confirmation by another procedure, medically 
established product or procedure. Thus, the device qualifies for IDE exemption.  
 
4.0 Patient Selection Inclusion & Exclusion 
4.1 Inclusion Criteria  
4.1.1 Referral for a pulmonary nodule that has not yet been biopsied and that meets 
the definition of an “indeterminate” nodules (i.e. 0.8-3.0 cm). 
4.1.2 No prior diagnosis of lung cancer or other invasive malignancy within the past 
5 years. 
4.1.3 No history of rheumatologic disease. 
4.1.4 Age > 18 years. 
4.1.5 Ability to understand and willingness to sign a written informed consent and 
HIPAA consent document 
 
 
 
Figure 6. CellSieveTM filtration system. The 
microfilter is installed in a filter holder, which 
also serves as the assay reaction well. 
CellSieveTM
microfilter

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
12 
 
 
 
4.2 Exclusion Criteria   
4.2.1 Patients with active, known or suspected autoimmune disease.  
4.2.2 Prior diagnosis of lung cancer or other invasive malignancy within the past 5 
years. 
4.2.3 Uncontrolled intercurrent illness that would increase the risk of toxicity or limit 
compliance with study requirements. This includes but is not limited to, 
uncontrolled infection, symptomatic congestive heart failure, unstable angina 
pectoris, cardiac arrhythmia, or psychiatric illness/social situations that would 
limit compliance with study requirements. 
4.2.4 Known HIV-positive patients on combination antiretroviral therapy are 
ineligible because of the abnormal immune response that results from HIV 
disease (testing is not required). 
4.2.5 Patients should be excluded if they are known to be positive for hepatitis B virus 
surface antigen (HBV sAg) or hepatitis C virus ribonucleic acid (HCV 
antibody) indicating acute or chronic infection (testing is not required). 
4.2.6 Subjects with any history of interstitial lung disease or a history of > or = to 
grade 2 radiation pneumonitis.  
 
4.3 Inclusion of Women and Minorities 
Men and women, regardless of race, ethnic group or sexual orientation are eligible for 
this study.   
 
4.4 Patient Registration 
Participants may be registered from 8:00 am to 4:00 pm EST excluding holidays by 
emailing 
the 
Investigator-Sponsored 
Research 
Unit 
(ISRU) 
at: 
FCCC.MONITOR@fccc.edu. Eligible participants will be entered on study centrally 
once the following items have been received by email: 
 
 Completed registration form  
 Consent and HIPAA signature pages  
 Eligibility checklist 
 
For additional registration questions, please email FCCC.MONITOR@fccc.edu. 
The FCCC ISRU will notify the site by email once registration is confirmed and the 
sequence number has been assigned.  Participants must be registered and have received a 
sequence number prior to blood draw.   
  
Exceptions to the current registration policies will not be permitted. 
 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
13 
 
 
 
5.0 Study Plan 
 
5.1 Duration of study 
The study duration is anticipated to be three years. Patients would be registered 
during the first 2 years and followed for a maximum of 3 years since the beginning 
of the study. Patient who is registered towards the end of 2nd year will be followed 
for 12 months, i.e, end of the study. 
 
5.2 Duration of Follow up 
Patients will be in the study from the time of enrollment until the follow up. Follow 
up is the time when a CT scan and nodule assessment is done after the biopsy. Patients 
will be followed for a minimum of one year from accrual (last patient accrued) to a 
maximum of three years (patient accrued at the beginning of study).  
 
5.3 Criteria for Discontinuation 
Patients will be removed from study when any of the following criteria apply: 
 
 Patient decided to withdraw from the study.  
 Sponsor-investigator decides to remove patient from the study due to non-
compliance 
 The study is discontinued 
 
The reason for study removal and the date the patient was removed must be 
documented in the medical record and case report form. 
 
 
6.0 Laboratory Studies 
These studies will be performed at Creatv Microtech. The outcomes of the study are 
determination of the prevalence, positive and negative predictive value of CAMLs in 
pulmonary nodules.    
 
7.0 Study Calendar 
 
Study 
Enrollment 
Scan 
21 
Scan 
31 
Biopsy or other 
diagnostic/therapeutic 
procedure1 
Follow up 
Informed consent 
x 
 
 
 
 
Medical History 
x 
 
 
x 
 
Physical exam 
x 
 
 
 
 
Smoking history 
x 
 
 
 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
14 
 
 
 
Occupational and 
other exposures 
x 
 
 
 
 
Medications 
x 
 
 
 
 
PFTs1 
x 
 
 
 
 
CT chest 
x 
 
 
 
x 
CT/PET or PET1 
 
 
 
 
x 
CAML 
x 
 
 
x 
 
Nodule(s) 
measurement 
x 
x 
x 
x 
x 
Nodule 
characteristics 
x 
x 
x 
x 
x 
1 If clinically indicated 
 
8.0 Measurement of Lung Nodules 
Bidimensional measurements of lung nodules will be performed.  Measurements may be 
done by radiologist or pulmonary physician from CT scans with 5 mm (or less) cuts, 
using lung windows in the axial plane.   
 
9.0 Statistical Considerations 
Aim 1: Demographic and clinical characteristics of the study population will be 
summarized using standard methods (e.g., means, standard deviations, medians, binomial 
proportions, frequencies, two-sided confidence intervals). The proportion of patients with 
presence of CAMLs (CAML+) at the initial screen, with 95% two-sided confidence 
intervals, will be tabulated for the entire population. These statistics will also be used to 
summarize the presence of CAMLs at the time of an invasive follow-up procedure. The 
concordance of CAML results measured at two time points within the same individual will 
be evaluated using Cohen’s Kappa. 
 
Aim 2:  Positive Predictive Value (PPV), Negative Predictive Value (NPV), sensitivity and 
specificity of CAMLs at the initial screen (along with two-sided 95% confidence intervals 
(CI)) will be computed for the entire study population.  Patients with biopsy confirmed 
lung cancer during the entire duration of the study since initial CAML test will be defined 
as “diseased”; otherwise, they will deemed “disease free”. We conservatively estimate that 
we will be able to accrue 1,000 patients with pulmonary nodules.  We anticipate that ~35 
and ~965 patients will be CAML+ CAML- at the initial screen, respectively.  The expected 
accuracy of PPV and NPV estimates are presented in table 1. 
Table 1.  Accuracy of PPV and NPV estimates. 
PPV or NPV estimate Two-sided 95% CI for PPV Two-sided 95% CI for NPV 
0.5 
±0.166 
±0.032 
0.7 
±0.152 
±0.029 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
15 
 
 
 
 
Aim 3: We will use logistic regression models to assess the utility of presence/absence of 
CAMLs after accounting for clinical factors and nodule characteristics.  The primary 
analysis will be at the patient level, since this approach is most consistent with the potential 
future application of a validated CAML test in the clinic. The dependent variable will be a 
binary indicator of patient disease status as described for Aim 2 (1=diseased, 0=disease 
free).  Independent variables will include presence/absence of CAMLs as well as factors 
previously identified in the literature as important predictors of lung cancer status including 
age, gender, smoking status, lesion diameter, spiculation, family history of lung cancer, 
emphysema, clear borders, and exposure to asbestos or other common pulmonary 
carcinogens.xv xvi xvii When more than one lesion is detected in the same patient, lesion-
specific covariate values (e.g., nodule diameter, spiculation) for that patient will be based 
on the nodule with highest risk of lung cancer.  Continuous covariates may be modelled 
using restricted cubic splines to account for non-linear effects. As recommended by Pepe 
et al, Seshan et al  and Vickers et al , the significance of the association between CAML 
test results and cancer status controlling for previously established clinical and radiological 
characteristics will be assessed using a Wald statistic from the multivariable logistic 
regression model (two-sided, 5% type I error). xviii xix  Table 2 displays detectable 
differences between CAML+ and CAML– patients from these multivariable xxmodels, 
under a number of conditions.xxi These estimates assume data are available from 1,000 
patients with suspicious nodules (35 CAML+ and 965 CAML-), and approximately 3.5% 
of patients will subsequently have biopsy-confirmed lung cancer.  
 
Table 2. Detectable differences in proportion with lung cancer between CAML+ and CAML – patients. 
Squared multiple correlation between CAML status 
and other independent variables in the model 
Detectable difference in the proportion with 
lung cancer between CAML+ and CAML – 
patients 
Power 
0.0 
0.111 
80% 
0.1 
0.118 
80% 
0.2 
0.127 
80% 
0.3 
0.138 
80% 
0.9 
±0.099 
±0.019 
Table 3. Two-sided 95% confidence 
intervals for varied AUCs  
AUC 
Lower 
Bound 
Upper Bound
0.80 
0.71 
0.89 
0.85 
0.77 
0.93 
0.90 
0.83 
0.97 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
16 
 
 
 
 
Receiver Operating Characteristic (ROC) 
curves and area under the ROC curve (AUC), with associated 95% two-sided confidence 
intervals, will be created to summarize the predictive accuracy of the model. Given the 
anticipated sample size, the upper and lower bounds for 95% two-sided confidence 
intervals for a range of possible AUCs are presented in Table 3.xxii In addition, the 
performance of the model will be evaluated using leave-one-out cross validation.  
 
In secondary analyses, we will test second-order interactions between presence/absence of 
CAMLs and other covariates to explore whether test performance differs among subsets of 
the population defined by demographic, clinical and nodule characteristics.   
 
In exploratory analyses we will conduct nodule-specific analyses using methods similar to 
those described above.  In this case, the dependent variable will be a binary indicator of 
nodule disease status (1=cancer detected, 0=cancer not detected).  To account for the fact 
that some subjects may have multiple nodules, the logistic models will be fit using 
generalized estimating equation methods (GEE) ( and robust variance estimates will be 
used for inference.xxiii The power estimates in Table 2 are based on the assumption that 
there will be only 1 nodule per patient. Given that some subjects will have multiple nodules, 
the actual power of these exploratory analyses will likely exceed the stated estimates.  
We will also evaluate the value of adding CAMLs to previously defined algorithms for 
evaluation of pulmonary nodules and the ability of CAMLs to potentially replace other 
known variables.   
 
Trial feasibility:  The trial calls for a total of 1000 evaluable patients accrued over 2 years. 
To assess the feasibility of this accrual rate, we examined the number of potentially eligible 
patients seen in the FCCC pulmonary clinic for FY 2017 (7/1/2016 to 6/30/2017).  We 
found that there were over 1200 patients referred for evaluation of pulmonary nodules. The 
exact size of these nodules has not been captured in the data base, but the majority are 
within the indeterminate range. At the VA Philadelphia, the pulmonary nodule clinic 
performs over 1500 bronchoscopies/year and sees over 200 patients/year with pulmonary 
nodules measuring .8-3.0 cm.  Therefore, between the two institutions, we feel confident 
that we will be able to enroll 1000 patients with indeterminate nodules within 24 months 
of activation.  
 
10.0 
Data and Safety Monitoring Plan 
10.1 Monitoring Plan  
This study does not involve any intervention, thereby posing minimal risk to the 
patient. The patient’s visit will be as needed for standard of care and no visit is needed 
specifically for this study. Therefore, sponsor investigator will be responsible for 
conduct of the study. Investigator sponsored research unit (ISRU) will be conducting 
spot check of the study to ensure timely entry of patient and related study data.  
 
0.95 
0.90 
1.00 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
17 
 
 
 
10.2 Data & Safety Monitoring Board (DSMB)  
The study is purely observational with no interventions.  It does not involve more 
than minimal risk to the patients, and will not be reviewed by DSMB. 
 
11.0 
Administrative   
This study will be conducted in accordance with local, state and Federal regulations and 
according to accepted good clinical practice guidelines. 
 
11.1 Data Reporting 
Patients will be registered in OnCore and patient data will be entered at each site in 
electric case report forms in electronic data capture system RedCap that will be 
password protected. The FCCC Study Monitor will request case report forms to be 
completed within 2 weeks of the protocol visit.  Participating sites are responsible to 
respond to queries prior to the next scheduled monitoring visit.  
 
All patient information will be stored in an EDC system accessible only to the study 
team members for the purpose of entering, reviewing and analyzing data.  Any paper 
records, such as case report files, produced will be stored in a secure location. 
Confidentiality of the patient data will be maintained at all time. 
 
Patients registered in the trial will be assigned a registration number. If needed, data 
will transferred in a de-identified manner between institutional encrypted emails 
only.  
 
11.2 Retention of Records   
All the study related records will be collected form the participating sites as per 
contract and retained at Fox Chase Cancer Center for 3 years after the trial ends. 
 
11.3 Informed Consent 
The IRB approved informed consent documents must be signed by the patient, or the 
patient’s legally authorized representative, before his or her participation in the study.  
The case history for each patient shall document that informed consent was obtained 
prior to participation in the study.  A copy of the informed consent documents must 
be provided to the patient or the patient’s legally authorized representative.  If 
applicable, they will be provided in a certified translation of the local language. 
 
Original signed consent forms must be filed in each patient’s study file or medical 
record with a copy in the study file. 
 
12.0 References 
i Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017.CA Cancer J Clin. 2017 
Jan;67(1):7-30. PMID: 2805510 
                                                 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
18 
 
 
 
                                                                                                                                                 
ii Aberle DR, DeMello S, Berg CD, Black WC, Brewer B, Church TR, Clingan KL, Duan 
F, Fagerstrom RM, Gareen IF, Gatsonis CA, Gierada DS, Jain A, Jones GC, Mahon I, 
Marcus PM, Rathmell JM, Sicks J; National Lung Screening Trial Research Team. Results 
of the two incidence screenings in the National Lung Screening Trial. N Engl J Med. 2013 
Sep 5;369(10):920-31. PMID: 24004119 
iii Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM.Executive 
Summary: Diagnosis and management of lung cancer, 3rd ed: American College of Chest 
Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):7S-
37S. PMID: 23649434 
iv  Swensen SJ,Silverstein, MD, Ilstrup,DM,  Schleck CD, Edell ES.  The Probability of 
Malignancy in Solitary Pulmonary Nodules:Application to Small Radiologically 
Indeterminate Nodules Arch Intern Med. 1997;157:849-855 
v McWilliams A, Tammemagi MC, Mayo JR,  et al. Probability of cancer in pulmonary 
nodules detected on first screening CT.  N Engl J Med. 2013 Sep 5;369(10):910-9. PMID: 
24004118 
vi Field JK, Smith RA, Aberle DR, Oudkerk M, Baldwin DR, Yankelevitz D, Pedersen JH, 
Swanson SJ, Travis WD, Wisbuba II, Noguchi M, Mulshine JL International Association 
for the Study of Lung Cancer Computed Tomography Screening Workshop 2011 report. J 
Thorac Oncol. 2012 Jan;7(1):10-9. 
vii van Klaveren RJ, Oudkerk M, Prokop M, et al. Management of lung nodules detected 
by volume CT scanning. N Engl J Med 2009;361: 2221–2229. 
viii Walter JE, Heuvelmans MA, de Jong PA, Vliegenthart R, van Ooijen PMA, Peters RB, 
Ten Haaf K, Yousaf-Khan U, van der Aalst CM, de Bock GH, Mali W, Groen HJM, de 
Koning HJ, Oudkerk M. Occurrence and lung cancer probability of new solid nodules at 
incidence screening with low-dose CT: analysis of data from the randomised, controlled 
NELSON trial. 
Lancet 
Oncol. 
2016 Jul;17(7):907-916. doi: 10.1016/S1470-
2045(16)30069-9. Epub 2016 Jun 6. PMID: 27283862 
ix Kinsinger LS1, Anderson C2, Kim J1, Larson M1, Chan SH1, King HA3, Rice KL4, 
Slatore CG5, Tanner NT6, Pittman K1, Monte RJ7, McNeil RB3, Grubber JM8, Kelley 
MJ9, Provenzale D3, Datta SK3, Sperber NS3, Barnes LK10, Abbott DH10, Sims KJ10, 
Whitley RL10, Wu RR3, Jackson GL3. JAMA Intern Med. 2017 Mar 1;177(3):399-406.  
x Roberts HC1, Patsios DA, Paul NS, DePerrot M, Teel W, Bayanati H, Shepherd F, 
Johnston MR.Screening for malignant pleural mesothelioma and lung cancer in individuals 
with a history of asbestos exposure. J Thorac Oncol. 2009 May;4(5):620-8. 
xi Adams DL, Martin SS, Alpaugh RK, Charpentier M, Tsai S, Bergan RC, Ogden IM, 
Catalona W, Chumsri S, Tang CM, Cristofanilli M. Circulating giant macrophages as a 
potential biomarker of solid tumors. Proc Natl Acad Sci U S A. 2014 Mar 4;111(9):3514-
9. PMID: 24550495 
xii Adams DL, Bergan RC, Martin SS,  Chumsri S,  Charpentier M,  Lapidus RG, Alpaugh 
RK, Cristofanilli M, Tsai S, Tang C-M, Edelman MJ. Correlation of cancer-associated 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
19 
 
 
 
                                                                                                                                                 
macrophage-like cells with systemic therapy and pathological stage in numerous 
malignancies.   J Clin Oncol 33, 2015 (abstr 11095). 
xiii Adams, DL, Adams, DK, He, J, Kalhor, N, Zhang, M, Xu, T, Gao, H, Reuben, JM, Qiao, 
Y, Komaki, R, Liao, Z, Edelman, MJ, Tang, CM,  and Lin, SH. Sequential tracking of PD-
L1 expression and RAD50 induction in circulating tumor and stromal cells of lung cancer 
patients undergoing radiotherapy, Clin Canc Res Aug. 2017, In press 
xiv Adams DL, Adams DK, Alpaugh RK, Cristofanilli M, Martin SS, Chumsri S, Tang CM, 
Marks JR.. Circulating Cancer-Associated Macrophage-Like Cells Differentiate Malignant 
Breast Cancer and Benign Breast Conditions. Cancer Epidemiol Biomarkers Prev. 2016 
Jul;25(7):1037-42 
xv McWilliams A, Tammemagi MC, Mayo JR, Roberts H, Liu G, Soghrati K, Yasufuku K, 
Martel S, Laberge F, Gingras M, Atkar-Khattra S, Berg CD, Evans K, Finley R, Yee J, 
English J, Nasute P, Goffin J, Puksa S, Stewart L, Tsai S, Johnston MR, Manos D, Nicholas 
G, Goss GD, Seely JM, Amjadi K, Tremblay A, Burrowes P, MacEachern P, Bhatia R, 
Tsao MS, Lam S. Probability of cancer in pulmonary nodules detected on first screening 
CT. The New England journal of medicine. 2013;369(10):910-9.. PubMed PMID: 
24004118; PMCID: PMC3951177 
xvi Swensen SJ, Silverstein MD, Ilstrup DM, Schleck CD, Edell ES. The probability of 
malignancy in solitary pulmonary nodules. Application to small radiologically 
indeterminate nodules. Archives of internal medicine. 1997;157(8):849-55. Epub 
1997/04/28. PubMed PMID: 9129544 
xvii Zhang M, Zhuo N, Guo Z, Zhang X, Liang W, Zhao S, He J. Establishment of a 
mathematic model for predicting malignancy in solitary pulmonary nodules. Journal of 
thoracic disease. 2015;7(10):1833-41. Epub 2015/12/02. doi: 10.3978/j.issn.2072-
1439.2015.10.56. PubMed PMID: 26623107; PMCID: PMC4635307 
xviii Pepe MS, Kerr KF, Longton G, Wang Z. Testing for improvement in prediction model 
performance. Stat Med. 2013;32(9):1467-82. Epub 2013/01/09. doi: 10.1002/sim.5727. 
PubMed PMID: 23296397; PMCID: PMC3625503 
xix Seshan VE, Gonen M, Begg CB. Comparing ROC curves derived from regression 
models. Stat Med. 2013;32(9):1483-93. Epub 2012/10/05. doi: 10.1002/sim.5648. PubMed 
PMID: 23034816; PMCID: PMC3617074 
xx Vickers AJ, Cronin AM, Begg CB. One statistical test is sufficient for assessing new 
predictive markers. BMC medical research methodology. 2011;11:13. Epub 2011/02/01. 
doi: 10.1186/1471-2288-11-13. PubMed PMID: 21276237; PMCID: PMC3042425 
xxi Hsieh FY, Bloch DA, Larsen MD. A simple method of sample size calculation for linear 
and logistic regression. Stat Med. 1998;17(14):1623-34. Epub 1998/08/12. PubMed PMID: 
9699234 
xxii Hanley, JA, McNeil BJ. The meaning and use of the area under a receiving operating 
characteristics (ROC) curve. Radiology. 1982; 148:29-36 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
20 
 
 
 
                                                                                                                                                 
xxiii Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. 
Biometrics. 1986;42(1):121-30. Epub 1986/03/01. PubMed PMID: 3719049 
xxiv Zhaomei M, Chun W, Zhong Y, Giovanna R, Carl S, Ling L, Zhu Z, Hushan Y, 
Cristofanilli M. Prognostic values of cancer associated macrophage-like cells (CAML) 
enumeration in metastatic breast cancer. Breast Cancer Res Treat. 2017; 165 (3): 733-41 
 
ON STUDY FORM 
 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
21 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
22 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
23 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
24 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
25 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
26 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
27 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
28 
 
 
 
                                                                                                                                                 
FOLLOW UP FORM 
 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
29 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
30 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
31 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
32 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
33 
 
 
 
                                                                                                                                                 
 

18-4003 
Copyright© 2016 Fox Chase Cancer Center® Office of Clinical Research.  All rights reserved. 
Version Date 04/26/2019 
34