Functional Imaging of T-Cell Activation With [18F]F-AraG in Urothelial Carcinoma Patients Receiving Neoadjuvant Therapy or Patients With Cancer Receiving Standard of Care Anti-PD-1/L1
Phase: PHASE2
Conditions: Bladder Cancer
Sponsor: Lawrence Fong

Proprietary and Confidential 
The information in this document is considered privileged and confidential, and may not be disclosed to others except 
to the extent necessary to obtain Institutional Review Board approval and informed consent, or as required by 
Federal and State laws.  Persons to whom this information is disclosed should be informed that this information is 
privileged and confidential and that it should not be further disclosed. 
Functional imaging of T-cell activation with [18F]F-AraG in urothelial carcinoma 
patients receiving neoadjuvant therapy or patients with cancer receiving standard of 
care anti-PD-1/L1  
Protocol Number:  CC # 16709 
Study Drug:  2′-deoxy-2′-[18F]fluoro-9-β-Darabinofuranosylguanine ([18F]F-AraG) 
Version Number:  3.0 
Version Date:  02-20-2018 
IND Number: 131349 
Principal Investigator (Sponsor-Investigator) 
Lawrence Fong, MD 
University of California San Francisco 
  
 
 
 
E-mail: Lawrence.Fong@ucsf.edu
Statistician 
 
Revision History 
Version 1.0 
03-20-16
Version 1.1 
06-01-16
Version 1.2 
06-29-16
Version 1.3 
Version 1.4 
07-25-16
08-29-16
Version 1.5 
Version 2.0 
06-27-17
02-13-18
Version 3.0 
02-20-18
NCT# 03007719

 
Version date: 02/20/2018 
Protocol CC#: 16709 
Phase II – [18F]F-AraG 
 
Page 2 of 35 
Protocol Signature Page 
Protocol No.: 16709 
Version Date: 02-20-2018 
1. I agree to follow this protocol version as approved by the UCSF Protocol Review Committee 
(PRC), Institutional Review Board (IRB), and Data Safety Monitoring Committee (DSMC).  
2. I will conduct the study in accordance with applicable IRB requirements, Federal regulations, 
and state and local laws to maintain the protection of the rights and welfare of study 
participants.  
3. I certify that I, and the study staff, have received the requisite training to conduct this 
research protocol.  
4. I have read and understand the information in the Investigators’ Brochure (or Manufacturer’s 
Brochure) regarding the risks and potential benefits. I agree to conduct the protocol in 
accordance with Good Clinical Practices (ICH-GCP), the applicable ethical principles, the 
Statement of Investigator (Form FDA 1572), and with local regulatory requirements. In 
accordance with the FDA Modernization Act, I will ensure the registration of the trial on the 
www.clinicaltrials.gov website.  
5. I agree to maintain adequate and accurate records in accordance with IRB policies, Federal, 
state and local laws and regulations. 
UCSF Principal Investigator / Study Chair 
 
 
Printed Name 
 
 
Signature 
 
Date 
 
 
 

 
Version date: 02/20/2018 
Protocol CC#: 16709 
Phase II – [18F]F-AraG 
 
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Abstract 
Title 
Functional imaging of T-cell activation with [18F]F-AraG in urothelial 
carcinoma patients receiving neoadjuvant or patients with cancer receiving 
standard of care anti-PD-1 or anti-PD-L1 
 
Patient 
population 
1. Patients with localized bladder cancer who are eligible for the UCSF 
phase 2 clinical trial of neoadjuvant anti-PD-1 or anti-PD-L1 before 
definitive surgery (NCT02451423) (Cohort 1), and  
2. Patients with any cancer type who are planned to initiate standard of care 
(SOC) anti-PD-1 or anti-PD-L1 (Cohort 2). 
 
Rationale for 
Study 
[18F]F-AraG is a novel PET imaging agent that has demonstrated selectivity 
for activated T-cells in preclinical models and T-cell leukemia cell lines.  
[18F]F-AraG has the potential to serve as a noninvasive functional biomarker 
in the monitoring of T-cell mediated anti-tumor immune response following 
administration of an immunotherapeutic agent. [18F]F-AraG had been 
administered in six healthy volunteers with no > Grade 1 adverse events, and 
the biodistribution of [18F]F-AraG has been determined in these volunteers on 
which radiation dosimetry estimated have been based.  
In this study, [18F]F-AraG uptake in the tumor before and after treatment with 
the anti-PD-1 or anti-PD-L1 antibody will be measured in localized bladder 
cancer patients receiving neoadjuvant anti-PD-1 or anti-PD-L1 in the context 
a clinical trial, as well as in patients with any cancer type (locally advanced or 
metastatic)  receiving SOC anti-PD-1 or anti-PD-L1.  Clinical response as well 
as T cell infiltration within the tumor of a pre-treatment biopsy or resection 
specimen will be correlated with changes in [18F]F-AraG uptake. In the 
neoadjuvant cohort, pathologic response as well as T cell infiltration within 
the tumor of the surgical specimen will also be correlated with changes in 
[18F]F-AraG uptake. Results from this pilot study will help to guide future 
clinical trials of [18F]F-AraG in the monitoring of anti-tumor immune 
responses. 
 
Primary 
Objective 
To assess the change in [18F]F-AraG uptake in primary and/or metastatic 
tumor(s) on whole-body [18F]F-AraG PET/MR imaging associated with 
neoadjuvant and SOC anti-PD-1 or anti-PD-L1 treatment. 
 

 
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Secondary 
Objectives 
1. To correlate change in [18F]F-AraG uptake within the primary tumor with 
clinical and pathologic response in patients treated with neoadjuvant 
anti-PD-1 or anti-PD-L1 (Cohort 1). 
2. To assess [18F]F-AraG uptake in lymphoid organs before and after anti-
PD-1 or anti-PD-L1 (Cohort 1 and 2). 
 
Exploratory 
Objectives 
1. To correlate change in [18F]F-AraG uptake within the primary tumor with 
quantification of tumor-infiltrating T cells in cystectomy specimen (Cohort 
1).  
2. To correlate change in [18F]F-AraG uptake within the primary tumor  
and/or metastatic tumor(s) with quantification of tumor-infiltrating T cells 
in a pre-treatment biopsy or resection specimen (Cohort 1 and 2). 
Study Design 
This is a single-center cross-sectional imaging study in patients with localized 
bladder cancer undergoing neoadjuvant atezolizumab as part of the 
companion clinical trial CC# 14524 (NCT02451423; Phase 2 study of 
atezolizumab in non-metastatic bladder transitional cell carcinoma), and 
patients with any cancer type (locally advanced or metastatic) receiving 
standard of care (SOC) anti-PD-1 or anti-PD-L1. For the neoadjuvant cohort, 
study participants will undergo whole body PET/MR imaging with [18F]F-AraG 
within 7 days of initiating atezolizumab and within 7 days before surgery. For 
the SOC cohort, study participants will undergo whole body PET/MR imaging 
with [18F]F-AraG within 7 days of initiating Cycle 1 anti-PD-1 or anti-PD-L1, 
and between Cycle 1 Day 15 (C1D15) and Cycle 2 Day 7 (C2D7) anti-PD-1 
or anti-PD-L1 (see Study Schema). A Simon’s two-stage design will be 
utilized. 
Number of 
patients 
A total of 31 patients will be enrolled over an accrual period of approximately 
20 months. 12 patients will be enrolled in the neoadjuvant atezolizumab 
cohort, and approximately 19 patients will be enrolled in the SOC anti-PD-1 
or anti-PD-L1 cohort.  
Duration of 
Therapy 
Each patient will undergo two PET/MR imaging scans. The first imaging will 
be performed within 7 days of starting anti-PD-1 or anti-PD-L1 (baseline). The 
second imaging will be performed within 7 days before surgery in the 
neoadjuvant cohort, and between C1D15 and C2D7 anti-PD-1 or anti-PD-L1 
in the SOC cohort. A bolus injection of [18F]F-AraG will be administered at 
each imaging time point. Each injection will be followed by up to two whole-
body PET/MR scans. Each probe injection plus PET/MR imaging session is 
estimated to last up to three hours. 
Duration of 
Follow up 
All patients will be followed for 7 days after each [18F]F-AraG PET/MR imaging 
time point for safety assessment.  

 
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Duration of 
study 
The study is anticipated to reach completion 20 months from the time the 
study opens to accrual. 
Study Drugs 
2′-deoxy-2′-[18F]fluoro-9-β-Darabinofuranosylguanine ([18F]F-AraG) is a 
radiopharmaceutical imaging agent that will be produced under CGMP 
(Current Good Manufacturing Practice) regulations under the direction of Dr. 
Jim Slater in the Department  of Radiology and Biomedical Imaging 
Radiopharmaceutical Facility at UCSF. A one-time nominal injection dose of 
<5.7mCi for male subjects and <4.4mCi for female subjects will be 
administered at each imaging time point. A simultaneous whole body MRI will 
be used for attenuation correction and anatomic localization of [18F]F-AraG 
uptake and SUV calculation. 
Safety 
Assessments 
Patients will be evaluated one day and one week via telephone visit after each 
radiopharmaceutical injection for safety follow-up. All adverse events will be 
recorded. Due to the noninvasive and non-therapeutic nature of the study, 
potential risks of the study are anticipated to be low. 
Unique 
Aspects of 
this Study 
To our knowledge, this is the first study to investigate changes in activated T 
cell localization in the setting of immunotherapy for cancer utilizing functional 
PET imaging. 
 
 
 

 
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Study Schema: 
 
 
 
 
Cohort 2: Standard of care (SOC) (N=19) 
Screening
Anti-PD-1 or anti-PD-L1 every 3 weeks until disease 
progression or unacceptable toxicity per SOC
Screening
Atezolizumab 1200mg every 3 weeks x 
1-3 cycles per CC# 14524
Surgery
Cohort 1: Neoadjuvant (N=12) 
Within 7 days of 
C1D1 atezolizumab 
Within 7 days before 
surgery 
Within 7 days of C1D1 
anti-PD-1 or anti-PD-L1 
Between C1D15 and C2D7 
anti-PD-1 or anti-PD-L1 

Age ≥18 

ECOG 0-1 

Eligible for CC# 14524 or eligible to 
receive anti-PD-1 or anti-PD-L1 per 
SOC 

Measurable disease 

No prior immunotherapy or known 
immunodeficiency 
Whole body [
18F]F-AraG PET/MRI imaging 

 
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List of Abbreviations 
AE 
adverse event 
BMP 
basic metabolic panel 
BUN 
blood urea nitrogen 
CBC 
complete blood cell (count) 
CGMP 
Current Good Manufacturing Practice 
CR 
complete response 
CRC 
Clinical Research Coordinator 
CRF 
case report form 
CT 
computerized tomography 
CTCEA 
Common Terminology Criteria for Adverse Events 
CTLA-4 
cytotoxic T-lymphocyte-associated protein 4 
CTMS 
Clinical Trial Management System 
dCK 
deoxycytidine kinase 
dGK 
doexyguanosine kinase 
DSMC 
Data and Safety Monitoring Committee 
DSMP 
Data and Safety Monitoring Plan 
ECOG 
Eastern Cooperative Oncology Group 
FAC 
2-fluoro-d-(arabinofuranosyl)cytosine 
F-AraG 
2′-deoxy-2′-fluoro-9-β-D-arabinofuranosylguanine 
FDA 
Food and Drug Administration 
FDG 
fluorodeoxyglucose 
F/U 
follow-up 
GCP 
Good Clinical Practice 
HDFCCC 
Helen Diller Family Comprehensive Cancer Center 
HIPAA 
Health Insurance Portability and Accountability Act (HIPAA) 
HIV 
human immunodeficiency virus 
ICF 
informed consent form 
ICH 
International Conference on Harmonization 
IND 
investigational new drug application 
IRB 
Institutional Review Board 
IHC 
Immunohistochemistry 
IV 
Intravenous 
MR 
magnetic resonance 
MRI 
magnetic resonance imaging 
NCI 
National Cancer Institute 

 
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List of Abbreviations 
PD-1 
programmed cell death protein 1 
PD-L1 
programmed death-ligand 1 
PET 
positron emission tomography 
PK 
Pharmacokinetics 
PR 
partial response 
PRC 
Protocol Review Committee 
RECIST 
Response Evaluation Criteria in Solid Tumors 
SOC 
standard of care 
SUV 
standardized uptake values 
TURBT 
transurethral resection of bladder tumor 
UA 
urinalysis 
WBC 
white blood cell 
 
 

 
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Table of Contents 
Protocol Signature Page ......................................................................................................... 2 
Abstract 
3 
List of Abbreviations ................................................................................................................ 7 
1 
Background and Study Rationale ................................................................................. 11 
2 
Objectives and Endpoints of the Study ......................................................................... 14 
2.1 
Objectives ......................................................................................................... 14 
2.1.1 
Primary Objective ......................................................................................... 14 
2.1.2 
Secondary Objectives ................................................................................... 14 
2.1.3 
Exploratory Objectives ................................................................................. 15 
2.2 
Endpoints .......................................................................................................... 15 
2.2.1 
Primary Endpoint .......................................................................................... 15 
2.2.2 
Secondary Endpoints .................................................................................... 15 
3 
Study Design ................................................................................................................ 15 
3.1 
Characteristics .................................................................................................. 15 
3.2 
Number of Subjects .......................................................................................... 16 
3.3 
Eligibility Criteria ............................................................................................. 16 
3.3.1 
Inclusion Criteria .......................................................................................... 16 
3.3.2 
Exclusion Criteria ......................................................................................... 16 
3.4 
Duration of Follow Up ..................................................................................... 17 
3.5 
Subject Replacement ........................................................................................ 17 
4 
Imaging Agent .............................................................................................................. 18 
5 
Study Procedures and Observations ............................................................................ 19 
5.1 
Study Assessments ........................................................................................... 19 
5.2 
Study Procedures .............................................................................................. 19 
5.3 
Follow Up Procedures ...................................................................................... 20 
5.4 
Prohibited Medications ..................................................................................... 20 
5.5 
Safety ................................................................................................................ 21 
6 
Study Calendar ............................................................................................................ 21 
7 
Reporting and Documentation of Results ..................................................................... 22 
7.1 
Evaluation of efficacy (or Activity) .................................................................. 22 
7.1.1 
Definitions .................................................................................................... 22 
7.2 
Evaluation of Safety ......................................................................................... 22 
7.3 
Definition of Adverse Events ........................................................................... 22 
7.3.1 
Adverse Event ............................................................................................... 22 
7.3.2 
Adverse Reaction .......................................................................................... 22 
7.4 
Recording of an Adverse Event ........................................................................ 23 
7.5 
Follow-up of Adverse Events ........................................................................... 24 
7.6 
Expedited Reporting ......................................................................................... 24 
8 
Statistical Considerations and Image Analysis ............................................................. 25 
8.1 
Image Processing and Analysis ........................................................................ 25 
8.2 
Sample Size Determination .............................................................................. 25 
8.3 
Accrual Estimates ............................................................................................. 26 

 
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8.4 
Interim Analysis and Safety Stopping Rule ..................................................... 26 
8.5 
Analytic Plan .................................................................................................... 26 
9 
Study Management ...................................................................................................... 27 
9.1 
Pre-study Documentation ................................................................................. 27 
9.2 
Institutional Review Board Approval ............................................................... 27 
9.3 
Informed Consent ............................................................................................. 27 
9.4 
Changes in the Protocol .................................................................................... 28 
10 
Protection of Human Subjects ...................................................................................... 28 
10.1 
Protection from Unnecessary Harm ................................................................. 28 
10.2 
Protection of Privacy ........................................................................................ 28 
References 
29 
Appendices 
30 
Appendix 1 
Performance Status Criteria .......................................................................... 30 
Appendix 2 
Data and Safety Monitoring Plan for a Phase 2 or 3 Institutional Study ......... 31 
Appendix 3 
UCSF Policy/Procedure for Required Regulatory Documents for a UCSF 
Investigator-Initiated Oncology Clinical Trials with an Investigator held 
Investigational New Drug (IND) ..................................................................... 33 
Appendix 4 MRI Screening Form ........................................................................................... 35 
  
 
 
 

 
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1 
Background and Study Rationale 
In recent years, advances in immunotherapy have resulted in remarkable and durable clinical 
responses in a subset of patients with advanced cancers. However, even among the tumor types 
that respond – including advanced melanoma and renal cell carcinoma – only 20%-30% of 
patients benefit from treatment, suggesting intrinsic immune resistance or an insufficient immune 
response (Restifo N et al., 2016). Furthermore, because immunotherapeutic agents act by 
inducing cancer-specific immune responses, clinical responses are typically delayed in 
comparison to conventional cytotoxic agents (Wolchok JD et al., 2009). A significant unmet need 
in the field is therefore the development of biomarkers to predict which patients are most likely to 
benefit from immunotherapy. 
Molecular imaging of immune activation by positron emission tomography (PET) is a potential 
noninvasive strategy to monitor immune activation after treatment with immunotherapy. Increased 
activity of nucleoside salvage pathways has been associated with the proliferation of adaptive 
and innate immune cells (Fox CJ et al., 2005, Soler C., 2001). In preclinical models of cancer and 
autoimmunity, the PET probe [18F]–2-fluoro-d-(arabinofuranosyl)cytosine ([18F]-FAC), which 
targets the deoxycytidine salvage pathway, was shown to localize to sites of immune activation 
(Radu CG et al., 2008) and is predominantly accumulated in proliferative CD8+ T cells (Nair-Gill 
E et al., 2010). 
Recently, a radiofluorinated AraG imaging agent, [18F]F-AraG (2′-deoxy-2′-fluoro-9-β-D-
arabinofuranosylguanine; trade name VisAcT) was synthesized (Namavari M et al., 2010) with a 
goal of development for human use. F-AraG is a fluorinated purine derivative with selective T-cell 
toxicity. A water-soluble AraG prodrug, Nelarabine, is FDA approved for the treatment of relapsed 
T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphomas (DeAngelo DJ, 2009). 
[18F]F-AraG preferentially accumulates in murine and human activated T cells than in naive T cells 
(Figure 1). The accumulation of [18F]F-AraG in human activated T cells is also significantly higher 
than other immune cells, including B cells, macrophages, and dendritic cells (unpublished data). 
Furthermore, endogenously induced anti-tumor immune response in a viral induced 
rhabdomyosarcoma (MSV) mouse model was correlated with enhanced [18F]F-AraG uptake 
within the tumors (Figure 2a). Analysis of isolated tumors showed that tracer preferentially 
accumulated in activated CD8+ T cells (Figure 2b). 
[18F]F-AraG is a high affinity substrate for doexyguanosine kinase (dGK) and a low affinity 
substrate for deoxycytidine kinase (dCK). Both dGK and dCK are over-expressed in activated T 
cells. Blocking the expression of either dGK or dCK causes reduction in [18F]F-AraG 
accumulation, while over-expression of either dGK or dCK leads to increased accumulation of 
[18F]F-AraG. 
The first-in-human study of [18F]F-AraG was performed at UCSF in 2015 (Yaghoubi S et al., 2015). 
[18F]F-AraG was administered at a subpharmacologic, tracer microdose consistent with imaging 
practices in six healthy volunteers (3 males and 3 females). The distribution of the tracer was 
evaluated over the first 4 hours after injection. A representative whole body PET/MR image in a 
healthy volunteer is shown in Figure 3. The tracer was well tolerated by all patients and there 
were no > Grade 1 adverse events. The only AE that occurred in more than one volunteer was 
positive WBC esterase in the urinalysis without urinary symptoms. Normal uptake was seen in 
the clearance organs: liver, kidneys and bladder. There appeared to be uptake in the thyroid and 
parotid glands, as well as limited accumulation in the cardiac muscle.  In these first-in human 
studies, no additional drugs were administered to subjects as the biodistribution was determined 

 
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for radiation dose estimates.  However, in the present study, oral fluid intake and a diuretic 
(furosemide) will be administered for subjects to allow rapid clearance of the excreted radiotracer 
from the renal collecting systems and to provide diluted radiotracer within the background of the 
bladder, and to enable clear evaluation of distribution of the radiopharmaceutical in the walls of 
the ureters, bladder, and surrounding structures.   
Given that immunotherapeutic strategies, in particular immune checkpoint antibodies, focus on 
the generation of T-cell-based antitumor immunity, we hypothesize that uptake of [18F]F-AraG 
within the tumor will correlate with T-cell mediated immune response in cancer patients treated 
with immune checkpoint blockade. In May 2016, atezolizumab (Tecentriq), an anti-PD-L1 
developed by Genentech Inc. was granted FDA approval for the treatment of previously treated 
locally advanced or metastatic urothelial carcinoma that had progressed during or following 
platinum-containing chemotherapy or that had progressed within 12 months of neoadjuvant or 
adjuvant treatment with platinum-containing chemotherapy. This approval was based on results 
of a single-arm phase 2 study of atezolizumab in 310 patients with locally advanced or metastatic 
urothelial carcinoma, demonstrating an objective response rate (ORR) of 14.8% overall, and an 
ORR of 26% in patients classified as PD-L1 positive by immunohistochemistry (Rosenberg JE, 
2009). Since then, in April 2017, atezolizumab was also approved in the front-line setting in 
patients with locally advanced or metastatic urothelial carcinoma who are not eligible for cisplatin-
based chemotherapy (Balar AV et al., 2017).   
Currently, PD-L1 inhibitors are approved for bladder cancer, non-small cell lung cancer, and 
Merkel cell skin cancer (Merkel cell carcinoma), and PD-1 inhibitors are approved for melanoma 
of the skin, non-small cell lung cancer, kidney cancer, bladder cancer, head and neck cancers, 
and Hodgkin lymphoma. FDA-approved anti-PD-1/L1 medications include: 
• 
Pembrolizumab 
• 
Avelumab 
• 
Atezolizumab 
• 
Nivolumab 
• 
Durvalumab 
 
In this study, patients with localized bladder cancer eligible for a companion neoadjuvant trial of 
atezolizumab in non-metastatic bladder transitional cell carcinoma (CC# 14524; NCT02451423), 
as well as patients with any cancer type (locally advanced or metastatic) planned to receive anti-
PD-1 or anti-PD-L1 per SOC will undergo two whole body PET/MR imaging to assess for changes 
in tracer uptake with PD-L1 blockade. The neoadjuvant cohort in this study provides a unique 
opportunity to evaluate the correlation of post-treatment intratumoral immune filtration as well as 
pathologic clinical response with tracer uptake. Results from this study will guide the development 
of future clinical trials investigating the role of [18F]F-AraG in the monitoring of anti-tumor immune 
responses. 
 
 

 
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Figure 1: [18F]F-AraG preferentially accumulates in activated T cells than in naive T cells. 
(A) Uptake of [18F]F-AraG in human and mouse primary T cells post-stimulation. (B) Pan T cells 
were isolated from spleen and lymph nodes of mice. Untreated cells as well as CD3/CD28 
activated T cells (48 hours) were incubated with [18F]F-AraG before subcutaneous implantation 
into the shoulders before PET/CT imaging. 
A.                                                                                                     B. 
      
 
 
Figure 2: Visualization of endogenously induced anti-tumor immune response in a viral 
induced rhabdomyosarcoma (MSV) mouse model with [18F]F-AraG PET. (A) Viral induced 
rhabdomyosarcoma was implanted in the left hindleg, and P815 mastocytoma (control) was 
implanted in the right shoulder. PET/CT was performed on day 14 during the peak anti-tumor 
immune response in the rhabdomyosarcoma model. (B) CD8+, CD4+ and C19+ cells were 
isolated from rhabdomyosarcoma tumor one hour after probe injection for radioactivity assay. 
 
A.                                                 B. 
    
 
 

 
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Figure 3: Whole body [18F]F-AraG PET/MR image in a healthy volunteer. 
 
 
2 
Objectives and Endpoints of the Study 
2.1 
Objectives 
2.1.1 Primary Objective 
To assess the change in [18F]F-AraG uptake in primary and/or metastatic tumor(s) on whole-body 
[18F]F-AraG PET/MR imaging associated with neoadjuvant and SOC anti-PD-1 or anti-PD-L1 
treatment. 
2.1.2 Secondary Objectives 
1. To correlate change in [18F]F-AraG uptake within the primary tumor with clinical and 
pathologic response in patients treated with neoadjuvant atezolizumab (Cohort 1). 
 
2. To assess [18F]F-AraG uptake in lymphoid organs before and after anti-PD-1 or anti-PD-L1 
(Cohort 1 and 2).   
 

 
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2.1.3 Exploratory Objectives 
1. To correlate change in [18F]F-AraG uptake within the primary tumor with quantification of 
tumor-infiltrating T cells in cystectomy specimen (Cohort 1). 
2. To correlate change in [18F]F-AraG uptake within the primary tumor  and/or metastatic 
tumor(s) with quantification of tumor-infiltrating T cells in a pre-treatment biopsy or resection 
specimen (Cohort 1 and 2). 
 
2.2 
Endpoints 
2.2.1 Primary Endpoint 
To describe the change between pre-treatment and post-treatment maximum standardized 
uptake values (SUVmax) in the primary and/or metastatic tumor(s) on whole-body [18F]F-AraG 
PET/MR imaging by study cohort.    
 
2.2.2 Secondary Endpoints 
1. 
To compare change in SUVmax of the primary tumor in patients who achieve pathologic down-
staging (e.g. complete pathologic response) or clinical response (measured by RECIST 
v1.1), and those without pathologic or clinical response at time of surgery in patients receiving 
neoadjuvant atezolizumab (Cohort 1). 
 
2. 
To describe the change between pre-treatment and post-treatment SUVmax in lymphoid 
organs (e.g. lymph nodes) on whole-body [18F]F-AraG PET/MR imaging (Cohort 1 and 2). 
 
 
2.2.3 Exploratory Endpoints 
 
1. 
To correlate change in SUVmax of the primary tumor with the number of tumor-infiltrating 
CD3+ and CD3+CD8+ T cells in the surgical specimen quantified by immunohistochemistry 
(IHC) and image analysis in patients receiving neoadjuvant atezolizumab (Cohort 1). 
2. 
To correlate change in SUVmax of the primary and/or metastatic tumor(s) with the number of 
tumor-infiltrating CD3+ and CD3+CD8+ T cells in the pre-treatment biopsy or resection 
specimen quantified by immunohistochemistry (IHC) and image analysis in patients receiving 
SOC anti-PD-1 or anti-PD-L1 (Cohort 1 and 2). 
 
3 
Study Design 
3.1 
Characteristics 
This is a single-center cross-sectional imaging study in patients with localized bladder cancer 
undergoing neoadjuvant atezolizumab as part of the companion clinical trial CC# 14524 
(NCT02451423; Phase 2 study of atezolizumab in non-metastatic bladder transitional cell 

 
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carcinoma), and patients with any cancer type (locally advanced or metastatic) receiving SOC 
anti-PD-1 or anti-PD-L1. Only anti-PD-1/L1 FDA approved for a given cancer will be used for 
Cohort 2. For the neoadjuvant cohort, study participants will undergo whole body PET/MR 
imaging with [18F]F-AraG within 7 days of initiating atezolizumab and within 7 days before surgery. 
For the SOC cohort, study participants will undergo whole body PET/MR imaging with [18F]F-AraG 
within 7 days of initiating Cycle 1 anti-PD-1 or anti-PD-L1 and between Cycle 1 Day 15 and Cycle 
2 Day 7 anti-PD-1 or anti-PD-L1. 
3.2 
Number of Subjects 
A total of 31 patients will be enrolled over an accrual period of approximately 20 months. Twelve 
(12) patients will be enrolled in the neoadjuvant atezolizumab cohort, and 19 patients will be 
enrolled in the SOC anti-PD-1 or anti-PD-L1cohort. 
3.3 
Eligibility Criteria 
Patients must have baseline evaluations performed prior to the first injection of [18F]F-AraG and 
must meet all inclusion and exclusion criteria. In addition, the patient must be thoroughly informed 
about all aspects of the study, including the study visit schedule and required evaluations and all 
regulatory requirements for informed consent. The written informed consent must be obtained 
from the patient prior to enrollment. The following criteria apply to all patients enrolled onto the 
study unless otherwise specified. 
3.3.1 Inclusion Criteria 
1. Age >18 years 
2. Histologically or cytologically documented cancer to which anti-PD1 or anti-PDL1 are 
approved therapies 
3. Eligible for with plan to undergo neoadjuvant treatment with atezolizumab followed by 
surgery as part CC# 14524, or planned to undergo treatment with anti-PD-1 or anti-PD-L1 
per standard of care  
4. Must have measurable disease by RECIST v1.1 regardless of disease stage (e.g. 
localized, locally advanced, or metastatic) 
5. In female patients, negative pregnancy test with no plans to become pregnant during the 
duration of the study  
6. Able to provide informed consent and follow the study guidelines 
7. Archival tumor tissue from biopsy or resection will be required for all patients. Archival 
tissue should be of good quality based on total and viable tumor contents. Fine-needle 
aspiration, brushing, and cytologic cell pellets are not acceptable. 
 
3.3.2 Exclusion Criteria  
1. History of prior treatment with immune checkpoint antibodies (e.g. anti-PD-1, anti-PD-L1, 
anti-CTLA-4 antibody) or co-stimulatory agonist antibodies (e.g. anti-41BB, anti-OX40) 
 

 
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a. Prior intravesical treatment with BCG is allowed. However, the last dose must be 
at least 6 weeks from time of enrollment and patients must have documented 
progressive disease at least 6 weeks from completion of last BCG. 
 
2. Diagnosis of immunodeficiency including history of Human Immunodeficiency Virus 
(HIV) 
 
3. Receiving systemic steroid therapy or any form of immunosuppressive therapy within 7 
days prior to first injection of [18F]F-AraG.  
a. Topical and inhaled corticosteroids are allowed. 
 
4. Prior allogeneic stem cell or solid organ transplant 
 
5. Known psychiatric or substance abuse disorders that would interfere with cooperation 
with the requirements of the study 
 
6. Biopsy or resection of the primary tumor within 14 days the first injection of [18F]F-AraG 
 
7. Contraindication to MRI imaging, as determined through review of the UCSF MRI 
screening form by study investigator (Appendix 4) 
a. UCSF screening form available online: 
https://radiology.ucsf.edu/sites/radiology.ucsf.edu/files/wysiwyg/research/brainch
ange/MRI%20Screening%20Form-BrainChange.pdf 
 
8. Evidence of active infection within 14 days of study enrollment 
 
9. Female patients who are pregnant or breastfeeding 
  
10. Inability to receive furosemide (Lasix), in the opinion of the treating investigator 
 
11. Patients that plan to receive off-label use of anti-PD1 or anti-PDL1 
 
3.4 
Duration of Follow Up 
Patients will be followed for 7 days after each [18F]F-AraG PET/MR imaging time point for safety 
assessment. Specifically, patients will be evaluated by telephone one day and one week after 
each radiopharmaceutical injection for safety follow-up. All adverse events will be recorded and 
graded according to CTCAE v4.0. 
3.5 
Subject Replacement  
All patients who receive any dose [18F]F-AraG of will be analyzed for safety. Subjects who 
discontinue from study participation prior to completing a second PET/MR scan will be replaced. 
Patients removed from study for unacceptable treatment related adverse event(s) will be 
followed until resolution or stabilization of all treatment related AEs to Grade 0-1. 
 

 
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4 
Imaging Agent 
[18F]F-AraG is a radiopharmaceutical that will be produced under cGMP under the direction of 
Jim Slater, PhD., in the Department of Radiology and Biomedical Imaging Radiopharmaceutical 
Facility. The radiopharmaceutical will be prepared in the same facility in which the injection and 
imaging will take place, the China Basin Imaging Center. In a prior study of 6 healthy volunteers 
imaged with [18F]F-AraG, there were no Grade >1 adverse events related to tracer injection, and 
organ-specific dosimetry was within acceptable range.  
[18F]F-AraG will be administered by a licensed nuclear medicine technologist under the 
supervision of a physician boarded in nuclear medicine on an outpatient basis. It will be 
administered at a single time point intravenously prior to PET imaging, at a subpharmacologic, 
tracer microdose consistent with imaging practices. The one-time nominal injected dose will be 
less than or equal to 5.7 mCi for male patients and less than or equal to 4.4 mCi for female 
patients. A simultaneous whole body MRI (PET/MR) will be used for attenuation correction and 
anatomic localization of [18F]F-AraG uptake and SUV calculation. Each [18F]F-AraG injection will 
be followed by a whole body PET/MR acquisition, immediately followed by a limited PET/MR 
acquisition that includes only the pelvic region. The patient will not need to be repositioned 
between the acquisitions. The limited PET/MR dedicated pelvic region acquisition will not add 
any additional radiation exposure, and will require only 5-10 additional minutes. Each probe 
injection plus PET/MR imaging session (on and off the scanner) is estimated to last 
approximately 60 to 90 minutes. 
Patients will be asked to drink 16 ounces of water approximately 30 minutes prior to furosemide 
(Lasix) administration. 20 mg Lasix will be administered intravenously 10-30 minutes prior to 
injection of radiopharmaceutical. The patient will void 30 to 45 minutes after Lasix 
administration. PET/MR imaging will then be performed from the bottom up so that the 
surrounding tissues is optimally visualized. After completion of the whole body imaging, a repeat 
3-minute tumor image will be acquired at the end of imaging.  
Figure 4: Bladder tumor visualization with [18F]FDG. (A) No Lasix administration. (B) Patient 
with exophytic bladder mass with Lasix administration at time of tracer injection. (C) Patient with 
bladder thickening with Lasix administration at time of tracer injection.  
A.                                            B.                                          C. 
 

 
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5 
Study Procedures and Observations 
A written, signed, informed consent form (ICF) and a Health Insurance Portability and 
Accountability Act (HIPAA) authorization must be obtained before any study-specific 
assessments are initiated. A copy of the signed ICF will be given to the subject and a copy will be 
filed in the medical record. The original will be kept on file with the study records. 
5.1 
Study Assessments 
The Screening procedures and assessments must be completed within 28 days of the day 1 
Visit unless otherwise noted (i.e., baseline staging scans). 
• 
Vital signs 
• 
Height and weight 
• 
Physical examination and medical history 
• 
Performance status 
• 
Baseline staging scans with CT chest, head, and/or neck + CT or MRI of the 
abdomen/pelvis + bone scan within 42 days of study enrollment  
o Patients may receive staging scans and [18F]F-Ara PET/MR imaging on the same 
day if the patient meets eligibility criteria for the study as assessed by Principal 
Investigator prior to the completion of the scan. 
• 
MRI screening form (Appendix 4) 
• 
Tissue collection 
o Archival tumor tissue from biopsy or resection will be collected for all patients. 
• 
Baseline labs performed during screening window of Day -28 to Day +1 
o CBC with differential* 
o BMP* 
o Urinalysis*  
o Pregnancy test for women of childbearing potential* 
*If already performed in the screening window (e.g. during screening for corresponding 
neoadjuvant atezolizumab study protocol), will not need to be repeated. 
5.2 
Study Procedures 
[18F]F-Ara experimental PET radiopharmaceutical (hereafter referred to as 
“radiopharmaceutical”) 
• 
Vital signs and EKG will be recorded before and after completion of imaging. 
• 
Administration of Furosemide (Lasix) 
o Patients who are not eligible to receive Lasix are excluded from this study 
(Section 3.3.2). 

 
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o Because [18F]F-AraG is renally excreted with uptake in the urine, patients will be 
encouraged to drink 16 ounces of water approximately 30 minutes before 
furosemide (Lasix) administration, and will receive 20 mg of Lasix intravenously 
within 10-30 minutes prior to injection of the radiopharmaceutical.  
o Patients will void 30 to 45 minutes after Lasix administration. PET/MR imaging 
will then be performed from the bottom up so that the surrounding tissue is 
optimally visualized. 
o A Foley catheter may be placed if Lasix diuresis and voiding fails to provide 
adequate image quality. 
• 
[18F]F-AraG PET/MR imaging 
o Patient shall begin imaging between 1 to 180 minutes after the injection of the 
radiopharmaceutical. Coverage for the scan will extend from the top of the 
patient’s head through the toes.  
o Each [18F]F-AraG injection will be followed by a whole body PET/MR acquisition, 
immediately followed by a limited PET/MR acquisition that includes only the 
targeted tumor region. The patient will not need to be repositioned between the 
acquisitions. The limited PET/MR dedicated target region acquisition will not add 
any additional radiation exposure, and will require only 5-10 additional minutes.  
o Simultaneous whole body MRI (PET/MR) will be performed for attenuation 
correction. 
o Each probe injection plus PET/MR imaging session (on and off the scanner) is 
estimated to last approximately 60 to 90 minutes. 
o No formal report of the findings from imaging studies will be created. Each study 
will be reviewed by a board certified nuclear medicine physician and radiologist 
within one week after completion of the study. An expert molecular imaging 
investigator will analyze all data. 
 
Exception: If an acute and new finding is found on MRI, this finding will be 
reported and documented, and the investigator will be notified. 
5.3 
Follow Up Procedures  
Patients will be evaluated one day and one week by telephone after the radiopharmaceutical 
injection for safety follow-up. All adverse events will be recorded. 
• 
Cohort 1 (neoadjuvant cohort):Following completion of neoadjuvant atezolizumab cycles 
per corresponding study protocol, the patient will return for repeat imaging within 7 days 
of undergoing surgery. 
• 
Cohort 2 (SOC cohort): Between Cycle 1 Day 15 and Cycle 2 Day 7 anti-PD-1 or anti-
PD-L1, the patient will return for repeat imaging. 
 
5.4 
Prohibited Medications 
Patients should receive no systemic therapy for their cancer other than anti-PD-1 or anti-PD-L1 
prior to completion of the two planned [18F]F-AraG PET scans. 

 
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5.5 
Safety  
Patients will be evaluated via telephone on the day after and at one week after each 
radiopharmaceutical injection for safety follow-up. All adverse events will be recorded. For 
patients in the neoadjuvant cohort (Cohort 1), the principle investigator and study personnel 
(e.g. clinical research coordinator) of the corresponding neoadjuvant atezolizumab study will 
also be informed of the [18F]F-AraG PET/MR imaging dates for each patient, and will follow up 
with any adverse events related to imaging during subsequent study clinic visits (e.g. Cycle 1 
Day 1 visit after baseline imaging).   
 
Potential risks of the study are anticipated to be low. Should a patient experience a Grade 1 or 
Grade 2 adverse event at the time of baseline scan which subsequently resolves, he/she may 
proceed with undergoing the second (pre-surgery) PET/MR imaging.  
 
In the situation that a patient experiences a Grade 3 or higher adverse event at the time of 
baseline scan, the study should be permanently discontinued for that patient. The study will be 
halted after one serious adverse reaction attributable to [18F]F-AraG is seen or if over 20% of 
patients experience Grade 3 or higher toxicities for re-evaluation of tracer dose (Section 8.4). 
6 
Study Calendar 
 
 
First (baseline) imaging 
Second imaging 
 
Screening 
(Day -28 
to 1) 
Day 1 
(Image) 
Safety Follow Up 
Day 1 
(Image) 
Safety Follow-Up 
Day 2 
(Tele) 
Day 8 
(Tele) 
Day 2 
(Tele) 
Day 8 
(Tele) 
Informed consent 
X 
 
 
 
 
 
 
Medical history 
X 
 
 
 
 
 
 
Physical exam 
X 
 
 
 
 
 
 
Performance status 
X 
 
 
 
 
 
 
Baseline staging scans1 
X 
 
 
 
 
 
 
Height 
X 
 
 
 
 
 
 
Weight 
X 
 
 
 
 
 
 
Vitals2 
X 
X 
 
 
X 
 
 
Pregnancy test3 
X 
 
 
 
 
 
 
CBC, BMP and UA4 
X 
 
 
 
 
 
 
MRI screening form5 
X 
 
 
 
 
 
 
Tissue collection6 
X 
 
 
 
 
 
 
Furosemide (Lasix)7 
 
X 
 
 
X 
 
 
[18F]F-AraG PET/MR 
imaging8 
 
X 
 
 
X 
 
 
Electrocardiogram9 
 
X 
 
 
X 
 
 
AE Assessment9 
 
X 
X 
X 
X 
X 
X 
 
1 Patients may receive staging scans and [18F]F-Ara PET/MR imaging on the same day if the patient meets eligibility criteria for the 
study as assessed by Principal Investigator prior to the completion of the scan. 
2 Vitals consist of heart rate, blood pressure, blood oxygen %, temperature, and respiratory rate. On imaging days, vitals are 
collected before and after imaging. 
3 Pregnancy tests are performed for women of childbearing potential.   
4 Screening labs, including CBC with differential, BMP and urinalysis are required if not already performed by the corresponding 
neoadjuvant atezolizumab study protocol or SOC. 
5 The study investigator will review the UCSF MRI screening form to confirm no contraindication to MRI imaging. 
6 Archival tissue from tumor resection or biopsy should be of good quality based on total and viable tumor contents. Fine-needle 
aspiration, brushing, and cytologic cell pellets are not acceptable.  

 
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7 Patients will be encouraged to drink 16 ounces of water approximately 30 minutes before furosemide (Lasix) administration, and 
will receive 20 mg of Lasix intravenously within 10-30 minutes prior to injection of the radiopharmaceutical. Patients will void 30 to 
45 minutes after Lasix administration before PET/MR imaging. 
8 PET/MR imaging will be performed from the bottom up so that the surrounding tissues is optimally visualized. 
9 Electrocardiograms are assessed before and after imaging. Adverse events are assessed by a physician on the research team 
after imaging. 
 
7 
Reporting and Documentation of Results 
7.1 
Evaluation of efficacy (or Activity) 
7.1.1 Definitions 
Evaluable for toxicity 
All patients will be evaluable for toxicity from the time of [18F]F-AraG administration. 
7.2 
Evaluation of Safety 
Analyses will be performed for all patients receiving the radiotracer.  The study will use the CTCAE 
v4.0 for reporting of adverse events. 
7.3 
Definition of Adverse Events 
7.3.1 Adverse Event 
An adverse event (also known as an adverse experience) is defined as any untoward medical 
occurrence associated with the use of a drug in humans, whether or not considered drug related.  
More specifically, an adverse event (can be any unfavorable and unintended sign (e.g., an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a drug, 
without any judgment about causality.  An adverse event can arise from any use of the drug (e.g., 
off-label use, use in combination with another drug) and from any route of administration, 
formulation, or dose, including an overdose.  
7.3.2 Adverse Reaction 
An adverse reaction is defined as any adverse event caused by the use of a drug.  Adverse 
reactions are a subset of all suspected adverse reactions for which there is reason to conclude 
that the drug caused the event. 
7.3.2.1 Suspected  
A suspected adverse reaction is defined as any adverse event for which there is a reasonable 
possibility that the drug caused the adverse event. For the purposes of IND safety reporting, 
“reasonable possibility” indicates that there is evidence to suggest a causal relationship between 
the drug and the adverse event.  A suspected adverse reaction implies a lesser degree of certainty 
about causality than an adverse reaction. 
7.3.2.2 Unexpected 
An adverse event or suspected adverse reaction is considered unexpected if it is not listed in the 
investigator brochure or package insert(s), or is not listed at the specificity or severity that has 
been observed, or, if an investigator brochure is not required or available, is not consistent with 
the risk information described in the general investigational plan or elsewhere in the current 
application.  

 
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“Unexpected,” as used in this definition, also refers to adverse events or suspected adverse 
reactions that are mentioned in the investigator brochure as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug, but are not specifically mentioned as 
occurring with the particular drug under investigation. 
Adverse events that would be anticipated to occur as part of the disease process are considered 
unexpected for the purposes of reporting because they would not be listed in the investigator 
brochure.  For example, a certain number of non-acute deaths in a cancer trial would be 
anticipated as an outcome of the underlying disease, but such deaths would generally not be 
listed as a suspected adverse reaction in the investigator brochure. 
7.3.2.3 Serious 
An adverse event or suspected adverse reaction is considered serious if, in the view of either 
the investigator or sponsor, it results in any of the following outcomes:  
• 
Death 
• 
Life-threatening adverse event 
• 
Inpatient hospitalization or prolongation of existing hospitalization 
• 
A persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life function 
• 
Congenital anomaly/birth defect 
Important medical events that may not result in death, are life-threatening, or require 
hospitalization may be considered serious when, based upon appropriate medical judgment, they 
may jeopardize the patient or subject and may require medical or surgical intervention to prevent 
one of the outcomes listed in this definition.  Examples of such medical events include allergic 
bronchospasm requiring intensive treatment in an emergency room or at home, blood dyscrasias 
or convulsions that do not result in inpatient hospitalization, or the development of drug 
dependency or drug abuse. 
7.3.2.4 Life-threatening 
An adverse event or suspected adverse reaction is considered life-threatening if, in the view of 
either the investigator or sponsor, its occurrence places the patient or subject at immediate risk 
of death. It does not include an adverse event or suspected adverse reaction that, had it occurred 
in a more severe form, might have caused death.  
7.4 
Recording of an Adverse Event 
All grade 3 and above adverse events will be recorded using the NCI CTCAE v4.0.   The 
Investigator will assign attribution of the possible association of the event with use of the 
investigational drug.  

 
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Relationship  
Attribution  
Description  
Unrelated to investigational 
drug/intervention 
Unrelated 
The AE is clearly NOT related to the 
intervention  
Unlikely 
The AE is doubtfully related to the 
intervention  
Related to investigational 
drug/intervention 
Possible 
The AE may be related to the intervention  
Probable 
The AE is likely related to the intervention  
Definite 
The AE is clearly related to the intervention  
 
Signs or symptoms reported as adverse events will be graded and recorded by the Investigator 
according to the CTCAE.  When specific adverse events are not listed in the CTCAE they will be 
graded by the Investigator as none, mild, moderate or severe according to the following grades 
and definitions: 
Grade 0 
No AE (or within normal limits) 
Grade 1 
Mild; asymptomatic or mild symptoms; clinical or diagnostic observations only; 
intervention not indicated 
Grade 2 
Moderate; minimal, local, or noninvasive intervention (e.g., packing, cautery) 
indicated; limiting age-appropriate instrumental activities of daily living (ADL) 
Grade 
3: 
Severe or medically significant but not immediately life-threatening; 
hospitalization or prolongation of hospitalization indicated; disabling; limiting self-
care ADL 
Grade 
4: 
Life-threatening consequences; urgent intervention indicated 
Grade 
5: 
Death related to AE 
7.5 
Follow-up of Adverse Events 
All adverse events will be followed with appropriate medical management until resolved.  Patients 
removed from study for unacceptable adverse events will be followed until resolution or 
stabilization of the adverse event. For selected adverse events for which administration of the 
investigational drug was stopped, a re-challenge of the subject with the investigational drug may 
be conducted if considered both safe and ethical by the Investigator. 
 
7.6 
Expedited Reporting 
Reporting to the Data and Safety Monitoring Committee 
If a death occurs during the treatment phase of the study or within 30 days after the last 
administration of the study drug(s) and it is determined to be related either to the study drug(s) or 
to a study procedure, the Investigator or his/her designee must notify the DSMC Chair (or qualified 
alternate) within 1 business day of knowledge of the event.  The contact may be by phone or e-
mail. 
Reporting to UCSF Institutional Review Board 
The Principal Investigator must report events meeting the UCSF IRB definition of “Unanticipated 
Problem” (UP) within 10 business days of his/her awareness of the event.  

 
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Expedited Reporting to the Food and Drug Administration 
If the study is being conducted under an IND, the Sponsor-Investigator is responsible for 
determining whether or not the suspected adverse reaction meets the criteria for expedited 
reporting in accordance with Federal Regulations (21 CFR §312.32).  
The Investigator must report in an IND safety report any suspected adverse reaction that is both 
serious and unexpected.  The Sponsor-Investigator needs to ensure that the event meets all three 
definitions:  
• 
Suspected adverse reaction (as defined in 7.3.2.1) 
• 
Unexpected (as defined in 7.3.2.2) 
• 
Serious (as defined in 7.3.2.3) 
If the adverse event does not meet all three of the definitions, it should not be submitted as an 
expedited IND safety report. 
The timeline for submitting an IND safety report to FDA is no later than 15 calendar days after 
the Investigator determines that the suspected adverse reaction qualifies for reporting (21 CFR 
312.32(c)(1)).  
Any unexpected fatal or life-threatening suspected adverse reaction will be reported to FDA no 
later than 7 calendar days after the Investigator’s initial receipt of the information (21 CFR 
312.32(c)(2)).  
Any relevant additional information that pertains to a previously submitted IND safety report will 
be submitted to FDA as a Follow-up IND Safety Report without delay, as soon as the information 
is available (21 CFR 312.32(d)(2)). 
 
8 
Statistical Considerations and Image Analysis 
8.1 
Image Processing and Analysis 
Trained nuclear medicine physicians and molecular imaging scientists will evaluate the 
reconstructed PET, PET/MR images using a PET volume computer-assisted reading software 
package. Volumetric regions of interest will be chosen around tumors based on anatomic (MR) 
images and activity within the tumor will be expressed in a standardized uptake value (SUV) 
format where SUV will be defined as [concentration of tracer in tumor]/(injected dose/body 
weight). Tumor SUV at baseline (before anti-PD-1 or anti-PD-L1 treatment) will be compared 
with the post–therapy values to determine the change in SUV associated with the therapy. 
Whole body images will be analyzed to determine differences in tracer distribution relative to 
pre/post therapy and versus the normal subject pool already studied.    
8.2 
Sample Size Determination 
The sample size determination is based on the primary endpoint of the study, the change between 
pre-treatment and post-treatment SUVmax in the primary and/or metastatic tumor(s) and on [18F]F-
AraG PET/MR imaging. The null hypothesis is that post-treatment SUVmax increases by at least 
2-fold compared to baseline SUVmax in 1% patients. The alternative hypothesis is that post-
treatment SUVmax increases by at least 2-fold compared to baseline SUVmax in 20% patients. For 
the SOC cohort (Cohort 2), a Simon’s two-stage design will be used. Eight patients will be accrued 

 
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initially, if no patient is observed to have a post-treatment SUVmax that increases by at least 2-fold 
compared to baseline SUVmax, the study will be halted; otherwise, an additional 11 patients will 
be accrued. The null hypothesis will be rejected if 2 or more of the 19 patients are observed to 
have at least a 2-fold increase in post-treatment SUVmax compared to baseline SUVmax. This 
design yields a type I error rate of 0.05 and power of 80%. For the neoadjuvant cohort (Cohort 1), 
one-stage design will be applied with 12 patients accrued to ensure 80% power at a significance 
level of 0.05. 
8.3 
Accrual Estimates 
The anticipated accrual rate is approximately 1-2 patients per month, leading to an estimated total 
accrual period of 20 months. Twelve (12) patients are anticipated to be enrolled in the neoadjuvant 
atezolizumab cohort, and 19 patients are anticipated to be enrolled in the SOC anti-PD-1 or anti-
PD-L1 cohort. A total of 31 patients will be accrued. 
8.4 
Interim Analysis and Safety Stopping Rule 
Interim analysis will be performed only for the SOC cohort (Cohort 2). After 8 patients are imaged 
at both baseline and post-treatment time points, the acquired PET/MR imaging results will be 
reviewed. If the post-treatment SUVmax increases by at least 2-fold compared to baseline SUVmax 
for at least one patient, the study will continue accrual for a total of 19 patients. If no patient is 
observed to have a post-treatment SUVmax that increases by at least 2-fold compared to baseline 
SUVmax, the study will be halted and the imaging protocol re-evaluated, with particular attention 
to the post-treatment imaging time point. Subsequently, the scan results will be analyzed on a 
continuous basis, and accrual may be halted to adjust imaging parameters on an as needed basis. 
Complete safety data will also be analyzed at the time of interim analysis. Accrual will be halted 
after one serious adverse reaction attributable to [18F]F-AraG is seen. If Grade 3 or higher 
toxicities are observed in more than 20% of all patients accrued which are attributable to [18F]F-
AraG, the study will be stopped and the dose of the of [18F]F-AraG reexamined.  
8.5 
Analytic Plan 
The median and interquartile range of SUVmax within the tumor and lymphoid tissues across all 
patients will be descriptively reported for baseline (before treatment) and post-treatment images, 
separately. The nonparametric paired Wilcoxon Signed-rank test will be used to assess 
differences in SUVmax before and after treatment. The log2 ratio of post-treatment versus baseline 
SUVmax within the tumor and lymphoid tissues will also be calculated.  
 
To correlate change in SUVmax to clinical and/or pathologic response, patients will be divided into 
two groups: those who achieved clinical response and/or pathologic downs-staging, and those 
who did not. The median and interquartile range of change in SUVmax from baseline to pre-surgery 
in the different groups will be descriptively reported. For Cohort 1, clinical response will be 
determined by abdominal imaging performed <30 days after the last dose of atezolizumab prior 
to cystectomy compared to baseline pre-treatment imaging using RECIST v1.1 criteria, as 
specified in the companion treatment protocol (CC# 14524). For Cohort 1, pathologic response 
will be determined by evidence of down-staging (e.g. from muscle invasive to non-muscle 
invasive, or complete pathologic response) at the time of cystectomy.  
 
Immunohistochemistry for immune infiltration will be performed in the Fong lab (Fong L et al. J 

 
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Natl Cancer Inst 2014). Briefly, 5-micron FFPE slides from archival tumor tissue or cystectomy 
tissue will be used for staining. For double stains, slides will first be incubated with antibody to 
CD8 and visualized with horseradish peroxidase using DAB+, followed by incubation with 
antibody to CD3 and visualized with alkaline phosphatase using Permanent Red. Tissues will be 
counterstained with hematoxyclin before analysis. Automatic cell counts for single- and double-
stained cells will be determined using the Axiovision software (Zeiss, Peabody, MA). The 
correlation between change from baseline to post-treatment SUVmax on [18F]F-AraG PET and 
CD3+ and CD3+CD8+ immune infiltration (#/μm2) by IHC will be determined using Spearman’s 
rho statistic, separately. 
9 
Study Management 
9.1 
Pre-study Documentation 
This study will be conducted in accordance with the ethical principles that have their origin in the 
Declaration of Helsinki as stated in 21 CFR §312.120(c)(4); consistent with GCP and all applicable 
regulatory requirements. 
Before initiating this trial, the Investigator will have written and dated approval from the Institutional 
Review Board for the protocol, written informed consent form, subject recruitment materials, and 
any other written information to be provided to subjects before any protocol related procedures 
are performed on any subjects.   
The clinical investigation will not begin until either FDA has determined that the study under the 
Investigational Drug Application (IND) is allowed to proceed or the Investigator has received a 
letter from FDA stating that the study is exempt from IND requirements.  
The Investigator must comply with the applicable regulations in Title 21 of the Code of Federal 
Regulations (21 CFR §50, §54, and §312), GCP/ICH guidelines, and all applicable regulatory 
requirements.  The IRB must comply with the regulations in 21 CFR §56 and applicable regulatory 
requirements. 
9.2 
Institutional Review Board Approval 
The protocol, the proposed informed consent form, and all forms of participant information related 
to the study (e.g. advertisements used to recruit participants) will be reviewed and approved by 
the UCSF Institutional Review Board.  Prior to obtaining IRB approval, the protocol must be 
approved by the Helen Diller Family Comprehensive Cancer Center Site Committee and by the 
Protocol Review Committee (PRC).  The initial protocol and all protocol amendments must be 
approved by the IRB prior to implementation.   
9.3 
Informed Consent 
All participants must be provided a consent form describing the study with sufficient information 
for each participant to make an informed decision regarding their participation.  Participants must 
sign the IRB-approved informed consent form prior to participation in any study specific 
procedure.  The participant must receive a copy of the signed and dated consent document.  The 
original signed copy of the consent document must be retained in the medical record or research 
file.  

 
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9.4 
Changes in the Protocol 
Once the protocol has been approved by the IRB, any changes to the protocol must be 
documented in the form of an amendment.  The amendment must be signed by the Investigator 
and approved by PRC and the IRB prior to implementation.   
If it becomes necessary to alter the protocol to eliminate an immediate hazard to patients, an 
amendment may be implemented prior to IRB approval.  In this circumstance, however, the 
Investigator must then notify the IRB in writing within five (5) working days after implementation.  
The Study Chair and the UCSF study team will be responsible for updating any participating sites. 
10 
Protection of Human Subjects 
10.1 Protection from Unnecessary Harm  
Each clinical site is responsible for protecting all subjects involved in human experimentation. This 
is accomplished through the IRB mechanism and the process of informed consent. The IRB 
reviews all proposed studies involving human experimentation and ensures that the subject’s 
rights and welfare are protected and that the potential benefits and/or the importance of the 
knowledge to be gained outweigh the risks to the individual. The IRB also reviews the informed 
consent document associated with each study in order to ensure that the consent document 
accurately and clearly communicates the nature of the research to be done and its associated 
risks and benefits.  
10.2 Protection of Privacy 
Patients will be informed of the extent to which their confidential health information generated 
from this study may be used for research purposes. Following this discussion, they will be asked 
to sign the HIPAA form and informed consent documents. The original signed document will 
become part of the patient’s medical records, and each patient will receive a copy of the signed 
document. The use and disclosure of protected health information will be limited to the individuals 
described in the informed consent document. 

 
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References 
Balar AV, Galsky MD, Rosenberg JE, et al. Atezolizumab as first-line treatment in cisplatin-
ineligible patients with locally advanced and metastatic urothelial carcinoma: a single arm, 
multicenter, phase 2 trial. Lancet Oncol 2017. 389(10064):67-76. 
DeAngelo DJ. Nelarabine for the treatment of patients with relapsed or refractory T-cell acute 
lymphoblastic leukemia or lymphoblastic lymphoma. Hemato Oncol Clin North Am 2009. 
23(5):1121-35. 
Fox CJ, Hammerman PS, Thompson CB, et al. Fuel feeds function: energy metabolism and the 
T-cell response. Nat Rev Immunol 2005. 5(11):844-852. 
Fong L, Carroll P, Weinberg V, et al. Activated lymphocyte recruitment into the tumor 
microenvironment following preoperative sipuleucel-T for localized prostate cancer. J Natl 
Cancer Inst 2014. 106(11). 
Nair-Gill E, Wiltzius SM, Wei XX, et al. PET probes for distinct metabolic pathways have 
different cell specificities during immune responses in mice. J Clin Invest 2010. 120(6):2005-
2015. 
Namavari M, Chang Y, Kusler B, et al. Synthesis of 2’-Deoxy-2’-[18F]Fluoro-9-β-D-
Arabinofuranosylguanine: a novel agent for imaging T-cell activation with PET. Mol Imaging Bio 
2011. 13(5):8212-818. 
Radu CG, Shu CJ, Nair-Gill E, et al. Molecular imaging of lymphoid organs and immune 
activation by positron emission tomography with a new [18F]-labeled 2'-deoxycytidine analog." 
Nat Med 2008. 14(7):783-788. 
Restifo NP, Smyth MJ, Snyder A. Acquired resistance to immunotherapy and future challenges. 
Nat Rev Cancer 2016. 16(2):121-126. 
Rosenberg JE, Hoffman-Censits J, Powles T, et al. Atezolizumab in patients with locally 
advanced and metastatic urothelial carcinoma who have processed following treatment with 
platinum-based chemotherapy. Lancet 2016;387(10031):1909-1920. 
Soler C, Garcia-Manteiga J, Valdes R, et al. Macrophages require different nucleoside transport 
systems for proliferation and activation. FASEB J 2001. 15(11):1979-1988. 
Wolchok JD, Hoos A, O’Day S, et al. Guidelines for the evaluation of immune therapy activity in 
solid tumors: immune-related response criteria. Clin Cancer Res 2009. 15(23)7412-7420. 
Yaghoubi S, VanBrocklin H, Verdin E, et al. First in human study of [18F]F-AraG, a PET tracer 
for monitoring anti-tumor immune response during cancer immunotherapy. World Molecular 
Imaging Conference, 2015. 
 
 

 
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Appendices 
Appendix 1 Performance Status Criteria 
ECOG Performance Status Scale 
Karnofsky Performance Scale 
Grade 
Descriptions 
Percent 
Description 
0 
Normal activity 
Fully active, able to carry on all 
pre-disease performance 
without restriction 
100 
Normal, no complaints, no evidence 
of disease 
90 
Able to carry on normal activity; 
minor signs or symptoms of disease 
1 
Symptoms, but ambulatory 
Restricted in physically 
strenuous activity, but 
ambulatory and able to carry out 
work of a light or sedentary 
nature (e.g., light housework, 
office work) 
80 
Normal activity with effort; some 
signs or symptoms of disease 
70 
Cares for self, unable to carry on 
normal activity or to do active work 
2 
In bed < 50% of the time 
Ambulatory and capable of all 
self-care, but unable to carry out 
any work activities 
Up and about more than 50% of 
waking hours 
60 
Requires occasional assistance, but 
is able to care for most of his/her 
needs 
50 
Requires considerable assistance 
and frequent medical care 
3 
In bed > 50% of the time 
Capable of only limited self-
care, confined to bed or chair 
more than 50% of waking hours 
40 
Disabled, requires special care and 
assistance 
30 
Severely disabled, hospitalization 
indicated 
Death not imminent 
4 
100% bedridden 
Completely disabled 
Cannot carry on any self-care 
Totally confined to bed or chair 
20 
Very sick, hospitalization indicated 
Death not imminent 
10 
Moribund, fatal processes 
progressing rapidly 
5 
Dead 
0 
Dead 
 

 
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Appendix 2 Data and Safety Monitoring Plan for a Phase 2 or 3 Institutional Study 
The UCSF Helen Diller Family Comprehensive Cancer Center (HDFCCC) Data and Safety 
Monitoring Committee (DSMC) is responsible for monitoring data quality and subject safety for 
all HDFCCC institutional clinical studies.  A summary of DSMC activities for this study include:  
• 
Review of subject data 
• 
Review of suspected adverse reactions considered “serious” 
• 
Monitoring every six months (depending on study accrual) 
• 
Minimum of a yearly regulatory audit 
Monitoring and Reporting Guidelines 
Investigators will conduct continuous review of data and subject safety and discuss each 
subject’s treatment at monthly Site Committee meetings. These discussions are documented in 
the Site Committee meeting minutes. The discussion will include the number of subjects, 
significant toxicities in accordance with the protocol, and observed responses. 
All institutional Phase 2 or 3 studies are designated with a moderate risk assessment. The data 
is monitored twice per year with twenty percent of the subjects monitored (or at least three 
subjects if the calculated value is less than three). 
Adverse Event Review and Monitoring 
All grade(s) 3-5 adverse events, whether or not unexpected, and whether or not considered to 
be associated with the use of the study drug, will be entered into OnCore®, UCSF’s Clinical 
Trial Management System. 
All grade(s) 3-5 adverse events entered into OnCore® will be reviewed on a monthly basis at 
the Site Committee meetings. The Site Committee will review and discuss the selected toxicity, 
the toxicity grade, and the attribution of relationship of the adverse event to the administration of 
the study drug(s). 
In addition, all suspected adverse reactions considered “serious” entered into OnCore®, will be 
reviewed and monitored by the Data and Safety Monitoring Committee on an ongoing basis and 
discussed at DSMC meetings, which take place every six weeks. 
If a death occurs during the treatment phase of the study or within 30 days after the last 
administration of the study drug(s) and it is determined to be related either to the study drug(s) 
or to a study procedure, the Investigator or his/her designee must notify the DSMC Chair within 
1 business day of knowledge of this event. The contact may be by phone or e-mail. 
Increase in Adverse Event Rates 
If an increase in the frequency of Grade 3 or 4 adverse events (above the rate reported in the 
Investigator Brochure or package insert) is noted in the study, a report should be submitted to 
the DSMC at the time the increased rate is identified. The report will indicate if the incidence of 
adverse events observed in the study is above the range stated in the Investigator Brochure or 
package insert. 
If at any time the Investigator stops enrollment or stops the study due to safety issues, the 
DSMC Chair and DSMC Manager must be notified within 1 business day via e-mail. The DSMC 
must receive a formal letter within 10 business days and the IRB must be notified. 
 
 

 
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Data and Safety Monitoring Committee Contacts: 
DSMC Chair:  
 
DSMC Monitors  
Phone:  
Email: 
Address:  
 
 
 
 
 
 
UCSF Helen Diller Family 
Comprehensive Cancer Center 
San Francisco, CA 94143 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
*  DSMP approved by NCI 09/February2012 
 

 
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Appendix 3 UCSF Policy/Procedure for Required Regulatory Documents for a 
UCSF Investigator-Initiated Oncology Clinical Trials with an Investigator held 
Investigational New Drug (IND) 
Purpose 
This policy defines the required Regulatory Documents for Single Site and Multicenter 
Investigator Initiated Oncology Clinical Trials at the Helen Diller Family Comprehensive Cancer 
Center (HDFCCC) where the Principal Investigator (PI) holds the IND. 
Background 
The International Conference on Harmonization (ICH) Good Clinical Practices (GCP) Guidelines 
define Essential Regulatory Documents as those documents which individually and collectively 
permit evaluation of the conduct of a trial and the quality of data produced. These documents 
serve to demonstrate compliance with standards of GCP and with all applicable regulatory 
requirements. Filing essential documents in a timely manner can greatly assist in the successful 
management of a clinical trial. 
The Regulatory Documents will consist of electronic files in both iMedRIS and OnCore®, as well 
as paper files in the Regulatory Binders for both the Coordinating Site and the Participating 
Site(s) in the HDFCCC Investigator Initiated Oncology Clinical Trials. 
Procedures 
1.   HDFCCC Essential Regulatory Documents 
Documents Filed in iMedRIS: 
• 
IRB approvals for initial submission of application, all modifications, and continuing 
annual renewals 
• 
Current and prior approved protocol versions with signed protocol signature page(s) 
• 
IRB approval letters and Informed Consent Form(s) (ICF) 
• 
Current and prior versions of the Investigator Brochure (IB). 
• 
Serious Adverse Event Reporting 
• 
Protocol Violations and Single Patient Exception (SPE) Reports to IRB with supporting 
fax documentation 
Documents Filed in OnCore®: 
• 
Package Insert (if the study drug is commercial) or Investigator Brochure 
• 
Protocol Review Committee (PRC) approved protocols, protocol amendments and 
Summary of Changes (SOC) 
• 
Patient handouts 
• 
Screening/enrollment log 
• 
Data and Safety Monitoring Committee (DSMC) monitoring reports 
• 
OnCore® Case Report Form (CRF) completion manual 
 
 

 
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Documents Filed in Regulatory Binder: 
• 
Completed Food and Drug Administration (FDA) 1572 document with Principal 
Investigator’s signature 
• 
For all Principal Investigators and Sub-Investigators listed on the FDA 1572, will need 
Financial Disclosure Forms, CVs, MD Licenses, Drug Enforcement Agency (DEA) 
Licenses, and Staff Training Documents (i.e. Collaborative Institute Training Initiative 
(CITI), etc.) 
• 
Site Initiation Visit (SIV) minutes and correspondence with participating site(s). 
• 
As applicable, approvals for Biosafety Committee, Radiation Committee, and Infusion 
Center 
• 
Serious Adverse Event (SAE) reports to IRB and sponsor. 
• 
MedWatch reporting to FDA and sponsor 
• 
Delegation of Authority Form 
• 
Drug Destruction Standard Operating Procedure (SOP) 
• 
For all laboratories listed on the FDA 1572, will need CLIA certifications, CAP 
certifications, lab licenses, CVs of Lab Directors, and laboratory reference ranges 
 
 

 
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Appendix 4 MRI Screening Form 
Available online: 
https://radiology.ucsf.edu/sites/radiology.ucsf.edu/files/wysiwyg/research/brainchange/MRI%20
Screening%20Form-BrainChange.pdf