A Study to Evaluate Vascular Normalization in Patients With Recurrent Glioblastoma Treated With Bevacizumab Using FMISO PET and Vascular MRI
Phase: NA
Conditions: Recurrent Glioblastoma
Sponsor: Massachusetts General Hospital

Status Page 
 
 
 
PROTOCOL 13-482 
 
 
 
 
 Permanently 
Closed to New Accrual  
 
 
 
 
 
 
 
 
 
 
 
Closure Effective Date: 01/09/2019 
No new subjects may be enrolled in the study as described above.  
Any questions regarding this closure should be directed to the 
study’s Principal Investigator 
 
 
 
 

CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
Version Date: 3/28/2019 
 
A study to evaluate vascular normalization in patients with recurrent glioblastoma treated 
with bevacizumab and lomustine using FMISO PET and vascular MRI 
 
Principal Investigator:  Elizabeth Gerstner, M.D. 
Pappas Center for Neuro-Oncology 
55 Fruit Street, Yawkey 9E 
Boston, MA 02114 
Phone: 617-724-2887 
Fax: 617-643-2591 
egerstner@mgh.harvard.edu 
 
Co-Investigators:  
 
 
 
 
Umar Mahmood, M.D., Ph.D. 
Martinos Center for Biomedical Imaging 
Charlestown, MA 02129 
Phone : 617-726-6477 
umahmood@mgh.harvard.edu 
 
 
 
 
 
 
 
 
 
 
Patrick Wen, M.D. 
 
 
 
 
 
 
 
 
 
Center for Adult Neuro-Oncology 
 
 
 
 
 
 
 
 
 
Dana-Farber Cancer Institute 
 
 
 
 
 
 
 
 
 
44 Binney Street 
 
 
 
 
 
 
 
 
 
Boston, MA 
 
 
 
 
 
 
 
 
 
pwen@partners.org 
 
 
 
Agent(s): FMISO  
 
  
 
 
SCHEMA 
ClinicalTrials.gov Identifier: NCT02076152

CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
 
 
 
 
Population: Recurrent glioblastoma patients receiving bevacizumab and lomustine. 
 
 
 
 
 
Population: Recurrent glioblastoma patients receiving bevacizumab monotherapy. 
 

CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
TABLE OF CONTENTS 
1. 
OBJECTIVES .................................................................................................................................................... 5 
1.1 
Study Design ............................................................................................................................................... 5 
1.2 
Primary Objectives ..................................................................................................................................... 6 
1.3 
Secondary Objectives ................................................................................................................................. 6 
2. 
BACKGROUND ................................................................................................................................................ 6 
2.1 
Study Agent(s) ............................................................................................................................................. 6 
2.2 
Study Disease.............................................................................................................................................. 7 
2.3 
Rationale .................................................................................................................................................... 7 
3. 
PARTICIPANT SELECTION .......................................................................................................................... 8 
3.1 
Eligibility Criteria ...................................................................................................................................... 8 
3.2 
Exclusion Criteria .................................................................................................................................... 9 
3.3 
Inclusion of Women, Minorities and Other Underrepresented Populations ............................................ 11 
4. 
REGISTRATION PROCEDURES ................................................................................................................ 11 
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions ..................................................................... 11 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions ................................................................. 11 
4.3 
General Guidelines for Other Participating Institutions ................................................................... 12 
4.4 
Registration Process for Other Participating Institutions ...................................................................... 12 
5. 
STUDY PLAN .................................................................................................................................................. 12 
5.1 
Pre-MR-PET Scan Criteria .................................................................................................................... 13 
5.2 
MR-PET Scan Procedure ........................................................................................................................ 13 
5.3 
Definition of Dose-Limiting Toxicity ..................................................................................................... 14 
5.4 
General Concomitant Medication and Supportive Care Guidelines ........................................................ 14 
5.5 
Duration of Therapy .................................................................................................................................. 14 
5.6 
Duration of Follow Up ............................................................................................................................. 15 
5.7 
Criteria for Removal from Study .............................................................................................................. 15 
6. 
EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS .................................... 15 
6.1 
Anticipated Toxicities ............................................................................................................................... 15 
6.2 
Toxicity Management ............................................................................................................................... 16 
6.3 
Dose Modifications/Delays ....................................................................................................................... 16 
7. 
DRUG FORMULATION AND ADMINISTRATION ................................................................................. 17 
7.1 
FMISO ...................................................................................................................................................... 18 
7.2 
Bevacizumab ............................................................................................................................................. 19 
Please refer to the FDA-approved package insert for more information. ............................................................ 19 

CONFIDENTIAL 
This document is confidential. Do not disclose or use except as authorized. 
8. 
CORRELATIVE/SPECIAL STUDIES .......................................................................................................... 21 
8.1 
Pharmacokinetic Studies .......................................................................................................................... 21 
8.2 
Pharmacodynamic Studies ....................................................................................................................... 21 
9. 
STUDY CALENDAR ...................................................................................................................................... 23 
10. 
ADVERSE EVENT REPORTING REQUIREMENTS .......................................................................... 25 
10.1 
Definitions ................................................................................................................................................ 25 
10.2 
Procedures for AE and SAE Recording and Reporting ............................................................................ 27 
10.3 
Reporting Requirements ........................................................................................................................... 28 
10.4 
Reporting to the Study Sponsor ................................................................................................................ 28 
10.5 
Reporting to the Institutional Review Board (IRB)................................................................................... 29 
10.6 
Reporting to the Food and Drug Administration (FDA) .......................................................................... 29 
10.7 
Reporting to the NIH Office of Biotechnology Activities (OBA) .............................................................. 29 
10.8 
Reporting to the Institutional Biosafety Committee (IBC) ........................................................................ 29 
10.9 
Reporting to Hospital Risk Management .................................................................................................. 30 
10.10 
Monitoring of Adverse Events and Period of Observation ....................................................................... 30 
11. 
DATA AND SAFETY MONITORING ..................................................................................................... 30 
11.1 
Data Reporting ......................................................................................................................................... 30 
11.2 
Safety Meetings ......................................................................................................................................... 31 
11.3 
Monitoring ................................................................................................................................................ 31 
12. 
REGULATORY CONSIDERATIONS ..................................................................................................... 32 
12.1 
Protocol Review and Amendments ........................................................................................................... 32 
12.2 
Informed Consent ..................................................................................................................................... 32 
12.3 
Ethics and Good Clinical Practice (GCP) ............................................................................................... 32 
12.4 
Study Documentation ................................................................................................................................ 33 
12.5 
Records Retention ..................................................................................................................................... 33 
12.6 
Multi-center Guidelines ............................................................................................................................ 33 
13. 
STATISTICAL CONSIDERATIONS ....................................................................................................... 34 
13.1 
Sample Size/Accrual Rate ......................................................................................................................... 34 
13.2 
Reporting and Exclusions ......................................................................................................................... 35 
14. 
PUBLICATION PLAN ............................................................................................................................... 35 
15. 
REFERENCES ............................................................................................................................................ 36 
16. 
APPENDICES ............................................................................................................................................. 40 
Appendix A: Performance Status Criteria ............................................................................................................ 40 

 
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1. OBJECTIVES 
 
1.1 Study Design 
 
Our goal is to explore changes in tumor vasculature resulting from treatment with bevacizumab 
and the impact these changes have on tumor oxygenation. Results from this study will shed 
light on the vascular normalization hypothesis. This study will evaluate patients with recurrent 
glioblastoma with simultaneous FMISO PET and MRI to assess changes in tumor blood flow, 
blood volume, vessel caliber, and vascular permeability with advanced MRI while 
simultaneously measuring tumor oxygenation status with FMISO PET.  
 
We plan to study patients with recurrent glioblastoma whose clinical care plan includes 
treatment with bevacizumab.  We will perform FMISO-PET at 3 time points in all patients: 
before beginning bevacizumab, prior to the second dose of bevacizumab, and prior to the third 
dose of bevacizumab.  In addition, patients will undergo advanced MRI scans 1 day after start 
of bevacizumab and monthly for 6 months of treatment.  
 
This study protocol is being amended to account for the publication of recent data which has 
impacted clinical practice. Based on the published results from the 3-arm BELOB study 
(Nederlands Trial Register, www.trialregister.nl, number NTR1929) there has been a shift to 
treating patients with combination bevacizumab and lomustine rather than bevacizumab alone 
(Taal et al 2014). In this randomized, phase 2, multicenter trial the combination of 
bevacizumab and lomustine was associated with superior overall survival.  Although this study 
was not formally designed for comparisons across the 3 arms it has influenced the practice of 
neuro-oncology with some shift away from bevacizumab monotherapy. A randomized, phase 
3 trial is underway comparing bevacizumab + lomustine versus lomustine alone 
(NCT01290939).  
 
For this protocol, there will now be 2 cohorts of patients. Cohort A includes patients with 
recurrent GBM treated with bevacizumab and lomustine and cohort B includes patients 
receiving bevacizumab monotherapy. The majority of our patients at MGH are currently 
treated with combination therapy so will help speed up accrual. However, not every patient 
can receive combination therapy so we are including the second, exploratory cohort of patients 
treated with bevacizumab monotherapy. 
 
Lomustine is not expected to have its own anti-angiogenic effects so adding this therapy will 
not impact the interpretation of the anti-vascular effects of bevacizumab. In general, alkylating 
agents such as temozolomide or lomustine are not thought to target endothelial cells. In humans 
treated with alkylating agents, we do not see the remarkable decrease in contrast enhancement 
seen with anti-VEGF therapy. For example, there was very little change in tumor volume in 
patients treated with lomustine alone in both the REGAL study and BELOB study) (Batchelor 
2013, Taal 2014). If there was a true effect on tumor vasculature, we would see more change 
in the post-contrast images similar to the responses seen in the ant-VEGF treated arms. 
 
Furthermore, our own data comparing a cohort of patients with newly diagnosed GBM treated 
with standard radiation and temozolomide to a cohort of patients treated with standard 

 
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radiation, temozolomide, and cediranib (an anti-VEGF agent) did not show the same vascular 
normalization effects (as measured by changes in contrast enhancement, permeability, 
perfusion, and tumor oxygenation) in the temozolomide + RT alone group (Batchelor 2013). 
 
The PET studies will be performed using our human simultaneous MR-PET imaging camera. 
No diagnostic decisions or therapy decisions will be based on any results obtained from these 
PET scans, and we expect no change in the care of these patients. The success of these studies 
should enable methods that could be used in larger studies to more completely understand the 
role of anti-angiogenic agents in the treatment of cancer. 
 
1.2 Primary Objectives 
1. To determine if bevacizumab improves tumor blood flow/perfusion. 
2. To determine if bevacizumab reduces tumor hypoxia.  
 
1.3 Secondary Objectives 
1. To explore the link between flow, permeability, and tumor hypoxia. 
a. Measure tumor blood flow with MRI perfusion and compare with tumor 
hypoxic volume. 
b. Estimate permeability from Ktrans MRI measurements and compare with 
tumor hypoxic volume. 
2. To explore the link between tumor hypoxia and blood biomarkers of angiogenesis 
 
2. BACKGROUND 
 
2.1 Study Agent(s) 
 
2.2 
FMISO 
Since the 1980s, interest in radiolabeled nitroimidazoles, and particularly FMISO, 
as nuclear imaging agents of hypoxia has been growing. Intracellular 
nitroreductases metabolize nitroimidazoles in the setting of low oxygen levels, thus 
trapping them in hypoxic cells. Importantly, the metabolism of nitroimidazoles 
relies on an active electron transport chain so only live cells can trap FMISO. The 
binding of FMISO is related to the level of hypoxia, and oxygen levels of 3 to 10 
mm Hg lead to FMISO binding (Rasey et al, 1990; Gross et al, 1995). Several 
studies have demonstrated that the uptake of FMISO correlates well with invasive 
polarographic oxygen electrodes, the gold standard to determine tissue oxygenation 
(Koh et al, 1992; Bernsen et al, 2000; Rasey et al 1987; Rasey et al, 1996).  
Preliminary studies of FMISO uptake in glioma have demonstrated the feasibility 
of this technique both in animal models and in humans (Valk et al, 1992). In a 
glioma rat model, FMISO uptake was significantly greater in tumor tissue than in 
surrounding normal brain (Tochon-Danguy et al 2002). Cher et al showed that all 
high-grade gliomas have increased FMISO uptake while low-grade gliomas did 
not, which is consistent with the underlying biology of gliomas—higher-grade 

 
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tumors are more hypoxic than lower-grade tumors (Cher et al, 2006). In 22 
participants with newly-diagnosed GBM, the greater the volume and degree of 
hypoxia based on FMISO imaging, the shorter time-to-tumor progression and 
survival (Spence et al, 2008). In addition, histological studies of tumors have 
correlated tissue pimonidazole staining, a marker of tissue hypoxia, and CAIX with 
FMISO uptake (Troost et al, 2006; Dubois et al 2004). In one of these studies, the 
glioma model had the strongest correlation between FMISO uptake and 
pimonidazole staining (Troost et al, 2006).  Ex vivo autoradiography has also been 
used to confirm the correlation of FMISO and tumor hypoxia (Sorensen et al, 2005).  
 
 
2.3 Study Disease 
 
An estimated 51,410 primary brain tumors were diagnosed in 2007, and 19% of these tumors 
were glioblastomas 1.  GBM is the most common malignant primary brain tumor and is a 
uniformly fatal disease with 5-year survival rates less than 4% despite aggressive treatment 
with surgery, radiation and chemotherapy.  There is no curative therapy for patients with 
GBM.  Current standard of care for patients with newly diagnosed GBM is concomitant 
involved field radiation and oral temozolomide chemotherapy followed by monthly 
temozolomide for 6-12 months (Stupp et al., 2005).  If patients relapse, there is no standard 
of care treatment and some patients will be treated with temozolomide again, albeit on a 
different dosing schedule.  Instead of 5 consecutive days every month, patients may be treated 
with a lower daily dose of temozolomide but for more days every month (Perry et al., 2010).  
The goal of this dose dense regimen is to saturate the enzyme, MGMT, which is believed to 
counteract the DNA-damaging effects of temozolomide. Bevacizumab was recently 
approved by the FDA for recurrent GBM and is ultimately used in most recurrent GBM 
patients.  
 
2.4 
Rationale 
 
The dependence of tumor growth and metastasis on angiogenesis — which has been 
extensively demonstrated in animal models — has provided a powerful rationale for anti-
angiogenic approaches to cancer therapy (van de Beek, 2007; Carmeliet & Jain, 2000; 
Kleihues, Burger, & Scheithauer, 1993).  Targeting blood vessels in brain tumors has 
been a particularly attractive strategy, given the characteristic high degree of endothelial 
proliferation, vascular permeability, and pro-angiogenic growth-factor expression (for 
example, VEGF) (Dvorak, 2002; Sundberg, 2001).  The approval of bevacizumab, which 
neutralizes VEGF, in May 2009 for recurrent glioblastoma (rGBM) represented the first 
new therapy for this disease in many years. A strong anti-edema effect is clearly seen 
with anti-VEGF therapy in many patients. Whether this conveys a survival benefit is still 
not clear; cediranib did not improve survival over lomustine in rGBM in a recent phase 
III trial, and while definitive phase III studies of bevacizumab are underway, recent data 
suggests that bevacizumab does not improve overall survival when given to newly 
diagnosed glioblastoma patients (Lai et al., 2010). 
 

 
8
Bevacizumab is not an effective monotherapy outside the brain, but it is effective when 
combined with other drugs. The mechanism of this clinical efficacy is still incompletely 
understood. Anti-VEGF therapies have been shown to promote vascular “normalization” 
(Batchelor et al., 2007; Jain, 2005; Willett et al., 2004) in many patients, which could 
improve local tumor blood flow and therefore cytotoxic chemotherapy delivery to the 
tumor. We have shown that the ‘normalization window’ of the anti-VEGF agent cediranib 
can be detected using serial, non-invasive MRI techniques in rGBM (Batchelor et al., 
2007), and we have seen increases in blood flow (Sorensen et al 2012). The outstanding 
question is whether or not this increased perfusion also translates into improved tumor 
oxygenation. Since anti-VEGF therapies were originally designed to block blood vessel 
formation, in theory these agents could potentially also inhibit drug delivery to the tumor 
and make therapies such as radiation, which rely on oxygenation less effective (Jain, 
2005; Jain, 2001).  
 
Our novel hybrid MR-PET technology should allow us to assess both hypoxia and 
vascular changes to determine the time course and interplay between vascular physiology 
and tumor oxygenation.   
 
 
3. PARTICIPANT SELECTION 
 
3.1 
Eligibility Criteria 
 
Participants must meet the following criteria on screening examination to be eligible to 
participate in the study: 
 
3.1.1 Participants must have histologically confirmed glioblastoma and evidence of 
recurrence. Patients with low-grade tumors who have progressed to glioblastoma 
are eligible. 
   
3.1.2 Participants must have measurable disease, defined as at least one lesion that can be 
accurately measured in at least one dimension (longest diameter to be recorded) as 
> 10 mm. See section 10 for the evaluation of measureable disease. 
 
3.1.3 For cohort A, only patients for whom their neuro-oncologist has planned to give 
bevacizumab with lomustine are eligible for this study. 
3.1.4  For cohort B, only patients for whom their neuro-oncologist has planned to give 
bevacizumab monotherapy are eligible for this study. 
  

 
9
3.1.5 Age > 18 years. Because no dosing or adverse event data are currently available on 
the use of FMISO in participants <18 years of age, children are excluded from this 
study but will be eligible for future pediatric trials. 
 
3.1.6 Life expectancy of greater than 3 months. 
 
3.1.7 Karnofsky performance status > 60 (see Appendix A). 
  
3.1.8 Participants must have normal organ and marrow function as defined below: 
• Leukocytes > 3,000/mcL 
• Absolute neutrophil count > 1,500/mcL 
• Platelets > 75,000/mcL for bevacizumab monotherapy cohort; >100,000 
/mcL for bevacizumab + lomustine cohort 
• Total bilirubin within normal institutional limits 
• AST (SGOT)/ALT (SGPT) < 2.5 X institutional upper limit of normal 
• Creatinine within normal institutional limits or creatinine clearance > 60 
mL/min/1.73 m2 for subjects with creatinine levels about institutional 
normal. 
3.1.9 Patient must be able to undergo MRI and PET scans. 
 
3.1.10  Patients on cortiosteroids must be maintained on a stable corticosteroid regimen for 5 
days prior each MR-PET scan. 
 
3.1.11 The effects of FMISO on the developing human fetus are unknown. For this reason and 
because radiopharmaceuticals agents are known to be teratogenic, women of child-
bearing potential and men must agree to use adequate contraception (hormonal or 
barrier method of birth control; abstinence) prior to study entry and for the duration of 
study participation. Should a woman become pregnant or suspect she is pregnant while 
participating in this study, she should inform her treating physician immediately. 
 
 
 
3.1.12 
Ability to understand and the willingness to sign a written informed consent 
document. 
 
 
3.2 Exclusion Criteria 
 

 
10
Participants who exhibit any of the following conditions at screening will not be 
eligible for admission into the study. 
 
3.2.1 History of allergic reactions attributed to compounds of similar chemical or 
biologic composition to temozolomide or FMISO. 
 
3.2.2 Participants who have already received anti-VEGF or experimental anti-
angiogenic therapy for glioblastoma. 
 
3.2.3 Uncontrolled intercurrent illness including, but not limited to ongoing or active 
infection, symptomatic congestive heart failure, unstable angina pectoris, 
cardiac arrhythmia, or psychiatric illness/social situations that would limit 
compliance with study requirements. 
 
3.2.4 Pregnant women are excluded from this study because FMISO is a 
radiopharmaceutical agent with the potential for teratogenic or abortifacient 
effects. Because there is an unknown but potential risk of adverse events in 
nursing infants secondary to treatment of the mother with radiopharmaceutical 
agents, breastfeeding should be discontinued if the mother is treated with 
radiopharmaceutical agents. These potential risks may also apply to other 
agents used in this study. 
  
3.2.5 HIV-positive individuals on combination antiretroviral therapy are ineligible 
because of the potential for pharmacokinetic interactions with FMISO. In 
addition, these individuals are at increased risk of lethal infections when treated 
with marrow-suppressive therapy. Appropriate studies will be undertaken in 
participants receiving combination antiretroviral therapy when indicated. 
 
3.2.6 Patients with intracerebral hemorrhage deemed significant by treating physician 
are excluded. 
 
3.2.7 Patients who are no suitable to undergo MRI or use gadolinium contrast due to: 

 
11
• 
Claustrophobia 
• 
Presence of metallic objects or implanted medical devices in body (i.e. 
cardiac pacemaker, aneurysm clips, surgical clips, prostheses, artificial 
hearts, valves with steel parts, metal fragments, shrapnel, tattoos near the 
eye, or steel implants) 
• 
Sickle cell disease 
• 
Renal failure 
• 
Reduced renal function, as determined by creatinine clearance 
< 30 mL/min based on a serum creatinine level obtained within 28 days 
prior to registration 
 
 
3.2.8 Inclusion of Women, Minorities and Other Underrepresented Populations 
 
Both men and women and members of all races and ethnic groups are eligible 
for this trial. 
 
 
4. REGISTRATION PROCEDURES 
   
4.1 
General Guidelines for DF/HCC and DF/PCC Institutions 
 
Institutions will register eligible participants with the DF/HCC Quality Assurance 
Office for Clinical Trials (QACT) central registration system. Registration must 
occur prior to the initiation of therapy. Any participant not registered to the protocol 
before treatment begins will be considered ineligible and registration will be denied.  
 
A member of the study team will confirm eligibility criteria and complete the 
protocol-specific eligibility checklist. 
  
Following registration, participants may begin protocol treatment. Issues that 
would cause treatment delays should be discussed with the Principal Investigator. If 
a participant does not receive protocol therapy following registration, the participant’s 
protocol status must be changed. Notify the QACT Registrar of participant status 
changes as soon as possible. 
 
4.2 
Registration Process for DF/HCC and DF/PCC Institutions 
 
The QACT registration staff is accessible on Monday through Friday, from 8:00 AM to 
5:00 PM Eastern Standard Time. In emergency situations when a participant must begin 
treatment during off-hours or holidays, call the QACT registration line at 617-632-3761 
and follow the instructions for registering participants after hours. 
   
The registration procedures are as follows: 
 

 
12
1. 
Obtain written informed consent from the participant prior to the performance of 
any study related procedures or assessments. 
 
2. 
Complete the protocol-specific eligibility checklist using the eligibility 
assessment documented in the participant’s medical/research record. To be 
eligible for registration to the study, the participant must meet each 
inclusion and exclusion criteria listed on the eligibility checklist. 
  
Reminder: Confirm eligibility for ancillary studies at the same time as eligibility 
for the treatment study. Registration to both treatment and ancillary studies will 
not be completed if eligibility requirements are not met for all studies. 
  
3. 
Fax the eligibility checklist(s) and all pages of the consent form(s) to the QACT 
at 617-632-2295. 
  
Exception: DF/PCC Affiliate sites must fax the entire signed consent form 
including HIPAA Privacy Authorization and the eligibility checklist to the 
Network Affiliate Office. The Network Affiliate Office will register the 
participant with the QACT. 
  
4. 
The QACT Registrar will (a) validate eligibility, (b) register the participant on 
the study, and (c) randomize the participant when applicable. 
  
5. 
The QACT Registrar will send an email confirmation of the registration and/or 
randomization to the person initiating the registration immediately following 
the registration and/or randomization. 
  
4.3 General Guidelines for Other Participating Institutions 
 
N/A 
 
4.4 
Registration Process for Other Participating Institutions 
 
N/A 
 
5. STUDY PLAN 
 
This study does not add any additional treatment to patients with malignant glioma who are 
already scheduled to receive bevacizumab plus lomustine (cohort A) or bevacizumab 
monotherapy (cohort B). All treatment decisions will be at the discretion of the treating 
physician. There will be no change in the diagnosis or management of the patient based on any 
procedures or tests carried out as a part of this study. 
 

 
13
In brief, bevacizumab will be administered at a dose of 10 mg/kg i.v. every 14 days per standard 
of care and the drug label.  Lomustine will be given at 90mg/m2 every 6 weeks for a maximum 
of 6 cycles. (Taal 2014) A cycle is defined as 6 weeks (42 days).  The study duration is  42 
weeks (6 cycles).  Patients will be treated after  42 weeks or at the time of progression per 
discretion of their responsible physician.  Standard computerized order entry (COE) orders will 
be utilized for administering this drug. 
 
There are no expected toxicities and potential risks for FMISO. All study related scans will be 
performed at the Martinos Center for Biomedical Imaging in Charlestown.   
 
5.1 
Pre-MR-PET Scan Criteria 
5.1.1 Stable dose of corticosteroids for 5 days prior to MR-PET scan (if on 
corticosteroids). 
5.1.2 Creatinine clearance >30 mL/min based on a serum creatinine level obtained 
within 30 days. 
5.1.3 β-HCG in woman of childbearing age (prior to each MR-PET scans). 
Please see 
http://healthcare.partners.org/phsirb/Guidance/Pregnancy_Testing_in_Research_Involving
_Radiation.1.09.pdf for Pregnancy Testing guidelines) 
5.1.4 Adequate laboratory values as outlined in eligibility criteria. 
5.2   MR-PET Scan Procedure  
                                   MA at the Martinos Center. Two lines will be placed for each scan: one venous line to    
inject the FMISO and gadolinium for the MRI scan, and a second to draw blood to assay 
for radioactivity and metabolites. If a patient has a port, the port can replace one of the 
IVs. 
5.2.1 FMISO PET scans 
 
The PET scan will be up to 90 minutes.  There will be one injection of FMISO in 
the PET protocol. The blood will be drawn by a nuclear medicine technologist or a 
nurse trained in radiation safety. 
 
FMISO will be intravenously injected at a dose of 3.7 MBq/kg (0.1 mCi/kg) 
(maximum 260 MBq, 7 mCi) in < 15 mL. The IV will remain in place for injection 
of the gadolinium for the MRI scan. 
 
Blood draws will be performed at approximately t=20, 40, 60, 115, 120, 125 
minutes after the injection. The whole blood will be counted and then centrifuged 
to separate plasma from cells. Aliquots of plasma and blood will be separately 
counted for radioactivity.  The plasma will be further analyzed using high 
performance liquid chromatography for radiolabeled metabolites. Blood will be 
transported to the well counter and HPLC systems in a properly shielded container.  
 

 
14
PET volumes will be reconstructed using the ordinary Poisson ordered subsets 
expectation maximization (OP-OSEM) 3D algorithm. Corrections will be applied 
for variable detector dead time and efficiency, random coincidences, photon 
attenuation and scatter, and decay. 
 
5.2.2 MRI Scan 
MR scans will be performed with the same sequences and in the same order during 
each visit, including T1- and T2-weighted volumetric images, fluid attenuated 
inversion recovery (FLAIR), contrast agent enhanced T1-weighted permeability, 
diffusion tensor imaging (DTI), T2/T2*-weighted perfusion scans, and MR 
Spectroscopy. The “Autoalign” package available from the manufacturer will be 
used to achieve the same slice prescription in the same patient at each visit. Each 
MRI will last 60-75 minutes versus 45 minutes for standard brain MRIs. 
Gadolinium-diethylenetriaminepentaacetic acid (or gadopentetate dimeglumine, 
Gd-DTPA) will be used as a contrast agent and injected intravenously twice in each 
scan session. The maximum contrast dose that could be given is 0.3 mmol/kg per 
visit, in line with the FDA-approved dosing for this class of contrast agents. 
 
5.3 
Definition of Dose-Limiting Toxicity 
N/A 
 
5.4 
General Concomitant Medication and Supportive Care Guidelines 
Corticosteroids: Should be used at the lowest possible dose to control cerebral edema and 
mass effect and discontinued if possible. 
Anti-coagulation: Therapeutic anticoagulation with low molecular weight heparin or 
warfarin is permitted. Patients in warfarin must have INR <3. 
Anti-seizure medications: Should be used as indicated. 
 
5.5 
Duration of Therapy 
 
Patients may remain on study unless one of the following criteria applies: 
• Intercurrent illness that prevents administration of FMISO or bevacizumab 
• Unacceptable adverse event(s), 
• Unacceptable adverse reaction  
• Participant decides to withdraw from the study,  
• General or specific changes in the participant's condition render the participant 
unacceptable for bevacizumab, MRI or PET in the opinion of the treating 
investigator. 

 
15
Importantly, the following do NOT remove the patient from the study if they have 
already undergone the first MR-PET scan: 
• Disease progression 
 
5.6 
Duration of Follow Up  
 
Participants will be followed for 3 years after removal from study or until death, 
whichever occurs first. Participants removed from study for unacceptable adverse events 
will be followed until resolution or stabilization of the adverse event. Patients will be 
followed for survival, subsequent treatments received, and response to treatment by chart 
review or phone call if patient does not return to clinic. Follow-up will be assessed every 
3 months. 
  
5.7 
Criteria for Removal from Study  
 
Participants will be removed from study when any of the criteria listed in Section 5.5 
applies. The reason for study removal and the date the participant was removed must be 
documented in the study-specific case report form (CRF). Alternative care options will 
be discussed with the participant.  In the event of unusual or life-threatening 
complications, participating investigators must immediately notify the Principal 
Investigator at 617-724-8770. 
 
6. EXPECTED TOXICITIES AND DOSING DELAYS/DOSE MODIFICATIONS  
 
Dose delays and modifications will be made using the following recommendations. Toxicity 
assessments will be done using the CTEP Active Version of the NCI Common Terminology 
Criteria for Adverse Events (CTCAE) which is identified and located on the CTEP website at: 
http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
 
If possible, symptoms should be managed symptomatically. In the case of toxicity, 
appropriate medical treatment should be used (including anti-emetics, anti-diarrheals, etc.). 
 
All adverse events experienced by participants will be collected from the time of the first 
dose of study treatment, through the study and until the final study visit. Participants 
continuing to experience toxicity at the off study visit may be contacted for additional 
assessments until the toxicity has resolved or is deemed irreversible.  
 
6.1 
Anticipated Toxicities 
  
A list of the adverse events and potential risks associated with the agents administered 
in this study appear below and will determine whether dose delays and modifications 
will be made or whether the event requires expedited reporting in addition to routine 
reporting. 
  
6.1.1 Adverse Event List(s) for FMISO 

 
16
There are no known adverse effects of FMISO. 
6.1.2 Adverse Event List for lomustine 
Nausea, vomiting, poor appetite, myelosuppression, infection, bleeding, pulmonary 
toxicity, liver toxicity, mucositis, alopecia, optic nerve atrophy, renal toxicity. 
6.1.3 Adverse Event List for bevacizumab 
 
Hypertension: An increased incidence of hypertension has been reported. Grade 4 
and 5 hypertension events are rare as are hypertensive crisis, hypertensive 
encephalopathy, and reversible posterior leucoencephalopathy syndrome (RPLS). 
 
Proteinuria: An increased incidence of proteinuria up to 38% has been observed. 
Patients with HTN may be at increased risk of developing proteinuria.  
 
Thromboembolic events: Both venous and arterial thromboembolic events (TE) 
have been reported with a range of 2.8-17.3% in bevacizumab treated patients 
compared to 3.2%-15.6% in chemotherapy alone treated patients.  
 
The following have been additional reported complications of bevacizumab: 
gastrointestinal perforation, fistula development, wound healing delay, hemorrhage 
(Grade 3 and 5 events reported in 4.0% of patients), tumor associated hemorrhage, 
and congestive heart failure. 
 
 
6.2 
Toxicity Management 
 
 
Patients will be managed symptomatically as clinically indicated. Hypertension in 
particular should be treated at the first sign of elevated blood pressure.  
 
6.3 
Dose Modifications/Delays 
6.3.1 FMISO 
No dose reduction of FMISO is permitted. 
6.3.2 Lomustine 
 
Doses subsequent to the initial dose should be adjusted according to the 
hematologic response of the patient to the preceding dose. The following schedule 
is suggested as a guide to dosage adjustment:  
 
Table: Lomustine Dose Modifications for Hematological Toxicity  
 
Nadir After Prior Dose 
Dose Reduction 
Leukocytes 
Platelets 
 

 
17
>4,000 
>100,000 
None 
3,000-3,999 
75,000-99,999 
None 
2,000-2,9999 
25,000-74,999 
70mg/m2 
<2,000 
<25,000 
50mg/m2 
 
Complete blood counts should be monitored weekly starting 4 weeks after 
lomustine dose and repeat courses should not be given before 6 weeks as 
hematologic toxicity is delayed and cumulative. Growth factor support is 
permitted. Lomustine may be dose reduced a maximum of 2 times. 
 
If toxicities (as determined CTCAE version 4.0) of grade >2 are observed (except 
alopecia, nausea and vomiting) and related to lomustine, then the dose of 
lomustine should be held until recovery to grade ≤ 1.  
 
All grade 3 or 4 nonhematological toxicities related to lomustine (except alopecia, 
anorexia, nausea and vomiting) should have resolved to grade ≤ 1 and lomustine 
should be re-initiated at a dose of 70mg/m2. A second dose reduction of lomustine 
to 50 mg/m2 is permitted if there are grade 3 or 4 toxicities at the dose of 70 
mg/m2.  
 
If a patient develops unacceptable toxicity to lomustine, bevacizumab may be 
continued as monotherapy.  
 
Lomustine may be held for a maximum of 12 weeks from the scheduled date of 
cycle initiation to allow for resolution of toxicity. 
 
The maximum number of cycles of lomustine is 6. 
6.3.3 Bevacizumab 
  
Prior to each bevacizumab infusion, the following parameters should be met: 
platelet count >75,000/mcL, proteinuria < grade 3, creatinine <1.5xULN, 
hypertension < grade 4.  
 
 
If toxicities (as determined CTCAE version 4.0) of grade >2 are observed (except 
alopecia, nausea and vomiting) and related to bevacizumab, then the dose of 
bevacizumab should held until recovery to grade ≤ 1. All grade 3 or 4 non-
hematological toxicities (except hypertension, alopecia, nausea and vomiting) 
should have resolved to grade ≤ 1 for bevacizumab to be re-initiated at a dose of 
5mg/kg. Hypertension should be proactively managed and if cannot be controlled 
with anti-hypertensive medications to <grade 3, bevacizumab should be dose 
reduced to 5mg/kg. 
 
Bevacizumab may be held for up to 28 days to allow for resolution of toxicity.  
 
7. DRUG FORMULATION AND ADMINISTRATION  

 
18
 
7.1 
FMISO 
7.1.1 Description 
The chemical name is 1H-1-(3-[18F]-fluoro-2-hydroxy-propyl)-2-nitro-
imidazole. 
7.1.2 Form 
FMISO is an intravenous injection. The radiopharmaceutical product, FMISO, is 
the only active ingredient and it is dissolved in a solution of ≤10 mL of 95% 
isotonic saline: 5% ethanol (v:v). FMISO is provided as a ready to use isotonic, 
sterile, pyrogen-free, clear, and colorless solution. FMISO is typically packaged 
in a glass vial and does not contain any preservatives. 
 
7.1.3 Storage and Stability 
 
The FMISO will be produced the day of the scheduled PET scan by either the 
radiopharmacy lab at Brigham and Women’s Hospital (Nuclear Medicine/ 
Biomedical Imaging Research Core (BICOR)) or the Martinos Center for 
Biomedical Imaging. Proper transportation will take place according to Martinos 
Center policies. Following synthesis and quality control, the 
radiopharmaceutical will be used within 8-12 hours of the end of synthesis.  
 
7.1.4 Compatibility 
 
N/A 
7.1.5 Handling 
Qualified personnel, familiar with procedures that minimize undue exposure to 
themselves and the environment, should undertake the preparation, handling, and 
safe disposal of the chemotherapeutic agent in a self-contained and protective 
environment. 
 
7.1.6 Availability 
 
FMISO will be produced by either the radiopharmacy lab at Brigham and 
Women’s Hospital or the Martinos Center for Biomedical Imaging. Brigham and 
Women’s will provide FMISO if the Martinos Center is unable to produce the 
FMISO.  
 

 
19
7.1.7 Preparation 
 
FMISO will be produced as a fully prepared agent ready for intravenous 
administration.  Radioactivity dose can be adjusted by modifying the injection 
volume.  No other changes in constitution should be made.  
 
 
7.1.8 Administration 
 
FMISO is administered to subjects by intravenous injection by bolus of ≤10 mL. 
The FMISO dose for this protocol should be 3.7 MBq/kg (0.1 mCi/kg) up to a 
maximum of 260 MBq (7 mCi). 
 
7.1.9 Ordering 
 
FMISO will be prepared on a single injection basis as dictated by MR-PET 
scheduling of studies at the Martinos Center.  
 
7.1.10 Accountability 
 
The investigator, or a responsible party designated by the investigator, must 
maintain a careful record of the inventory and disposition of the agent 
(investigational or free of charge) using the NCI Drug Accountability Record or 
another comparable drug accountability form. (See the CTEP website at 
http://ctep.cancer.gov/protocolDevelopment  for the “Policy and Guidelines for 
Accountability and Storage of Investigational Agents” or to obtain a copy of the 
drug accountability form.) 
 
7.1.11 Destruction and Return 
At the end of the study, unused supplies of FMISO should be decayed in storage 
according to institutional policies.  This will be documented in the FMISO 
individual batch record and scan log. 
7.2 
Bevacizumab 
7.2.1 Description 
Please refer to the FDA-approved package insert for more information. 
 
7.2.2 Form 
Bevacizumab is an intravenous medication. 
 
7.2.3 Storage and Stability 
Bevacizumab will be stored per standard clinical guidelines. 
  
7.2.4 Compatibility 

 
20
 
N/A 
7.2.5 Handling 
 
 
Bevacizumab will be handled per standard clinical guidelines 
 
7.2.6 Availability 
 
 
Bevacizumab is commercially available. 
 
7.2.7 Preparation 
 
Bevacizumab will be prepared per standard guidelines 
  
7.2.8 Administration 
Administration will be IV per standard clinical guidelines. 
 
7.2.9 Ordering 
 
Bevacizumab will be ordered commercially. 
 
7.2.10 Accountability 
 
Per standard clinical guidelines 
 
7.2.11 Destruction and Return 
 
Per standard clinical guidelines. 
 
7.3 
Lomustine 
7.3.1 Description 
Please refer to the FDA-approved package insert for more information. 
 
7.3.2 Form 
Lomustine  is an oral medication. 
 
7.3.3 Storage and Stability 
Lomustine will be stored per standard clinical guidelines. 
  
7.3.4 Compatibility 
 

 
21
N/A 
7.3.5 Handling 
 
 
Lomustine will be handled per standard clinical guidelines 
 
7.3.6 Availability 
 
 
Lomustine is commercially available. 
 
7.3.7 Preparation 
 
Lomustine will be prepared per standard guidelines 
  
7.3.8 Administration 
Administration will be PO per standard clinical guidelines. 
 
7.3.9 Ordering 
 
Lomustine will be ordered commercially. 
 
7.3.10 Accountability 
 
Per standard clinical guidelines 
 
7.3.11 Destruction and Return 
 
Per standard clinical guidelines. 
 
 
 
 
8. CORRELATIVE/SPECIAL STUDIES  
8.1 
Pharmacokinetic Studies 
 
During PET data acquisition, blood samples will be drawn for analysis of total 
radioactivity and to determine the proportion of labeled radioactive metabolites.  
8.2 
Blood Biomarkers 
 
Blood may be collected at any time of the day on these time points 
 
NOTE: The treatment calendar does not include a day 0. 

 
22
 
Blood Biomarker Schedule  
   Baseline (within -14 days of treatment start date) 
   Cycle 1, 24-72 hours after start of bevacizumab 
Approximately day 14 (same day as FMISO PET)  
   Pre-Subsequent Cycles (within -5 days of start of cycle) 
 
Plasma will be collected for molecular markers (VEGF, PlGF, bFGF, SDF1alpha, Il-1b, 
Il-6, Il-8, TNF-alpha, collagen IV, Ang1, Ang2, thrombospondin, sVEGFR-1/2, SNPs) 
and circulating mononuclear cells (CECs, CEPs, VEGFR2 expressing monocytes). 
 
The same blood samples obtained for molecular biomarkers will be used for cell 
collection. 
 
Collection and Handling Procedures for Dr. Jain’s lab (Steele Laboratory) 
• Collect ~9 ml of blood into a large Purple top EDTA tube 
• Gently invert five to six times to ensure adequate mixing and prevent 
coagulation. 
• Cool the tube immediately in an ice bath. 
• Label tube and cover label with freezer tape. Refer to section 8.1.3.2. for 
information regarding labels. 
• Place tube on wet ice and send to Dr. Jain’s lab (Steele Laboratory) 
 
For all Lab Samples, prepared label templates will be supplied by MGH. Complete the 
labels with patient identifiers printing each label with Study-No., patient ID, initials and 
day/time of sample collection (24-hour clock format, i.e., 6:30 pm = 18:30). A label 
example is provided below: 
 
Study-No.: 
Investigator: 
Patient-ID: 
Patient Initials: 
Date of sampling: (mm/dd/yy) 
Time of Sampling: (hh:mm) (24-hr) 
Sample Type: (Serum or Plasma)  
 
 
Blood Sample Packaging and Shipment 
• All blood samples must be contained for safety reasons. 
• Place individual samples in a clip-lock bag labeled with the sample ID and seal. 
• Individual samples may be batched; seal within a second clip-lock bag labeled 
with the study ID and seal. Samples should be stored at 4°C in freezer until they 
are ready for shipping. 
• Place samples within another plastic bag labeled with the study ID and institution 
(treatment site) ID as well as a biosafety label. (Triple bagging provides for ease 
in further packaging for shipping and protection from damage.) 
• Samples should be transported at 4°C with wet ice. 
 

 
23
All specimens from DFCI should be shipped to:  
 
Sylvie Roberge or Christina Koppel 
MGH, Cox-734 
100 Blossom St. 
Boston, MA 02114 
Phone: (617) 726-1353 
Pager: 14082 
Email: sylvie@steele.mgh.harvard.edu or christina@steele.mgh.harvard.edu 
8.3 
Pharmacodynamic Studies 
 
N/A 
 
 
9. STUDY CALENDAR 
 
Lomustine Arm 
 
Screening 
Pre-
bevacizumab 
and 
lomustine 
(Baseline) 
1 day after 
bevacizumab 
and lomustine 
(post-dose #1) 
Day 14 i (pre- 
bevacizumab 
dose #2) 
Day 28j (pre- 
bevacizumab 
dose #3) 
Day 42 (pre-
bevacizumab 
dose #4) 
FMISO PET 
+ MRI h 
 
Xa 
 
Xb 
Xb 
 
Vascular MRI 
scan 
 
X 
X 
X 
Xc 
Xc 
Informed 
consent 
X 
 
 
 
 
 
History 
X 
 
 
 
 
 
Physical 
exam (Ht, Wt, 
VS) 
X 
 
 
 
 
 
Steroid dose 
X 
 
X 
X 
X 
X 
KPS/MMSE 
X 
 
 
 
 
 
CBC with diff 
X 
 
 
X 
X 
X 
CMPd 
X 
 
 
 
 
X 
Urine analysis 
 
X 
 
X 
X 
X 

 
24
Blood 
Biomarkers 
 
X 
X 
X 
X g 
X 
B-HCGe 
X 
X 
 
X 
X 
 
Adverse event 
evaluation j 
 
X 
 
 
X 
X 
 
Follow-up f 
 
 
 
 
 
 
a – within 14 days prior to start of bevacizumab 
b – 0-3 days prior to dose of bevacizumab (can be performed same day as dose of bevacizumab as long as 
it is prior to the infusion) 
c – Every 6 weeks for 6 cycles per standard of care guidelines. MRI can be performed within 5 days of 
starting the next cycle of lomustine. If patient stops lomustine, MRI scans will continue every 6 weeks for 
the remainder of the 6 cycles time frame. After 6 cycles, MRIs will be performed per standard of care 
guidelines.  
d - Sodium, potassium, chloride, glucose, BUN, creatinine, calcium, total protein, albumin, total 
bilirubin, SGOT [AST], SGPT [ALT], alkaline phosphatase. 
e – Serum pregnancy test (for women of childbearing potential) to be performed at baseline and prior to 
each FMISO PET. See Section 5.1.3 and 
http://healthcare.partners.org/phsirb/Guidance/Pregnancy_Testing_in_Research_Involving_Radiation.1.0
9.pdf 
f  – Follow-up every 3 months will assess subsequent treatments, tumor response to treatment, and 
survival after completion of MRI on cycle 7 day 1  
g  – Every 6 weeks for 6 months (within 5 days of starting subsequent cycle) 
h  – if FMISO is not available, the patient will have an MRI scan only 
i  – bevacizumab should be given every 14 days +/-2 days but the MRI-PET scan should be done prior to 
the corresponding bevacizumab dose 
j– for AE’s related to PET, to be 24±6 hours post PET scan and can be phone call or clinic visit. Otherwise, 
for lomustine and bevacizumab, per DFHCC SOPs. 
 
 
 
Bevacizumab Monotherapy Arm 
 
Screening 
Pre-
bevacizumab 
and 
lomustine 
(Baseline) 
1 day after 
bevacizumab 
and lomustine 
(post-dose #1) 
Day 14j (pre- 
bevacizumab 
dose #2) 
Day 28j (pre- 
bevacizumab 
dose #3) 
FMISO PET 
+ MRI f 
 
Xa 
 
Xb 
Xb 
Vascular MRI 
scan 
 
X 
X 
X 
Xc 
Informed 
consent 
X 
 
 
 
 
History 
X 
 
 
 
 

 
25
Physical 
exam (Ht, Wt, 
VS) 
X 
 
 
 
 
Steroid dose 
X 
 
X 
X 
X 
KPS/MMSE 
X 
 
 
 
 
CBC with diff 
X 
 
 
X 
X 
CMPd 
X 
 
 
 
 
Urine analysis 
 
X 
 
X 
X 
Blood 
Biomarkers 
 
X 
X 
X 
Xh 
B-HCGe 
X 
X 
 
X 
X 
Adverse event 
evaluation  k 
 
X 
 
 
X 
X 
Follow-upg 
 
 
 
 
 
a – within 14 days prior to start of bevacizumab 
b – 0-3 days prior to dose of bevacizumab (can be performed same day as dose of bevacizumab as long as 
it is prior to the infusion) 
c – Every 4 weeks for 6 cycles  per standard of care guidelines. MRI can be performed within 5 days of 
bevazicumab dose. 
d - Sodium, potassium, chloride, glucose, BUN, creatinine, calcium, total protein, albumin, total 
bilirubin, SGOT [AST], SGPT [ALT], alkaline phosphatase. 
e – Serum pregnancy test (for women of childbearing potential) to be performed at baseline and prior to 
each FMISO PET. See Section 5.1.3 and 
http://healthcare.partners.org/phsirb/Guidance/Pregnancy_Testing_in_Research_Involving_Radiation.1.0
9.pdf 
f - if FMISO is not available, the patient will have an MRI scan only 
g – Follow-up every 3 months will assess subsequent treatments, tumor response to treatment, and 
survival after completion of MRI on cycle 7 day 1  
h – Every 4 weeks for 6 months (within 5 days of starting subsequent cycle) 
j – bevacizumab should be given every 14 days +/-2 days but the MRI-PET scan should be done prior to 
the corresponding bevacizumab dose 
 k – for AE’s related to PET, to be 24±6 hours post PET scan and can be phone call or clinic visit. 
Otherwise, for lomustine and bevacizumab, per DFHCC SOPs. 
 
 
 
10. ADVERSE EVENT REPORTING REQUIREMENTS 
10.1 Definitions 

 
26
10.1.1 Adverse Event (AE) 
 
An adverse event (AE) is any undesirable sign, symptom or medical condition or 
experience that develops or worsens in severity after starting the first dose of 
study treatment or any procedure specified in the protocol, even if the event is not 
considered to be related to the study.  
 
Abnormal laboratory values or diagnostic test results constitute adverse events 
only if they induce clinical signs or symptoms or require treatment or further 
diagnostic tests.  
10.1.2 Serious adverse event (SAE) 
 
A serious adverse event (SAE) is any adverse event, occurring at any dose and 
regardless of causality that:  
• Results in death 
• Is life-threatening. Life-threatening means that the person was at 
immediate risk of death from the reaction as it occurred, i.e., it does not 
include a reaction which hypothetically might have caused death had it 
occurred in a more severe form. 
• Requires or prolongs inpatient hospitalization (i.e., the event required at 
least a 24-hour hospitalization or prolonged a hospitalization beyond the 
expected length of stay). Hospitalization admissions and/or surgical 
operations scheduled to occur during the study period, but planned prior to 
study entry are not considered SAEs if the illness or disease existed before 
the person was enrolled in the trial, provided that it did not deteriorate in 
an unexpected manner during the trial (e.g., surgery performed earlier than 
planned). 
• Results in persistent or significant disability/incapacity. Disability is 
defined as a substantial disruption of a person’s ability to conduct normal 
life functions. 
• Is a congenital anomaly or birth defect; or 
• Is an important medical event when, based upon appropriate medical 
judgment, it may jeopardize the participant and require medical or surgical 
intervention to prevent one of the outcomes listed above. 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. 
 
Events not considered to be serious adverse events are hospitalizations for: 
• routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition, or for elective procedures 
• elective or pre-planned treatment for a pre-existing condition that did not 
worsen 

 
27
• emergency outpatient treatment for an event not fulfilling the serious 
criteria outlined above and not resulting in inpatient admission 
• respite care 
 
10.1.3 Expectedness 
 
Adverse events can be 'Expected' or 'Unexpected.'  
10.1.3.1 Expected adverse event 
 
Expected adverse events are those that have been previously identified as 
resulting from administration of the agent. For the purposes of this study, 
an adverse event is considered expected when it appears in the current 
adverse event list, the Investigator’s Brochure, the package insert or is 
included in the informed consent document as a potential risk.   
 
Refer to Section 6.1 for a listing of expected adverse events associated 
with the study agent(s). 
10.1.3.2 Unexpected adverse event 
 
 
For the purposes of this study, an adverse event is considered unexpected 
when it varies in nature, intensity or frequency from information 
provided in the current adverse event list, the Investigator’s Brochure, 
the package insert or when it is not included in the informed consent 
document as a potential risk.   
Attribution 
 
Attribution is the relationship between an adverse event or serious adverse event 
and the study treatment. Attribution will be assigned as follows: 
 
• Definite – The AE is clearly related to the study treatment. 
• Probable – The AE is likely related to the study treatment. 
• Possible – The AE may be related to the study treatment.  
• Unlikely - The AE is doubtfully related to the study treatment. 
• Unrelated - The AE is clearly NOT related to the study treatment. 
10.2 Procedures for AE and SAE Recording and Reporting 
 
Participating investigators will assess the occurrence of AEs and SAEs at all participant 
evaluation time points during the study.  
 
All AEs and SAEs whether reported by the participant, discovered during questioning, 
directly observed, or detected by physical examination, laboratory test or other means, 

 
28
will be recorded in the participant’s medical record and on the appropriate study-
specific case report forms.  
 
The descriptions and grading scales found in the revised NCI Common Terminology 
Criteria for Adverse Events (CTCAE) version 4.0 will be utilized for AE reporting. All 
appropriate treatment areas should have access to a copy of the CTCAE version 4.0. 
A copy of the CTCAE version 4.0 can be downloaded from the CTEP website at: 
 
 http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm.  
10.3 Reporting Requirements 
 
For multi-site trials where a DF/HCC investigator is serving as the principal 
investigator, each participating investigator is required to abide by the reporting 
requirements set by the DF/HCC. The study must be conducted in compliance with 
FDA regulations, local safety reporting requirements, and reporting requirements of the 
principal investigator.  
 
Each investigative site will be responsible to report SAEs that occur at that institution 
to their respective IRB. It is the responsibility of each participating investigator to 
report serious adverse events to the study sponsor and/or others as described below.  
 
Investigators must immediately report directly to the RDRC all adverse effects 
associated with the use of the radioactive drug [21 CFR 361.1 (d) 8] 
10.4 Reporting to the Study Sponsor 
Serious Adverse Event Reporting 
 
All serious adverse events that occur after the initial dose of study treatment, 
during treatment, or within 30 days of the last dose of treatment must be reported 
to the DF/HCC Overall Principal Investigator on the local institutional SAE form. 
This includes events meeting the criteria outlined in Section 11.1.2, as well as the 
following: 
 
• Grade 2 (moderate) and Grade 3 (severe) Events – Only events that are 
unexpected and possibly, probably or definitely related/associated with the 
intervention. 
 
• All Grade 4 (life-threatening or disabling) Events – Unless expected AND 
specifically listed in the protocol as not requiring reporting. 
 
• All Grade 5 (fatal) Events – When the participant is enrolled and actively 
participating in the trial OR when the event occurs within 30 days of the 
last study intervention.  
 

 
29
Note: If the participant is in long term follow up, report the death at the time 
of continuing review.  
 
Participating investigators must report each serious adverse event to the DF/HCC 
Overall Principal Investigator within 24 hours of learning of the occurrence. In 
the event that the participating investigator does not become aware of the serious 
adverse event immediately (e.g., participant sought treatment elsewhere), the 
participating investigator is to report the event within 24 hours after learning of it 
and document the time of his or her first awareness of the adverse event. Report 
serious adverse events by telephone, email or facsimile to: 
 
 
 
Elizabeth Gerstner, M.D. 
 
 
Phone: 617-724-8770 
 
 
Page #:  617-726-2000 #13385 
Fax: 617-643-2591 
egerstner@partners.org 
 
Within the following 24-48 hours, the participating investigator must provide 
follow-up information on the serious adverse event. Follow-up information should 
describe whether the event has resolved or continues, if and how the event was 
treated, and whether the participant will continue or discontinue study 
participation. 
Non-Serious Adverse Event Reporting  
 
Non-serious adverse events will be reported to the DF/HCC Overall Principal 
Investigator on the toxicity Case Report Forms.   
10.5 Reporting to the Institutional Review Board (IRB) 
 
Investigative sites within DF/HCC will report all serious adverse events directly to the 
DFCI Office for Human Research Studies (OHRS). 
10.6 Reporting to the Food and Drug Administration (FDA) 
 
N/A 
10.7 Reporting to the NIH Office of Biotechnology Activities (OBA) 
 
N/A 
 
10.8 Reporting to the Institutional Biosafety Committee (IBC) 
 
N/A 

 
30
10.9 Reporting to Hospital Risk Management 
 
Participating investigators will report to their local Risk Management office any subject 
safety reports or sentinel events that require reporting according to institutional policy. 
10.10 Monitoring of Adverse Events and Period of Observation 
 
All adverse events, both serious and non-serious, and deaths that are encountered from 
initiation of study intervention, throughout the study, and within 30 days of the last 
study intervention should be followed to their resolution, or until the participating 
investigator assesses them as stable, or the participating investigator determines the 
event to be irreversible, or the participant is lost to follow-up. The presence and 
resolution of AEs and SAEs (with dates) should be documented on the appropriate case 
report form and recorded in the participant’s medical record to facilitate source data 
verification.  
 
For some SAEs, the study sponsor or designee may follow-up by telephone, fax, and/or 
monitoring visit to obtain additional case details deemed necessary to appropriately 
evaluate the SAE report (e.g., hospital discharge summary, consultant report, or 
autopsy report).  
 
Participants should be instructed to report any serious post-study event(s) that might 
reasonably be related to participation in this study. Participating investigators should 
notify the DF/HCC Overall Principal Investigator and their respective IRB of any 
unanticipated death or adverse event occurring after a participant has discontinued or 
terminated study participation that may reasonably be related to the study.   
 
11. DATA AND SAFETY MONITORING 
11.1 Data Reporting 
11.1.1 Method  
The QACT will collect, manage, and monitor data for this study.  
Data Submission  
The schedule for completion and submission of case report forms (paper or 
electronic) to the QACT is indicated in the table below. In addition, investigators 
must immediately report directly to the RDRC all adverse effects associated with 
the use of the radioactive drug.  
 
 
Form 
Submission Timeline 

 
31
Eligibility Checklist 
Complete prior to registration with QACT 
On Study Form 
Within 14 days of registration 
Baseline Assessment Form 
Within 14 days of registration 
Treatment Form 
Within 10 days of the last day of the cycle 
Adverse Event Report Form 
Within 10 days of the last day of the cycle 
Response Assessment Form 
Within 10 days of the completion of the 
cycle required for response evaluation 
Off Treatment/Off Study 
Form 
Within 14 days of completing treatment or 
being taken off study for any reason 
Follow up/Survival Form 
Within 14 days of the protocol defined 
follow up visit date or call 
 
11.2 Safety Meetings 
 
The DF/HCC Data and Safety Monitoring Committee (DSMC) will review and monitor 
toxicity and accrual data from this trial. The committee is composed of clinical 
specialists with experience in oncology and who have no direct relationship with the 
study. Information that raises any questions about participant safety will be addressed 
with the Principal Investigator and study team. 
 
The DSMC will meet quarterly and/or more often if required to review toxicity and 
accrual data.  Information to be provided to the committee may include:  up-to-date 
participant accrual; current dose level information; DLT information; all grade 2 or 
higher unexpected adverse events that have been reported; summary of all deaths 
occurring within 30 days for Phase I or II protocols; for gene transfer protocols, 
summary of all deaths while being treated and during active follow-up; any response 
information; audit results, and a summary provided by the study team. Other 
information (e.g. scans, laboratory values) will be provided upon request.  
 
11.3 Monitoring  
 
Involvement in this study as a participating investigator implies acceptance of 
potential audits or inspections, including source data verification, by representatives 
designated by the DF/HCC Overall Principal Investigator (or Protocol Chair) or 
DF/HCC. The purpose of these audits or inspections is to examine study-related 
activities and documents to determine whether these activities were conducted and 
data were recorded, analyzed, and accurately reported in accordance with the protocol, 

 
32
institutional policy, Good Clinical Practice (GCP), and any applicable regulatory 
requirements.  
 
All data will be monitored for timeliness of submission, completeness, and adherence 
to protocol requirements. Monitoring will begin at the time of participant registration 
and will continue during protocol performance and completion.  
12. REGULATORY CONSIDERATIONS 
12.1 Protocol Review and Amendments 
This protocol, the proposed informed consent and all forms of participant 
information related to the study (e.g., advertisements used to recruit participants) and 
any other necessary documents must be submitted, reviewed and approved by a 
properly constituted IRB governing each study location.  
Any changes made to the protocol must be submitted as amendments and must be 
approved by the IRB prior to implementation. Any changes in study conduct must be 
reported to the IRB. The DF/HCC Overall Principal Investigator (or Protocol Chair) 
will disseminate protocol amendment information to all participating investigators.  
All decisions of the IRB concerning the conduct of the study must be made in 
writing. 
12.2 Informed Consent 
 
All participants must be provided a consent form describing this study and 
providing sufficient information for participants to make an informed decision 
about their participation in this study. The formal consent of a participant, using 
the IRB approved consent form, must be obtained before the participant is 
involved in any study-related procedure. The consent form must be signed and 
dated by the participant or the participant’s legally authorized representative, and 
by the person obtaining the consent. The participant must be given 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.  
12.3 Ethics and Good Clinical Practice (GCP) 
This study is to be conducted according to the following considerations, which 
represent good and sound research practice: 
• 
E6 Good Clinical Practice: Consolidated Guidance 
www.fda.gov/downloads/RegulatoryInformation/Guidances/UCM129515.pdf  
• 
US Code of Federal Regulations (CFR) governing clinical study conduct and 
ethical principles that have their origin in the Declaration of Helsinki 

 
33
o Title 21 Part 11 – Electronic Records; Electronic Signatures 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr11_02.html 
o Title 21 Part 50 – Protection of Human Subjects 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr50_02.html  
o Title 21 Part 54 – Financial Disclosure by Clinical Investigators 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr54_02.html  
o Title 21 Part 56 – Institutional Review Boards 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr56_02.html  
o Title 21 Part 312 – Investigational New Drug Application 
www.access.gpo.gov/nara/cfr/waisidx_02/21cfr312_02.html  
• 
State laws 
• 
DF/HCC research policies and procedures        
http://www.dfhcc.harvard.edu/clinical-research-support/clinical-research-unit-
cru/policies-and-procedures/  
It is understood that deviations from the protocol should be avoided, except when 
necessary to eliminate an immediate hazard to a research participant. In such case, 
the deviation must be reported to the IRB according to the local reporting policy.  
12.4 Study Documentation 
 
The investigator must prepare and maintain adequate and accurate case histories 
designed to record all observations and other data pertinent to the study for each 
research participant. This information enables the study to be fully documented and the 
study data to be subsequently verified. 
 
Original source documents supporting entries in the case report forms include but are 
not limited to hospital records, clinical charts, laboratory and pharmacy records, 
recorded data from automated instruments, microfiches, photographic negatives, 
microfilm or magnetic media, and/or x-rays.  
12.5 Records Retention 
 
All study-related documents must be retained for the maximum period required by 
applicable federal regulations and guidelines or institutional policies.  
12.6 Multi-center Guidelines 
N/A 
 

 
34
13. STATISTICAL CONSIDERATIONS  
Study Design/Endpoints 
The statistical design of the study pertains to Cohort A where the following hypotheses 
will be specifically tested.  The primary statistical analysis will be the comparison of 
hypoxic volumes measured by the baseline and day 14 [18F]FMISO PET scans. We 
expect all patients have some hypoxia at baseline, and will express the change day 14 
hypoxic volume relative to baseline. We will use two-sided, one-sample Wilcoxon test 
on log-transformed relative volumes to test the primary hypothesis. We will specifically 
test if there is a significant decrease in the percentage of the tumor with a HV (as defined 
as T/Bmax ≥1.2) from prior to bevacizumab infusion to day 14); thus, this is a continuous 
endpoint. The 1.2 cut-off is based on prior data from Spence et al showing that HV as 
defined in this way was predictive of patient survival (Spence et al, 2008). Additional 
exploratory analyses will look at the change in HV between baseline and day 28. The 
ROI delineating the contrast-enhancing and non-enhancing tumor will be co-registered 
to the FMISO PET scan to determine the area of interest on the PET scan and calculate 
the number of tumor voxels with a T/Bmax ≥1.2. This will allow us to generate a 
percentage of the entire tumor volume that is hypoxic. Based on personal communication 
(Dr. David Mankoff), we expect the SD of the within-person change between FMISO 
measurements under the null hypothesis to be approximately 10%. Using this value and 
N=30, we anticipate 80% power to detect an absolute mean change of approximately 5% 
or greater, based on a Wilcoxon signed rank test at the 0.05 two-tailed significance level. 
More generally, for any standard deviation for change from baseline, we will be able to 
detect an effect size of 0.55 standard deviation units or larger. 
We will also specifically test if there is a significant change in median tumor CBF from 
prior to bevacizumab infusion to each of the time points (day 1, day 14). We will use a 
repeated measures mixed effects model that will jointly model median tumor CBF at 
baseline, days 1 and 14, without assuming it to follow a parametric function of time, and 
accounting for correlation within person through a random effect.  Based on the model, 
we will assess the significance of the differences from baseline. For simplicity, we 
calculate power based on separate, two-sided, 0.05 level paired t-tests which are the 
simplest versions of the repeated measures models and which should underestimate the 
power that we will have from the full model. The models and t-tests are applied to median 
tumor CBF, a measured that is calculated for each subject. We expect that the collection 
of medians across subjects to be approximately normally distributed. Based on our 
preliminary data (N=29), we estimate the standard deviation (SD) of a within-subject 
CBF change averaged over tumor to be 0.2. With 30 patients, we will have 80% power 
to detect a difference of 0.11 in CBF. 
Vascular MRI Secondary Endpoints will include CBV, vessel diameter, and ktrans: 
Secondary analyses will consist, for each biomarker, of tests of change from baseline 
(we will apply log-transformation and test for a relative change). We will use two-sided, 
paired Wilcoxon tests, adjusting p-values by Holm’s method to account for multiple 
time-points, but not for multiple biomarkers — as each biomarker will be of separate 

 
35
interest. The power for at least one significant outcome is as for the primary analysis of 
FMISO PET scans given above. 
Similar secondary analyses will be conducted with the blood biomarker data in the same 
manner as with the imaging parameters. 
Cohort B is an exploratory cohort and will be summarized using descriptive statistics. 
Statistical graphics such as boxplots will be used to present the summary statistics at 
each time point. The differences in HV, CBF, CBV, vessel diameter, and ktrans (same 
as for Cohort A) before and during treatment will be tested using paired statistics but HV 
will be the variable of principle interest. Cox regression model or logistic regression 
model will be used to explore associations between changes of serum biomarker 
levels/imaging parameters and overall survival or progression-free survival. All 
estimated associations of biomarker changes during the disease process and the 
probability of death or disease progression will be reported along with 95% confidence 
intervals. Using the same assumptions as for Cohort A, for any standard deviation for 
change from baseline, we will be able to detect an effect size of 1.07 standard deviation 
units or larger for HV which will be the primary Aim for this cohort. Vascular MRI 
Secondary Endpoints will be handled as above for Cohort A. 
 
13.1 Sample Size/Accrual Rate 
 
30 patients will be enrolled in Cohort A with an accrual rate of ~1 per month.  A 
maximum of 10 patients will be enrolled in the exploratory cohort B. 
 
Stratification Factors 
 
N/A 
13.2 Reporting and Exclusions 
13.2.1 Evaluation of toxicity. All participants will be evaluable for toxicity for 24hours 
+/- 6hours after each MR-PET scan. 
 
14. PUBLICATION PLAN 
The Principal Investigator holds primary responsibility for publication of the study results. 
The results are to be made public via abstract meeting the requirements of the International 
Committee of Medical Journal Editors or via publication in a peer-reviewed journal within 
24 months of the end of data collection and analysis. A full report of the outcomes will be 
made public no later than three years after the end of data collection and analysis. 
 
 

 
36
 
 
 
 
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40
 
 
 
 
 
 
16. APPENDICES  
Appendix A: Performance Status Criteria 
 
ECOG Performance Status Scale 
 
 
Karnofsky Performance Scale 
Grade 
Description 
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-
20 
Very sick, hospitalization 
indicated. Death not imminent. 

 
41
care. Totally confined to bed or 
chair. 
10 
Moribund, fatal processes 
progressing rapidly.  
5 
Dead. 
0 
Dead. 
 
 
 
 
 

 
D: 3/12/2014 MML/LD 
 
DANA-FARBER CANCER INSTITUTE 
Nursing Protocol Education Sheet 
Protocol Number: 
13-482 
Protocol Name: 
Study to Evaluate Vascular Normalization in Patients with Recurrent Glioblastoma Treated 
with Bevacizumab Using  FMISO PET and Vascular MRI 
DFCI Site PI: 
Patrick Wen, M.D.  
DFCI Research Nurse: 
Debra LaFrankie, RN; Lisa Doherty, NP; Jennifer Rifenburg, NP; Sandra Ruland, RN 
    Page the DFCI research nurse or DFCI site PI if there are any questions/concerns about the protocol.   
Please also refer to ONC 15: Oncology Nursing Protocol Education Policy 
                                                                 ***Please Check for an Alert Page*** 
                    SPECIAL NURSING CONSIDERATIONS UNIQUE TO THIS PROTOCOL 
Study 
Design 
This study will explore the changes in tumor vasculature resulting from treatment with Bevacizumab and the impact 
these changes have on tumor oxygenation. The success of these studies should enable methods that could be used in 
larger studies to more completely understand the role of Anti-angiogenic agents in the treatment of cancer.  
Dose 
Calc 
Bevacizumab dose is calculated in mg/kg per standard of care. (Section 5.0) 
 
A cycle = 28 Days.  
Study Drug Administration 
Agent Administration Guidelines are found in Section  5.0 
Bevacizumab will be administered via I.V. infusion, every 14 days per standard of care. (Section 5.0, 7.2) 
MR-PET  
• 
Scans will be performed in Charlestown, MA at the Martinos Center. 
• 
2 IV lines will be placed for each scan: one venous line to inject the FMISO and Gadolinium for the MRI scan, and 
a second to draw blood to assay for radioactivity & metabolites.  
• 
If the Participant has a port, the port can replace one of the IVs.  
• 
FMISO PET scans will be approximately 60-75 minutes and begin approximately 90 minutes following the FMISO 
injection.(Section 5.2.1)  
• 
FMISO administration instructions are found in Section 7.1.8. 
• 
Gadolinium-diethylenetriaminepentaacetic acid will be used as a contrast agent and injected intravenously twice in 
each scan session. (Section 5.2.2)  
Dose Mod & 
Toxicity 
Dose Modifications/Dosing Delay for Toxicity are outlined in Section 6.3 
• NCI CTCAE vs. 4.0 will be used in grading toxicities.  (Section 6.3.2) 
• No dose reduction of FMISO is permitted. (Section 6.3.1) 
• Bevacizumab: Prior to each Bevacizumab infusion, the following parameters should be met: Platelet count 
>75,000/mcL, proteinuria < grade 3, creatinine <1.5xULN, hypertension < grade 4.  
• Dose Modifications for Bevacizumab are found in Section 6.3.2.  
• Bevacizumab may be held for a maximum of 28 days to allow for resolution of toxicity to < 1. (Section 6.3.2) 
Concom 
Meds 
Concomitant Therapy Guidelines are in Section 5.4 
•  
Req 
 Data  
Study Calendar and Assessment Required data found in Sections 8.0 & 9.0 
•  
Charting 
Tips 
Please be sure to DOCUMENT study medication actual UP/DOWN times in medical record 
• 
If there is a discrepancy in the infusion time, delay in administration, or the infusion takes longer than is 
permitted by the guidelines of the protocol, please document the reason for the discrepancy in the medical 
record. 
Please be sure to also DOCUMENT any required observation periods, any additional vital signs, routes of 
administration, or injection sites